Fidelity Indicators
1.1 Timely Engagement and Planning
The Program Manager is responsible for timely engagement, process documented in Program Manual pages 2-4 (Program Overview) and page 18 (Phase One – Engagement).
The Case Manager/Facilitator completes the initial Wraparound Plan of Care with family, Program Manager tracks timeliness, process documented in Program Manual pages 2-4 (Program Overview), page 18 (Phase One – Engagement) and pages 31-32 (Phase Three – Implementation).
The Case Manager/Facilitator schedules monthly Family Team Meetings (FTM) it is a standing agenda item at each FTM, process documented in Program Manual pages 2-4 (Program Overview), pages 27-29 (Phase Two – Plan Development).
Care Plan Review is a standing agenda item for Family Team Meetings (FTM), Case Manager/Facilitator updates the Plan of Care after monthly FTM, Program Manager tracks timeliness, process documented in Program Manual pages 2-4 (Program Overview), pages 27-29 (Phase Two – Plan Development) and in Family Profile Templates pages 8-9 (Child and Family Team Meeting Agenda)
Wrap Staff and supervisors are provided weekly supervision with opportunities for timeline feedback and engagement strategy, process documented in Program Manual pages 35-36 (Fidelity Monitoring Plan).
1.2 Led by Youth and Families
The Case Manager/Facilitator leads the development and documentation of the Family Vision and Team Mission Statements, process is documented in the Program Manual pages 18-22 (Phase One – Engagement) and pages 27-28 (Phase Two – Plan Development).
The Case Manager/Facilitator seeks and records Family Voice data, process is documented in Program Manual pages 27-28 (Phase Two – Plan Development) with specifics in Family Profile Template pages 1-4 (Initial Child and Family Team Meeting agenda).
The Program Manager and the Support Specialist observe FTMs and review documentation every 90 days. Process documented in Program Manual page 35 (Fidelity Monitoring Plan).
Feedback from families is elicited every 6 months with the WFI-EZ and informally every 90 days. Process documented in Program Manual pages 33-34 (Data and Reporting) and pages 35-36 (Fidelity Monitoring Plan).
1.3 Strength-Based
The Case Manager/Facilitator leads the team to complete a Team Strengths Inventory and Natural Supports Inventory during Phase 2. Process is documented in Program Manual Page 27 (Phase Two – Plan Development) and Family Profile Template pages 6-7 (Natural Supports and Team Strengths Inventory)
The Strengths Inventory includes but is not limited to IP-CANS data. The HNH Intake Questionnaire expands on strengths exploration. Process is documented in Program Manual Page 18 (Phase One – Engagement) and Family Profile Templates Page 7 (Team Strengths Inventory).
The Training Plan includes ongoing opportunities for strengths-based, solution-focused services training and staff are provided weekly supervision. Process documented in Program Manual pages 51-54
The Program Manager is responsible for eliciting feedback from families on a routine basis. Process documented in the Program Manual pages 33-36 (Data and Reporting/Fidelity Monitoring Plan).
1.4 Needs Driven
The Program Manager conducts an IP-CANS assessment during the Engagement phase. Process documented in Program Manual page 23-24 (Referral and Engagement).
All staff receive foundational training through UC Davis and are provided additional coaching and supervision on a regular basis. Process documented in Program Manual pages 51-54 (Training Plan)
The Case Manager/Facilitator is certified in IP-CANS assessments and utilizes the HNH Intake Questionnaire for further needs discovery. Process documented in Program Manual page 18-19 (Phase One – Engagement).
The Case Manager/Facilitator is responsible for tracking met and unmet needs and the care plan is updated with the progress. The Transition plan is reviewed with the family and then the entire team 90 days prior to the contract end date to ensure all needs are sufficiently met. Process documented in Program Manual pages 43-44 (Phase Four – Transition).
1.5 Individualized
Care plans are guided by IP-CANS assessment and thorough exploration of the family’s profile. Process documented in Program Manual pages 2-4 (Program Overview), pages 27-29 (Phase Two – Plan Development) and the Family Profile Templates pages 1-10.
All HNH Staff receive weekly coaching and adhere to an agency specific training plan utilizing UC Davis Wraparound Training module. Process documented in Program Manual pages 51-54 (Training Plan).
Case Managers/Facilitators receive weekly coaching and supervision and adhere to an agency specific training plan utilizing UC Davis Wraparound Training modules. Process documented in Program Manual pages 35-36 (Fidelity Monitoring Plan).
Care Plans are updated on a monthly basis and published by the Case Manager/Facilitator. All care plans are reviewed by the Program Manager every 90 days. Process documented in Program Manual pages 31-32 (Phase Three – Implementation).
The Program Manager utilizes monthly Parent Support group assessments and the 6 month WFI-Ez cycles to elicit family feedback. Quality assurance phone calls are conducted on a regular basis and utilized in monthly supervision and annual performance reviews. Process documented in Program Manual pages 33-34 (Data and Reporting Plan).
1.6 Use of Natural and Community Based Supports
The Case Manager/Facilitator completes the initial Natural Supports Inventory during Phase 1 and updates are made during Care Plan updates. Process documented in Program Manual page 18 and in the Family Profile Templates page 6 (Natural Supports Inventory).
All HNH Staff receive weekly coaching and adhere to an agency specific training plan utilizing UC Davis Wraparound Training modules and Skills Labs. Process documented in Program Manual pages 51-54 (Training Plan).
Care Plans are updated on a monthly basis and published by the Case Manager/Facilitator. All care plans are reviewed by the Program Manager every 90 days. Process documented in Program Manual pages 31-32 (Phase Three – Implementation).
The Program Manager utilizes monthly Parent Support group assessments and the 6 month WFI-Ez cycles to elicit family feedback. Quality assurance phone calls are conducted on a regular basis and utilized in monthly supervision and annual performance reviews. Process documented in Program Manual pages 33-34 (Data and Reporting Plan).
1.7 Culturally Respectful and Relevant
The Case Manager/Facilitator guides the family through the creation of a Family Profile during Phase 1. Process documented in Program Manual page 18 (Phase One – Engagement), pages 27-29 (Phase Two – Plan Development) and the Family Profile Templates pages 1-10.
All HNH Staff receive weekly coaching and adhere to an agency specific training plan utilizing UC Davis Wraparound Training modules and Skills Labs. Process documented in Program Manual pages 51-54 (Training Plan).
The Program Manager utilizes monthly Parent Support group assessments and the 6 month WFI-Ez cycles to elicit family feedback. Quality assurance phone calls are conducted on a regular basis and utilized in monthly supervision and annual performance reviews. Process documented in Program Manual pages 33-34 (Data and Reporting Plan).
1.8 High-Quality Team Planning and Problem Solving
The Case Manager/Facilitator guides the creation of a team agreement in the initial Family Team Meeting. Process documented in Program Manual page 27 (Phase Two – Plan Development) and in the Family Profile Templates page 10 (Team Agreement Template).
The Program Manager utilizes monthly Parent Support group assessments and the 6 month WFI-Ez cycles to elicit family feedback. Quality assurance phone calls are conducted on a regular basis and utilized in monthly supervision and annual performance reviews. Process documented in Program Manual pages 33-34 (Data and Reporting Plan)
Feedback is collected using WrapStat and integrated into weekly supervision and annual performance reviews. Data is collected by Program Manager and reviewed by the Operations Director/Clinical Director for continuous quality improvement. Process documented in Program Manual pages 36-37 (Fidelity Monitoring Plan)
Care Plans are updated on a monthly basis and published by the Case Manager/Facilitator. Action items are reviewed at each Family Team Meeting. Care plans and Family Team Meeting minutes are reviewed by the Program Manager every 90 days. Process documented in Program Manual pages 31-32 (Phase Three – Implementation) and pages 36-37 (Fidelity Monitoring Plan).
1.9 Outcomes Based Process
The HNH Care Plan template documents specific strategies, their unit and rate of measure and assigned action items with timeframes for reassessment. Process documented in Program Manual pages 31-32 (Phase Three – Implementation) and the Child and Family Plan of Care template.
The Case Manager/Facilitator reviews action item completion as a standing agenda item at Family Team Meetings. HNH staff action items are reviewed weekly in supervision and in team meetings. Process documented in Program Manual page 2-4 (Program Overview), page 19 (Phase One – Engagement) and in the Family Profile Templates pages 8-9 (Child and Family Team Meeting Agenda template)
Strategies and action items are reviewed on a weekly basis in individual supervision and in all staff meetings. All forms are living documents in agency cloud storage. Process documented in Program Manual page 30 (Phase Three – Implementation).
Initial IP-CANS are completed in Phase 1 by the Program Manager. The Case Manager/Facilitator is responsible for facilitating the IP-CANS every 90 days throughout Phase 3 and 4. Process documented in Program Manual page 10 (Program Overview), pages 23-24 (Referral and Engagement), page 33 (Data and Reporting Plan).
HNH staff utilize Opeeka to support tracking and share information amongst team members. IP-CANS data informs plan of care updates every 90 days in addition to monthly review and updates throughout Phase 3 and 4. Process documented in Program Manual page 33 (Data and Reporting Plan).
1.10 Persistence
The Program Manager is responsible for monitoring and encouraging team persistence with the guidance of the Clinical Supervisor. Process documented in Program Manual page 35-36 (Fidelity Monitoring Plan).
Weekly supervision is provided to all staff by the appropriate organizational leader. Org chart documented in the 2026 Wraparound Organizational Chart. Access to flexible funding and additional support is requested in weekly individual supervision and all staff meetings. Process documented in Program Manual page 30 (Phase Three – Implementation), pages 35-36 (Fidelity Monitoring Plan).
1.11 Transitions as a part of the Fourth Phase of HFW
Sustainable transition of services is a priority throughout Phase 3 in preparation for Transition. The Case Manager/Facilitator is responsible for leading the team through identifying readiness for transition and planning for the end of services. Process documented in Program Manual page 4 (Program Overview) and pages 43-44 (Phase Four – Transition).
The Case Manager/Facilitator is responsible for organizing transition celebrations according to the youth and family’s preferences and flexible funds, staff time, and community partnerships are prioritized for celebrations. Process documented in Program Manual page 44 (Phase Four – Transition).
Expected Outcomes
2.1 Youth and Family Satisfaction
HNH utilizes the WFI-Ez managed through WrapStat to record and evaluate youth and family satisfaction with HFW. The Program Manager is responsible for the evaluation cycles. Process documented in Program Manual page 33 (Data and Reporting Plan).
2.2 Improved School Functioning
HNH utilizes the WFI-Ez managed through WrapStat to record and evaluate improved school functioning over the course of HFW enrollment. The Case Manager/Facilitator tracks progress for school functioning needs and updates the Plan of Care accordingly with the team at each Family Team Meeting, guided by quarterly IP-CANS. The Program Manager is responsible for the evaluation cycles. Process documented in Program Manual page 31-32 (Phase Three – Implementation) and page 33 (Data and Reporting Plan).
2.3 Improved Functioning in the Community
HNH utilizes the WFI-Ez managed through WrapStat to record and evaluate improved functioning in the community over the course of HFW enrollment. The Case Manager/Facilitator tracks progress for community functioning needs and updates the Plan of Care accordingly with the team at each Family Team Meeting, guided by quarterly IP-CANS. The Program Manager is responsible for the evaluation cycles. Process documented in Program Manual page 31-32 (Phase Three – Implementation) and page 33 (Data and Reporting Plan).
2.4 Improved Interpersonal Functioning
HNH utilizes the WFI-Ez managed through WrapStat to record and evaluate improved interpersonal functioning over the course of HFW enrollment. The Case Manager/Facilitator tracks progress for interpersonal functioning needs and updates the Plan of Care accordingly with the team at each Family Team Meeting, guided by quarterly IP-CANS. The Program Manager is responsible for the evaluation cycles. Process documented in Program Manual page 31-32 (Phase Three – Implementation) and page 33 (Data and Reporting Plan).
2.5 Increased Caregiver Confidence
HNH utilizes the WFI-Ez managed through WrapStat to record and evaluate improved caregiver confidence over the course of HFW enrollment. The Case Manager/Facilitator tracks progress for caregiver confidence needs and updates the Plan of Care accordingly with the team at each Family Team Meeting, guided by quarterly IP-CANS. The Program Manager is responsible for the WFI-EZ evaluation cycles. Additional feedback on caregiver confidence is collected monthly during the agency hosted parent group. Process documented in Program Manual page 31-32 (Phase Three – Implementation) and page 33 (Data and Reporting Plan).
2.6 Stable and Least Restrictive Living Environment
HNH utilizes the WFI-Ez managed through WrapStat to record and evaluate the frequency of and types of placement changes over the course of HFW enrollment. The Case Manager/Facilitator tracks progress towards stable and least restrictive living environments and updates the Plan of Care accordingly with the team at each Family Team Meeting, guided by quarterly IP-CANS. The Program Manager is responsible for the WFI-Ez evaluation cycles. Process documented in Program Manual page 31-32 (Phase Three – Implementation) and page 33 (Data and Reporting Plan).
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
HNH utilizes the WFI-Ez managed through WrapStat to record and evaluate the frequency of hospital visits over the course of HFW enrollment. The Case Manager/Facilitator tracks progress towards fewer or no hospital visits and updates the Plan of Care accordingly with the team at each Family Team Meeting, guided by quarterly IP-CANS. The Program Manager is responsible for the WFI-Ez evaluation cycles. Process documented in Program Manual page 31-32 (Phase Three – Implementation) and page 33 (Data and Reporting Plan).
2.8 Reduction in Crisis Visits
HNH utilizes the WFI-Ez managed through WrapStat to record and evaluate the frequency of crises and level of involvement of professional support when crises occur over the course of HFW enrollment. The Case Manager/Facilitator tracks progress towards averting most crisis situations and manage impending crises without professional support and updates the Plan of Care accordingly with the team at each Family Team Meeting, guided by quarterly IP-CANS. The Program Manager is responsible for the WFI-Ez evaluation cycles. Process documented in Program Manual page 31-32 (Phase Three – Implementation) and page 33 (Data and Reporting Plan).
2.9 Positive Exit from HFW
HNH utilizes the WFI-Ez managed through WrapStat to record and evaluate the when and why families exit HFW. The Case Manager/Facilitator guides the family through exploring transition readiness and updates the Plan of Care accordingly with the team at each Family Team Meeting, guided by quarterly IP-CANS. The Program Manager is responsible for the WFI-Ez evaluation cycles. Process documented in Program Manual page 31-32 (Phase Three – Implementation) and page 33 (Data and Reporting Plan), pages 43-44 (Phase Four – Transition).
Engagement
3.1 Orientation
The Program Manager initiates the orientation conversation during Phase 1 and reviews the Program Overview documented in the Program Manual pages 1-17 (Program Overview). The Case Manager/Facilitator deepens family understanding of HFW throughout HFW enrollment.
3.2 Safety and Crisis stabilization
The Case Manager/Facilitator guides the family through developing and initial Family Safety Plan (crisis plan) in Phase 1. Process documented in the Program Manual page 18 (Phase One – Engagement) and in the Family Crisis and Safety Plan Template.
The Family Safety Plan (crisis plan) is kept updated in the family’s plan of Care through Phase 2 and into Phase 3. Process documented in Program Manual pages 27-29 (Phase Two – Plan Development) and pages 31-32 (Phase Three – Implementation).
The Program Manager with the support of the Case Manager/Facilitator ensures all Wraparound families are informed and able to access the agency 24/7 on call crisis response and provided with local community crisis response numbers as a backup. Process documented in Program Manual pages 16-17 (Program Overview) and in the Family Crisis and Safety Plan Template.
3.3 Strengths, Needs, Culture and Vision Discovery
The Case Manager/Facilitator is responsible for guiding the family through developing a Family Vision statement during Phase 1. Process documented in Program Manual page 18 (Phase One – Engagement) and in the Family Profile Templates pages 1-4 (Initial Family Team Meeting agenda).
The Case Manager/Facilitator is responsible for guiding the family through an initial Strengths/Needs/Culture discovery and is responsible for keeping the discovery updated in the Plan of Care as needed, at minimum every 90 days. Plans of Care are available and provided to all team members as they are added to the team and again every 90 days. Process documented in Program Manual page 27 (Phase Two – Plan Development) and Page 31 (Phase Three – Implementation).
3.4 Engage All Team Members
The Case Manager/Facilitator guides the family through the completion of an initial Natural Supports inventory in Phase 1. Process documented in Program Manual page 18 and Family Profile Templates page 6 (Natural Supports Inventory).
3.5 Arrange Meeting Logistics
The Case Manager/Facilitator is responsible for arranging meeting logistics. Process is documented in Program Manual page 27 (Phase Two – Plan Development) and page 30 (Phase Three – Implementation).
HNH Staff follow the agency specific training plan that utilizes the UC Davis Wraparound training modules and skills labs. Process is documented in the Program Manual page 51-54 (Training Plan).
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
The Case Manager/Facilitator leads the Child and Family team through the development of team agreements, team strengths inventory, and mission statement in the development of the Family Profile in Phase 1 and into Phase 2. Process documented in Program Manual page 2 (Program Overview), pages 18-19 (Phase One), and page 27 (Phase Two).
All documents including the strengths inventory is guided by the IP-CANS and kept updated as additional strengths are identified and again every 90 days. Process documented in Program Manual pages 27-32 (Phase Two through Phase Three)
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
The Program Manager conducts the initial IP-CANS assessment during Phase 1.
The Case Manager/Facilitator guides the Child and Family team in developing measurable goals and outcomes from identified needs. These steps are utilized to develop the individualized HFW Plan of Care after the initial full Child and Family Team Meeting. Process documented in Program Manual pages 27-29 (Phase Two).
The HNH Plan of Care template allows for easy documentation of identified & brainstormed strategies and additional documentation is recorded in weekly team meeting notes and progress notes from HNH staff. Process is documented in the Program Manual pages 27-28 (Phase Two – Plan Development) and pages 30-32 (Phase 3 – Implementation).
Case Managers/Facilitators receive continual training in the development of Plans of Care to guide strategy and action item development. Process documented in Program Manual pages 51-54 (Training Plan).
4.3 Develop an Individualized Child or Youth and Family Plan
Case Managers/Facilitators follow the agency specific training plan and engage in weekly supervision to ensure the development of specific and individualized Care Plans. Process documented in Program Manual pages 51-54 (Training Plan).
The Case Manager/Facilitator guides the development and updating of the Plan of Care. The entire CFT team contributes to the Plan of Care and the living document is distributed to all team members. Process is documented in Program Manual pages 30-32 (Phase Three – Implementation).
The Program Manager reviews all care plans on a regular basis to ensure fidelity. Process documented in Program Manual page 35 (Fidelity Monitoring Plan).
4.4 Develop a Crisis and Safety Plan
The Case Manager/Facilitator leads the Child and Family team in the development of the crisis and safety plan which is kept updated in the youth and family file. The Program Manager reviews all Family Safety Plan Process is documented in the Program Manual page 18 (Phase One – Engagement), page 27 (Phase Two – Plan Development) and in the Family Crisis and Safety Plan Template.
Implementation
5.1 Implement The Plan of Care
The Case Manager/Facilitator leads the team in monthly team meetings. All HNH staff meet weekly to collaborate and track action items and strategy progress. Process documented in Program Manual pages 3-4 (Program Overview) and pages 30-32 (Phase Three: Implementation)
All HNH staff follow the agency specific training plan utilizing UC Davis Wraparound training modules and skills labs. Process documented in Program Manual pages 51-54 (Training Plan)
5.2 Review and Update The Plan of Care
The Case Manager/Facilitator leads monthly review of the Plan of care progress and development as a standing agenda item. Plan adjustments are communicated to the entire team and kept on file. The Program Manager reviews all Plans of Care for accuracy and continuous quality improvement at least every 90 days. Process documented in Program Manual pages 27-32 (Phase 2 – Phase 3)
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
The Case Manager/Facilitator is responsible for and supported in developing team cohesion and trust. Support is provided in weekly supervision, coaching, and continual training. Process documented in Program Manual pages 27-32 (Phase 2 – Phase 3), pages 35-36 (Fidelity Monitoring Plan), and pages 52-53 (Training Plan)
Transition
6.1 Develop a Transition Plan
The Case Manager/Facilitator leads the team in the identifying readiness for transition, the development of a formal transition plan, and a warm handoff to post adoption services when applicable. Process documented in Program Manual pages 43-44 and the Transition Plan template Pages 1 – 5
6.2 Develop a Post-Transition Safety Plan
The Case Manager/Facilitator updates the Family Crisis and Safety Plan throughout the Transition phase in preparation for the end of formal HFW services. Plans are developed by the CFT and reviewed by the Program Manager. Process documented in Program Manual page 4 (Program Overview) and page 43 (Phase 4: Transition).
6.3 Create a Commencement and Celebrate Success
The Case Manager/Facilitator is responsible for planning and coordinating a celebration of commencement of HFW services that is specific and culturally relevant. Process is documented in Program Manual page 44 (Phase 4: Transition)
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
Families are central to the planning process. Their perspectives, preferences, and values drive decision-making. Family and youth /child perspectives are intentionally included throughout the wraparound process and the team strives to provide service options and choices that reflect the family values and preferences. Process is documented in the Program Manual page 5 (Program Overview) and pages 27-28 (Phase 2: Plan Development).
The Program Manager is responsible for eliciting family feedback through the WFI-EZ and quality assurance calls to be used in continuous quality improvement and workforce development. The Case Manager/Facilitator engages in weekly conversation at a minimum with the family to ensure ample opportunity to inform service planning and implementation. Process documented in Program Manual pages 9-10 (Program Overview) pages 33-34 (Continuous Quality Improvement – Data and Reporting Plan).
7.2 Community Leadership Team
N/A
7.3 Eligibility and Equal Access
The Program Manager is responsible for determining eligibility during the engagement phase. All eligible youth are able to receive services. Process documented in Program Manual pages 23-24 (Referral and Engagement)
The HNH HFW staffing plan enforces case load limits to balance assignments in a way that supports families with complex needs. Process documented in Program Manual pages 45-50 (Staffing Plan).
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
With the support of the Operations Director and Executive Director, the Program Manager is responsible for fiscal management within the Wraparound program. Funding at all levels is allocated for the successful delivery of HFW services. Fiscal management documented in the Program Manual pages 37-38 (Support Service Costs) and Page 39 (AAP Fiscal Management Policy and Procedure).
8.2 Equitable Funding Across System Partners
N/A
8.3 Cost Savings are Reinvested
N/A
8.4 Availability, Access, and Approval of Flex Funds
N/A
8.5 Collaborative Oversight of Flex Funds
N/A
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
N/A
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
The Program Manager is responsible for monitoring demographic information and population needs. Cultural, racial, and linguistic gaps in staffing are monitored and remedied by the Program Manager. Process is documented in the Program Manual page 45 (Workforce Development – Staffing Plan)
9.2 Tribally Responsive Workforce
The Program Manager with support of the Operations Director is responsible for building relationship with local tribal representatives to ensure staff are culturally respectful, responsive, and ready to serve Native children. Process documented in Program Manual page 45 (Workforce Development – Staffing Plan).
9.3 Flexible and Creative Work Environment
Led by the Operations Director, the Program Manager is responsible for facilitating a flexible and creative work environment for all HFW staff. Process documented in Program Manual pages 45-47 (Workforce Development – Staffing Plan).
9.4 Hiring, Performance Evaluation, and Job Descriptions
Led by the Executive and Operations Director and supported by the Humboldt NeuroHealth HR department, the Program Manager is responsible for the hiring and evaluation of HFW staff and maintenance of the job descriptions in adherence to the HFW model. Process described in the Program Manual pages 45-46 (Workforce Development – Staffing Plan).
9.5 Workforce Stability
The Humboldt NeuroHealth HR department works to ensure workforce stability across the agency, including the HFW program. Process documented in Program Manual page 46 (Workforce Development – Staffing Plan).
9.6 High Fidelity Training Plan
The Program Manager is responsible for tracking adherence to the Humboldt NeuroHealth HFW Training Plan. Process is documented in Program Manual page 51 (Training Plan).
9.7 Community-based Training Program
The Program Manager is responsible for tracking adherence to the HFW Training Plan. With the support of the Operations Director, the Program Manager is also responsible for identifying and facilitating community participation and collaboration to ensure lived experience is meaningfully incorporated into the HNH Wraparound training plan. Active engagement with community partners across Children’s Systems of Care strengthen community supports and strengthen partner participation in HFW teams. Process documented in Program Manual page 47 (Workforce Development – Staffing Plan) and pages 51-54 (Training Plan).
9.8 Coaching and Supervision
The Program Manager is responsible for adherence to the Training plan and ensuring all staff have open access to coaching and supervision as needed. Process documented in Program Manual page 51 (Training Plan) and pages 35-36 (Fidelity Monitoring Plan).
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
N/A
10.2 Evaluation Metrics & Outcomes
The Program Manager is responsible for evaluating metrics and outcomes and integrating it into continual program improvement. Process is documented in Program Manual page 33-34
Fidelity Indicators
1.1 Timely Engagement and Planning
Five Acres Wraparound staff engages families early and often, including Tribes in the case of an Indian child. First contact with families is made as soon as possible, but no later than 10 calendar days after referral; teams complete a HFW Plan of Care within 30 calendar days; teams review the plan within the context of a HFW team meeting at least every 30-45 calendar days; teams update the Plan of Care and distribute to all team members at least every 90 days and more often as needed.
(a) First contact with families is made as soon as possible, but no later than 10 calendar days after referral. Please see 1.1abcd Wrap Screening, Assessment, and Service Delivery
(b) Teams complete a Wraparound Plan of Care within 30 calendar days from start of services. Please see 1.1abcd Wrap Screening, Assessment, and Service Delivery
(c) Teams review the plan within the context of a HFW team meeting at least every 30-45 calendar days. Please see 1.1abcd Wrap Screening, Assessment, and Service Delivery
(d) Teams update the plan of care, distribute to all team members, and document the updated plan in the child or youth’s file at least every 90 days and more often as needed. Please see 1.1abcd Wrap Screening, Assessment, and Service Delivery
(e) Staff and their supervisors are provided with feedback on their ability to meet timelines for CQI purposes. Please see 1.1e Oversight and Audit Process and 1.1e Clinical Audit Tool.
(f) Staff are trained to timely engagement strategies that include encouraging alternate strategies when contact with the family is difficult. Please see 1.1f Wraparound Trainings
1.2 Led by Youth and Families
The Five Acres Wraparound team prioritizes the youth and family’s perspectives and voices in developing and modifying the mix of strategies and supports to ensure the best fit with their preferences. The youth and family’s values, culture, expertise, capabilities, interests, and skills are elicited, fully understood, and celebrated. They are viewed as critical to a successful process and are the basis for decision making and problem-solving. In the case of an Indian child, the HFW team prioritizes the perspectives and voices of the youth, family and Tribe. Tribes, in the case of an Indian child, must be an equal voice on the HFW team.
(a) Elicitation and use of families’ perspectives, including Tribes in the case of an Indian child (including development and documentation of the Family Vision and Team Mission statements). Please see 1.2ab Service Philosophy.
(b) Family values, culture, expertise, capabilities, interests and skills are elicited and clearly documented in the youth’s case file. Please see 1.2ab Service Philosophy.
(c) Supervisors/Coaches routinely observe HFW team meetings and review documentation to gather and provide feedback to staff to reinforce practice expectations, build skills, and increase confidence. Please see 1.2c Team Consultation Meeting and Supervision and 1.2c Clinical Supervision Form template.
(d) Feedback from families is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) to share their experience of the Wraparound process. Please see 1.2d Feedback Process.
1.3 Strength-Based
Functional strengths of the youth, the family, all team members, and the family’s community are collectively reviewed and utilized throughout the HFW process. Identified strengths are functional in nature and drive decision making and service planning. Five Acres Wraparound team members remain focused on solutions, rather than dwelling on negative events. The Integrated Practice-Child and Adolescents Needs and Strengths (IP-CANS) is critical and required for strengths identification.
(a) A strengths inventory is developed and updated for every member of the team, includes other resources in the family’s local community, and is posted at HFW team meetings. 1.3ab Strength Based Approach and 1.3ab CFT Planning Matrix.
(b) The identification of individualized strengths must include, but not be limited to, the strengths identified in the IP-CANS. Please see 1.3ab Strength Based Approach and 1.3ab CFT Planning Matrix.
(c) Staff receive ongoing coaching and training in providing strengths-based, solution-focused services. Please see 1.3c Strength Based Solution Focused Training and Supervision.
(d) Feedback from families regarding their experience of strengths-based services is routinely elicited and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes. Please see 1.3d Feedback Process.
1.4 Needs Driven
Five Acres Wraparound services and supports are focused on addressing the high priority underlying needs of the youth, as well as their family members.
(a) Underlying needs are identified and prioritized before goals and strategies are established for the youth and family. Please see 1.4a Needs Driven Approach.
(b) Staff receive ongoing training and coaching in identifying needs, developing needs statements that are reflective of the underlying reasons why problematic situations or behaviors are occurring, and utilizing needs-focused planning over problematic behavior-focused planning. Please see 1.4b Underlying Needs Training and Supervision.
(c) The identification of individualized needs must include, but not be limited to, the needs identified in the IP-CANS. Please see 1.4c Use of CANS.
(d) Transition is planned according to team and family agreement that needs are sufficiently met. Please see 1.4d Transition Planning.
1.5 Individualized
Five Acres Wraparound is committed to finding creative, highly individualized strategies that are customized to match each youth and family’s needs, strengths, values, culture, preferences and reduce harm over time. The Five Acres HFW plan is uniquely tailored to fit the family and capitalize on the assets of their community and informal networks and in the case of an Indian child, the Tribe.
(a) Forms/documentation allow for sufficient flexibility in creating individualized plans for each child/youth and family. Please see 1.5a Individualized Care and 1.5a Safety Plan Form.
(b) Staff receive ongoing training and coaching in providing flexible, creative, and highly individualized services and strategies. Please see 1.5b Individualized Care-Training and Coaching.
(c) Facilitators receive ongoing training and coaching in leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences. Please see 1.5c Facilitator Training and Supervision.
(d) HFW plans of care are routinely reviewed and assessed for use of individualized strengths, needs, outcomes, and strategies and for the presence of strategies that capitalize on the assets of the family’s community and informal networks. Please see 1.5d HFW Plan of Care.
(e) Family feedback regarding their experience of receiving customized services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes. Please see 1.5e Feedback Process.
1.6 Use of Natural and Community Based Supports
Five Acres Wraparound recognizes natural supports as integral team members. Five Acres HFW teams are strengthened by the contributions of natural supports. Five Acres HFW teams prioritize strategies in the HFW Plan of Care that utilize natural supports, and that take place in the family’s community, to reduce reliance on formal supports while fostering sustainability within the youth and family’s community.
(a) A natural and community supports inventory is developed and updated for every family. Please see 1.6a Natural and Community Based Supports.
(b) Staff receive ongoing training and coaching identification, engagement, and integration of natural supports in the HFW process and in decreasing reliance on formal supports. Please see 1.6b Use of Natural and Community Based Support- Training and Supervision.
(c) HFW plans of care are routinely reviewed and assessed for the inclusion of natural supports in the plan and for use of community and natural supports in the assigning of strategies and action items. Please see 1.6c Plan of Care- Natural and Community Based Supports.
(d) Family feedback regarding their experience of having natural supports engaged on their team is routinely elicited and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes. Please see 1.6d Feedback Process.
1.7 Culturally Respectful and Relevant
Five Acres Wraparound team recognize that a family’s traditions, values, and heritage are sources of great strength. Five Acres Wraparound team use strategies that are relevant to and respectful of the youth and family’s culture, including Tribes in the case of an Indian child. Five Acres Wraparound team work to connect families with individuals and organizations that provide culturally relevant support after the family transitions from formal HFW services.
(a) A strengths, needs, culture discovery is completed before the HFW plan of care is developed and is clearly documented in the child or youth’s case file. Please see 1.7a Culturally Respectful and Relevant Approach.
(b) Staff receive ongoing coaching and training in the elicitation and use of family and culture in planning and service delivery and in providing culturally respectful and relevant strategies. Please see 1.7b Culturally Respectful and Relevant Service Delivery – Training and Supervision.
(c) Feedback from families regarding their experience of culturally relevant and respectful services and strategies is routinely elicited and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes. Please see 1.7c Feedback Process.
1.8 High-Quality Team Planning and Problem Solving
Five Acres Wraparound team is comprised of formal and natural supports across all Children’s System of Care partners who work together to develop, implement, and monitor the individualized Plan of Care that meet the unique needs of the youth and family. All Five Acres Wraparound team members take ownership over their assigned tasks and collaborate to meet the youth and family’s needs. Teams experience optimism, commitment, and energization.
(a) Team agreements are created for each HFW team and documented in the youth’s file. Please see 1.8a Team Engagement and Agreement, 1.8a Family Engagement Planning Sheet, and 1.8a Staff Engagement Worksheet.
(b) Feedback from families and HFW team members regarding their experience of team engagement and collaboration is routinely elicited. Please see 1.8b Feedback Process.
(c) Feedback is used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes. Please see 1.8c CQI Process.
(d) HFW plans of care and meeting minutes are routinely reviewed and assessed for the shared ownership and follow through on strategies and action items. Please see 1.8d HFW Plan of Care Review Process.
1.9 Outcomes Based Process
The Five Acres Wraparound team monitors the success of the HFW Plan of Care—including progress toward meeting needs, strategy implementation, and task completion. These are measured objectively, reviewed routinely, and used to inform changes to the Plan as needed. Needs statements are linked to measurable outcomes and data from standardized instruments including the IP-CANS and are integrated into the planning process.
(a) The HFW plan of care includes specific, measurable strategies and action items with timeframes. Please see 1.9abc Outcome Based Process.
(b) Action item completion is tracked by facilitators and updated at HFW team meetings, or more often as needed. Please see 1.9abc Outcome Based Process.
(c) Forms and processes allow strategies and action items to be adjusted or changed as needed. These changes are communicated to all team members. Please see 1.9abc Outcome Based Process.
(d) There is a process in place for who will complete the IP-CANS and how the IP-CANS will be shared amongst all team members. Please see 1.9d CANS Administration, 1.9d Clinical Assistant Procedure, and 1.9d Clinical Assistant Procedure workflow.
(e) Data from the IP-CANS is used to support tracking and team decision-making, but does not replace using tracking of needs, goal completion, and action item completion to plan for transition. Please see 1.9e CANS Data.
1.10 Persistence
The Five Acres Wraparound team views setbacks and challenges not as evidence of a youth, or parent failure, but as an indicator of a need to revise the Plan. The Five Acres Wraparound team is committed to implementing a Plan that reflects the HFW Principles, even in the face of limited system capacity.
(a) Teams are supported to keep working with a youth and family even when faced with setbacks or limited progress until the HFW team (with preference given to family voice and choice) agrees that services should end. Please see 1.10a Persistence.
(b) There are clear processes for teams to access help when facing challenges including how to request additional coaching or supervision, how to access/request flexible funding, and how to access additional support. Please see 1.10b Accessing Additional Support and Flex Funds.
(c) Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision. Please see 1.10c Facilitator Trainings and Supervision.
1.11 Transitions as a part of the Fourth Phase of HFW
Transitions are planned for in advance and celebrated with full youth and family participation. Transitions only happen when the youth and family have had their needs met, not due to an adverse event or an administrative requirement.
(a) HFW teams are able to provide adequate transitions and families do not experience sudden loss of services due to adverse events or due to administrative requirements. Please see 1.11ab Transition Planning.
(b) Transitions out HFW are celebrated according to the youth and family’s culture, values, and preferences and administrative structures are supportive of engaging in celebration including access to flex funds, accommodating staff time for community resourcing, developing community partnerships, and ensuring staff are available to attend celebrations. Please see 1.11ab Transition Planning.
Expected Outcomes
2.1 Youth and Family Satisfaction
Five Acres has policies and procedures in place to evaluate youth and family satisfaction. Please see 2.1 Youth and Family Satisfaction, 2.1 Five Acres Client Satisfaction Survey, and 2.1 Five Acres Caregiver Satisfaction Survey
2.2 Improved School Functioning
Five Acres Wraparound Team has policies and procedures in place to record and evaluate school attendance and performance. Please see 2.2-2.8 Expected Outcomes, 2.2-2.8 Outpatient SIR Procedure, 2.2-2.8 SDOH Screening Tool, and 2.2-2.8 Special Incident Report (SIR) form.
2.3 Improved Functioning in the Community
Five Acres Wraparound Team has policies and procedures in place to record and evaluate school attendance and performance. Please see 2.2-2.8 Expected Outcomes, 2.2-2.8 Outpatient SIR Procedure, 2.2-2.8 SDOH Screening Tool, and 2.2-2.8 Special Incident Report (SIR) form.
2.4 Improved Interpersonal Functioning
Five Acres Wraparound Team has policies and procedures in place to record and evaluate school attendance and performance. Please see 2.2-2.8 Expected Outcomes, 2.2-2.8 Outpatient SIR Procedure, 2.2-2.8 SDOH Screening Tool, and 2.2-2.8 Special Incident Report (SIR) form.
2.5 Increased Caregiver Confidence
Five Acres Wraparound Team has policies and procedures in place to record and evaluate school attendance and performance. Please see 2.2-2.8 Expected Outcomes, 2.2-2.8 Outpatient SIR Procedure, 2.2-2.8 SDOH Screening Tool, and 2.2-2.8 Special Incident Report (SIR) form.
2.6 Stable and Least Restrictive Living Environment
Five Acres Wraparound Team has policies and procedures in place to record and evaluate school attendance and performance. Please see 2.2-2.8 Expected Outcomes, 2.2-2.8 Outpatient SIR Procedure, 2.2-2.8 SDOH Screening Tool, and 2.2-2.8 Special Incident Report (SIR) form.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Five Acres Wraparound Team has policies and procedures in place to record and evaluate school attendance and performance. Please see 2.2-2.8 Expected Outcomes, 2.2-2.8 Outpatient SIR Procedure, 2.2-2.8 SDOH Screening Tool, and 2.2-2.8 Special Incident Report (SIR) form.
2.8 Reduction in Crisis Visits
Five Acres Wraparound Team has policies and procedures in place to record and evaluate school attendance and performance. Please see 2.2-2.8 Expected Outcomes, 2.2-2.8 Outpatient SIR Procedure, 2.2-2.8 SDOH Screening Tool, and 2.2-2.8 Special Incident Report (SIR) form.
2.9 Positive Exit from HFW
Five Acres Wraparound Team has policies and procedures in place to record and evaluate school attendance and performance. Please see 2.9 Discharge Information.
Engagement
3.1 Orientation
Five Acres Wraparound team orients youth and families to the HFW process, including explaining the HFW principles and phases, addressing legal and ethical considerations, and explaining the role of each member on the team including the family’s role and the role of natural supports. Please see documents 3.1 Child and Family Team Meeting Agenda, 3.1 Child and Family Team Planning Matrix, 3.1 Debrief Meeting, 3.1 Family Engagement Planning Sheet, and 3.1 Staff Engagement Worksheet.
(a) The HFW process is fully explained to every family including an overview of the principles and phases, legal and ethical considerations, and the role of each team member including the family, natural supports, and Tribes in the case of an Indian child. Please see 3.1 (a) Orientation
(b) An overview of the HFW principles and phases can be found in 3.1 (b)
(c) An overview of legal and ethical considerations can be found is 3.1 (c)
(d) The role of each team member including the family and natural supports and Tribes in the case of an Indian child can be found in 3.1 (d)
3.2 Safety and Crisis stabilization
Five Acres Wraparound team addresses pressing needs and concerns so that the family and team can focus on the HFW process. If immediate response is necessary, the HFW team formulates a plan for immediate intervention and stabilization, including development of a written crisis plan and ensures access to 24/7 crisis response when needed. Please see 3.2 Safety and Crisis Stabilization and 3.2 Safety Plan Form Example.
(a) Initial crisis and safety concerns are discussed during engagement. If pressing concerns are brought forward, the Five Acres Wraparound team develops an immediate crisis response plan which is provided to the family and is documented in the chart. Please see 3.2 (a) Safety and Crisis Stabilization.
(b) The crisis plan is used to inform, but not replace, the HFW Safety Plan developed during the Plan Development phase. Please see 3.2 (b) Safety and Crisis Stabilization.
(c) All families are provided with information regarding how to access 24/7 crisis response when needed. 3.2 (c) Safety and Crisis Stabilization.
3.3 Strengths, Needs, Culture and Vision Discovery
The Five Acres Wraparound team facilitates conversations and activities with the youth and family to identify individual and family strengths, needs, culture, and their vision for a better future. The facilitator prepares a written summary document to clearly communicate strengths, needs, culture and vision to all team members, to orient new team members as they are added to the process, and to support the initial plan development process. Please see 3.3 Strengths, Needs, Culture and Vision Discovery, 3.3 CFT Planning Matrix, 3.3 (a) Family Engagement Planning Sheet.
(a) A Family Vision is completed with every family and documented in the youth’s chart during the Engagement phase. Please see 3.3. (a)
(b) A Strengths, Needs, Culture Discovery document is initiated with every youth, and family, is included in the youth’s chart, is updated at least every 90 days, and the team adds new strengths, needs, and cultural preferences as they are discovered. The document is provided to new team members as they are identified. Please see 3.3 (b).
3.4 Engage All Team Members
The Five Acres Wraparound team engages the participation of team members across all Children’s System of Care partners (including formal, natural supports, and Tribes, in the case of an Indian child), who care about and can aid the youth and family. The Five Acres HFW team encourages and facilitates their active participation by clarifying their roles and responsibilities on the team. The facilitator intentionally engages the team in activities to ensure a positive and collaborative team culture. Please see 3.4 (a) Family Engagement Planning Sheet and 3.4 (b) Staff Engagement Worksheet.
(a) A natural supports inventory is completed with all youth and families and is documented in the child or youth’s case file. Please see 3.4 (a).
(b) Children’s System of Care partners who should be included on the HFW team are identified and engaged. Please see 3.4 (b).
(c) The Five Acres HFW team works with the youth and family to identify potential team members (including formal, natural supports and Tribes, in the case of an Indian child) and discusses their role on the team. Please see 3.4 (c).
(d) Engagement and team building activities are documented in the youth’s file. Please see 3.4 (d).
3.5 Arrange Meeting Logistics
The Five Acres Wraparound team ensures that meetings take place at a time and in a location that is convenient and accessible to all team members with priority given to family needs and family voice and choice, taking into consideration family schedules, culture, and history of trauma, and ensuring equitable access for all youth and families. The Five Acres HFW team plans for and arranges meeting logistics such as transportation, interpretation, telehealth capability, etc. Please see 3.5 Arrange Meeting Logistics.
(a) Staff are flexible in working hours and scheduling meeting times and locations to accommodate family and Wraparound Team needs. Please see 3.5 (a).
(b) Staff are trained to work collaboratively with families and the other members of the HFW team to schedule meetings that are in alignment with family needs and preferences as well as maximize participation. Please see 3.5 (b).
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
Building upon the activities completed during engagement, the Five Acres facilitator leads the team in developing formal agreements on how the team will engage during meetings and make decisions, identifying and documenting additional strengths of the youth and family, other team members, and the community, and
creating a team mission statement that defines the overall purpose of the HFW team in alignment with the family vision.
(a) Before the HFW plan of care is developed, team agreements, a team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file. Please see 4.1 (a).
(b) The youth’s and family members’ strengths identified in engagement are updated to reflect any additionally discovered strengths as they are identified and are documented in the youth’s file. Please see 4.1 (b).
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
The Five Acres facilitator guides the team in reviewing needs identified during engagement, adding any additional needs, and prioritizing them. The Five Acres HFW team uses the prioritized needs to develop specific, measurable goals and outcomes. The Five Acres facilitator engages the team in brainstorming multiple creative strategies to meet the prioritized needs, goals, and outcomes before selecting strategies and assigning responsibility in the form of action items.
(a) Before the HFW plan of care is developed, underlying needs are identified and prioritized for each family and are documented in the youth’s file. Please see 4.2 (a).
(b) Measurable goals and outcomes are developed from these identified needs. Please see 4.2 (b).
(c) These goals and outcomes are developed collaboratively with the youth, family, and the rest of the HFW team. Please see 4.2 (c).
(d) Multiple individualized brainstormed strategies are documented in the youth’s file (e.g., in the HFW Plan of Care, in a form, in meeting minutes, or in progress notes) that can be referred to as needed. Please see 4.2 (d).
(e) Facilitators are trained to lead teams in identifying, prioritizing, and selecting strategies and developing action items. Please see 4.2 (e).
(f) These steps are utilized to develop the individualized HFW Plan of Care in a team-based, collaborative environment. Please see 4.2 (f).
4.3 Develop an Individualized Child or Youth and Family Plan
The Five Acres Wraparound team develops a comprehensive initial Plan of Care that is based on the prioritized needs, goals, and strategies of the family and youth. This is accomplished via a high‐quality team process across all Children’s System of Care partners, including the Tribe in the case of an Indian child, that elicits multiple perspectives, builds trust and shared vision amongst team members, and demonstrates the HFW principles.
(a) Facilitators receive ongoing training and coaching to engage the team in a planning process that elicits multiple perspectives, builds trust and shared vision, and demonstrates the HFW principles. Please see 4.3 (a).
(b) The Plan of Care comprehensively integrates goals and objectives identified by all Children’s System of Care partners. Please see 4.3 (b).
(c) The Plan of Care is documented in the child/youth’s file, is distributed to all team members, and meets all the criteria defined in items 1-6. Please see 4.3 (c).
(d) Procedures are in place to review Plans of Care for continuous quality improvement and to provide feedback to staff and supervisors/coaches for training and coaching purposes. Please see 4.3 (d).
4.4 Develop a Crisis and Safety Plan
The Five Acres facilitator leads the team in developing a crisis and safety plan that identifies and prioritizes safety needs, potential risk and crisis situations, as well as highly individualized proactive and reactive strategies for the youth, family, and team members to respond effectively. Identified strategies should be chosen by the youth and family, should be culturally relevant, and should maximize the use of natural supports wherever possible.
(a) An individualized crisis and safety plan is documented in the youth’s file, which identifies potential safety, high risk and crisis situations with proactive and reactive crisis management strategies chosen by the family members and including who should be called for support 24/7. Please see 4.4 (a).
(b) The development of the plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process. Please see 4.4 (b).
(c) Crisis and safety plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes. Please see 4.4 (c).
Implementation
5.1 Implement The Plan of Care
The Five Acres Wraparound team carries out the initial Plan of Care, monitoring completion of action items and strategies and their success in meeting needs and achieving outcomes in a manner consistent with the HFW principles. Teams celebrate successes as they occur.
(a) The facilitator leads the team to review strategies and action items at HFW team meetings (e.g., use of meeting agendas and meeting minutes that address action item completion and document progress), track individual assignments, check-in to support meeting timelines and deliverables, and adjust strategies and action items as needed. Please see 5.1 (a)
(b) Staff receive training and coaching on implementing the plan of care in alignment with the HFW principles. Training and processes address celebrating successes as they occur. Please see 5.1 (b).
5.2 Review and Update The Plan of Care
The Five Acres facilitator engages the team to continually review the Plan; assess the progress and the effectiveness of strategies; and update the Plan as needed, including changing goals and strategies if the needs of the youth and family change. The Five Acres facilitator documents and communicates, via meeting minutes and other forms of communication, completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the Plan. The Plan of Care is updated in an HFW team meeting and distributed to all team members at least every 90 days, and more frequently, as needed
(a) Reviews of strategies, progress, and action items occurs in a HFW team meeting setting. Please see 5.2 (a).
b) The facilitator leads the team to adjust the plan accordingly as successes occur, as new needs are identified, or as new strategies and action items are selected, and the updated plan is documented in the youth’s file. Please see 5.2 (b).
(c) The facilitator documents and communicates completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the plan. These updates are communicated to all team members, at a minimum, through the use of team meeting minutes. Please see 5.2 (c).
(d) Forms are able to be updated and individualized to meet the youth, family, and team’s changing needs. Please see 5.2 (d).
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
The Five Acres facilitator continually assesses and addresses team cohesion, trust, and commitment to ensure effective collaboration. When appropriate, teams seek and develop potential natural supports and add them to the team. Teams orient and engage new team members as they are added.
(a) Team agreements are utilized, reviewed regularly, and present at HFW team Meetings. Please see 5.3 (a).
(b) Facilitators receive ongoing training and coaching on building, engaging, and maintaining effective teams. Please see 5.3 (b).
(c) Use of natural supports are monitored over time and teams are provided feedback through coaching and supervision. Please see 5.3 (c).
(d) There are processes for orienting new team members (including formal and natural supports) to the team which include explaining the HFW process, reviewing current plans and strategies, and engaging in team building exercises. Please see 5.3 (d).
Transition
6.1 Develop a Transition Plan
When the family has reached pre-determined benchmarks indicating sufficient progress towards completing the team mission and goals, and the youth, family, and team agree the family is ready for transition, the Five Acres Wraparound team will begin developing a formal individualized transition plan. Led by the facilitator, the Five Acres HFW team will outline a purposeful transition process which identifies needs, services, and supports that will persist past formal HFW and includes strategies to transition any remaining support being provided by Five Acres Wraparound staff to those ongoing supports. For adoptive families utilizing Adoption Assistance Program (AAP) funding, families are educated on post adoptive services that can assist with transition.
(a) The facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process. Please see 6.1 (a).
(b) Once this determination has been made, the facilitator leads the team in creating an individualized transition plan that identifies needs, services, and supports, distributes the plan to all team members, and documents the plan in the youth’s file. Please see 6.1 (b).
(c) The development of the individualized transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process. Please see 6.1 (c).
(d) The team verifies that services and supports identified in the transition plan will persist past formal HFW and that the family is able to access them, including post adoption services if applicable. Please see 6.1 (d).
6.2 Develop a Post-Transition Safety Plan
The Five Acres facilitator leads the team in developing a crisis and safety plan (or adjusting the current crisis and safety plan) that identifies potential crisis situations that may occur after transitioning from formal HFW. The crisis and safety plan includes individualized, proactive, and reactive strategies for the youth, family, and other supports who will remain after HFW concludes. The youth and family play a pivotal role in identifying these strategies, which should be culturally relevant, and maximize the use of natural and community supports.
(a) The individualized crisis and safety plan is updated to reflect transition (or a new transition crisis and safety plan is completed) and documented in the youth’s file. The plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies that maximize use of natural support and that are chosen by the family. Please see 6.2 (a).
(b) The development of the crisis and safety transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process. Please see 6.2 (b).
(c) Processes are in place to review crisis and safety plans for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes. Please see 6.2 (c).
6.3 Create a Commencement and Celebrate Success
The Five Acres team ensures that the conclusion of formal HFW is celebrated in a manner that reflects a positive transition, is culturally relevant, and is meaningful to the youth and family.
(a) Transitions out of the Wraparound process are celebrated according to the family’s culture, values, and preferences. Please see 6.3 (a).
(b) Administrative structures are supportive of engaging in celebration (e.g., access to flex funds, time for community resourcing, community partnerships, ensuring staff are available to attend celebrations, etc.). Please see 6.3 (b).
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
Youth and family feedback is utilized to inform all levels of the HFW Program, including service planning and implementation, policy and procedure development, workforce development, and quality improvement of the Wraparound model.
(a) There are mechanisms in place for families to participate in decisions regarding local HFW implementation. Please see 7.1ab Youth and Family as Key Decision-Makers, 7.1a Consent to Participate in Wraparound, 7.1a Wraparound DCFS Intake Packet, Wraparound Policies and Procedures Manual (Pg. 20, 23, 26, 44, 45), and 7.1a Wraparound Warm Line.
(b) Family feedback is used in the decision-making regarding service planning and implementation, policy and procedure development, workforce development and quality improvement. Please see 7.1ab Youth and Family as Key Decision-Makers, 7.1b Satisfaction Survey Training, and 7.1b CANS IP Manual.
7.2 Community Leadership Team
The Five Acres Wraparound Team works collaboratively and engages in shared decision-making to ensure the CA Wraparound Standards are met at the organizational and systems level.
(a) There is an identified representative who actively participates on the Community Leadership Team. Please see 7.2a Community Leadership Team and Wraparound Policies and Procedures Manual (Pg. 23).
7.3 Eligibility and Equal Access
Five Acres HFW eligibility and referral criteria and processes ensure adequate, appropriate, and equitable access to HFW services and do not exclude families because of the severity or nature of their needs. Five Acres HFW is adequately publicized, available, and accessible so that youth and families who would benefit are able to participate. There is adequate program planning to ensure that once enrolled, families have access to an adequate array of services and 24/7 support to meet complex needs.
(a) Youth that meet established eligibility criteria are able to receive services and are not excluded based on the severity or nature of their needs. Please see 7.3ab Eligibility and Equal Access and Wraparound Policies and Procedures Manual (Pg. 6-8, 27, and 46).
(b) Staffing is planned to ensure appropriate case load assignments that support the intensity and frequency of services necessary to meet families’ complex needs and enable staff to provide 24/7 support to families in crisis. Please see 7.3ab Eligibility and Equal Access, 7.3b CBS Division Crisis Response Protocol and Wraparound Policies and Procedures Manual (Pg. 6-8, 27, and 46).
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
Five Acres HFW Program has fiscal practices that are aligned with the values and principles of Wraparound and ensure the CA Wraparound Standards are met. Budgets and contracts at all levels, regardless of county or provider-based service provision allocate funding for essential Wraparound operations which include required staffing, workforce development data collection, and data management systems and the costs of services.
(a) High fidelity direct services and supports to meet the immediate individualized needs of youth and families. Please see 8.1abc SE 1129 SOW Wraparound Pg. 5 and
8.1abc Wraparound FY26 Budget.
(b) Required workforce development and staffing including required roles or functions from Workforce Development standard 9.3. Please see 8.1abc SE 1129 SOW Wraparound (Pg. 5-6) and 8.1abc Wraparound FY26 Budget.
(c) Required data collection and/or data management systems. Please see 8.1abc SE 1129 SOW Wraparound (Pg. 19-20) and 8.1abc Wraparound FY26 Budget.
8.2 Equitable Funding Across System Partners
8.3 Cost Savings are Reinvested
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
Five Acres HFW Program has a process to ensure families have timely access to flexible funds to meet their urgent and individualized needs when these needs are not readily met by other resources. There is a defined approval process that ensures requests for flexible funds are evaluated based on approval/recommendation of the team.
(a) Flexible funds are available and included as a part of the funding plan for HFW. Please see 8.4ab Availability, Access, and Approval of Flex Funds and Wraparound Policies and Procedures Pg.48 and Pg.57.
(b) Processes to access and manage flexible funds are articulated. Please see 8.4ab Availability, Access, and Approval of Flex Funds and Wraparound Policies and Procedures Pg.48 and Pg.57.
8.5 Collaborative Oversight of Flex Funds
There is collaboration and shared oversight amongst funders and providers regarding the use and availability of flexible funds. A process is in place to ensure flexible funds are pooled and held to meet the needs of all families served. Tracking and accounting for flexible funds whether approved or denied includes the amount, purpose, and HFW team recommendation of the request.
(a) Flex fund use and availability is documented and transparently communicated to funders and providers, including information regarding the amount, purpose and HFW team recommendation of the request. Please see 8.5ab Collaborative Oversight of Flex Funds, Wraparound Policies and Procedures Pg. 48 and Pg.57, 8.5a Reasonable and Allowable Purchase Limits, 8.5a CSS Expenditure Coding Guide, and 8.5a Fillable CCS Supplemental Info Request Form.
(b) Flex funds are pooled and held to meet the needs of all families served. Please see 8.5ab Collaborative Oversight of Flex Funds and Wraparound Policies and Procedures Pg. 48.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
The Five Acres HFW Program ensures the requirements of any single funding source shall not limit the availability of flexible funding or the resources developed to meet the needs of the youth, families, Tribes and communities served by HFW.
(a) Flex funds and program resources are funded by braiding of available System of Care funding to ensure their availability. Please see 8.6abc Funding Sources and Program Requirements do not Limit Flex Funds and Wraparound Policies and Procedures Pg. 48 and Pg.57.
(b) When funding limitations exist in a single funding source, alternate funding options are explored or reliance on other funding sources is increased to fill gaps. Please see 8.6abc Funding Sources and Program Requirements do not Limit Flex Funds and Wraparound Policies and Procedures Pg. 48 and Pg.57.
(c) Requirements of any single funding source do not prohibit families from accessing flexible funds to meet their needs. Please see 8.6abc Funding Sources and Program Requirements do not Limit Flex Funds and Wraparound Policies and Procedures Pg. 48 and Pg.57.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
Five Acres hires staff that can appropriately meet the cultural, racial and linguistic needs of youth and families. Staffing reflects the cultural, racial and linguistic diversity of the youth, families and communities served.
(a) The demographic composition of the population served is monitored and processes are in place to recruit/hire staff according to population needs. Please see 9.1abc Culturally Responsive Workforce, Employee Handbook (pg. 22) and Wraparound Policies and Procedures Manual (Pg. 15).
(b) When unable to recruit/hire according to cultural, racial, and linguistic needs, efforts are made to meet families’ needs for cultural representation through alternative means such as engaging natural or formal supports on the HFW team. Please see 9.1abc Culturally Responsive Workforce, Employee Handbook (Pg. 22) and Wraparound Policies and Procedures Manual (Pg. 15).
(c) When unable to provide a staff member who can provide services in the family’s language, a translator or natural support person is utilized. Please see 9.1abc Culturally Responsive Workforce, Employee Handbook (Pg.22) and Wraparound Policies and Procedures Manual (Pg. 15).
9.2 Tribally Responsive Workforce
In the cases of Indian children, Five Acres team shall prioritize respect for tribal sovereignty, traditions, and values and ensure respectful communication, collaboration, and advocacy. The team has the goal of promoting positive outcomes through culturally rooted support systems and services, and the team is responsible for building partnerships with tribal representatives, encouraging participation in tribal traditions and ceremonies and understanding the value of services and supports that the Tribe can offer.
(a) Staff are trained on tribal sovereignty, traditions, and values, as well as how to ensure respectful communication, collaboration, and advocacy. Please see 9.2a Indian Child Welfare Act Training.
(b) When serving an Indian child, HFW teams build partnerships with tribal representatives, encouraging participation in tribal traditions and ceremonies and understanding the value of services and supports that the Tribe can offer. Please see 9.2b Tribal Partnership.
9.3 Flexible and Creative Work Environment
There is a high degree of collective responsibility for program quality and improvement, cohesion among staff members, open communication, and a clear sense of mission and compliance with HFW. Programs and its leaders create structures that promote staff creativity and flexibility.
(a) Program quality and improvement. Please see 9.3abcd Flexible and Creative Work Environment and Employee Handbook (Pg. 8 and Pg. 16).
(b) Cohesion (minimally including creating a positive team environment). Please see 9.3abcd Flexible and Creative Work Environment and Employee Handbook (Pg. 8 and Pg. 16).
(c) Open communication. Please see 9.3abcd Flexible and Creative Work Environment and Employee Handbook (Pg. 8 and Pg. 16).
(d) Creating a clear sense of mission and compliance with HFW philosophy (principles, values, phases and activities). Please see 9.3abcd Flexible and Creative Work Environment and Employee Handbook (Pg. 8 and Pg. 16).
9.4 Hiring, Performance Evaluation, and Job Descriptions
Programs have rigorous hiring practices and use meaningful performance assessments. Job descriptions for all positions reflect best practices regarding Wraparound skills and expertise and have clear expectations for performance. The following are roles or functions on a Five Acres HFW team.
(a) Each of the above roles or functions are met within the HFW program either through a unique position or through combining positions with clearly defined role descriptions and responsibilities. Please see 9.4abc Job Descriptions.
(b) The description and responsibilities of each role minimally includes the role purpose, functions and qualities (including skills, competencies and attributes) specific to each role or function. Examples of role descriptions can be found in the Wraparound Standards Toolkit. Please see 9.4abc Job Descriptions.
(c) Job descriptions for all required positions are specific to HFW and reflect the attitudes, skills, knowledge, and experience most likely to identify individuals who will be successful in the position. Please see 9.4abc Job Descriptions.
(d) The hiring process includes opportunities that allow candidates to demonstrate specific attitudes and skills essential to the position. Please see 9.4d LCM – Sample Job Posting, 9.4d Career Opportunities 5A, 9.4d Recruitment, Selection and Compensation Pg. 3 & Pg.6, and 9.4d Sample Interview Questions- Clinicians and Other Standard Positions.
(e) Employees are provided clear expectations for their performance and receive frequent feedback and coaching to support their success. Please see 9.4e Employee Self-Evaluation, 9.4e Performance Evaluation Part I, 9.4e Performance Evaluation Part 2, and 9.4e Supervision Template, 9.4e Workflow for Online Performance Evaluations.
9.5 Workforce Stability
Five Acres implement strategies to maintain a stable workforce and reduce turnover, including matching wages according to the community the program is in, maintaining manageable workloads for staff, implementing promotion/advancement structures, and providing wage increases or leadership opportunities that do not require a position change to achieve.
(a) Matching wages to cost of living in the location of the organization/service implementation area. Please see 9.5a Compensation Guide and 9.5ad Philosophy-Objectives.
(b) Maintaining manageable workloads for staff. Please see 9.5b Maintaining Manageable Workloads for Staff.
(c) Having clearly communicated and accessible promotion/advancement structures that are not prohibitive for those with lived experience. Please see 9.5cd Stable Workforce and 9.5cd 5A RIA Plan.
(d) Providing wage increases or leadership opportunities that do not require a position change to achieve. Please see 9.5cd Stable Workforce, 9.5cd 5A RIA Plan, 9.5cd Stable Workforce, and 9.5d Promotion Ladder Job Aid.
9.6 High Fidelity Training Plan
Five Acres has a high fidelity training plan that incorporates initial, annual, booster trainings, and ongoing trainings. The training plan includes both general HFW training and role-specific training for all roles, including specific training for all Clinical Supervisors and Wraparound Supervisors/Managers.
(a) All staff receive an initial HFW training using the Statewide Standardized Foundational HFW training through the UC Davis RCFFP. Please see 9.6a High Fidelity Wrap Training.
(b) All staff receive ongoing training both in general Wraparound and in their specific role through formal trainings, meetings, coaching, peer shadowing, and/or supervision. Please see 9.6b Wraparound Initial Trainings.
(c) All staff receive booster trainings at least annually in general Wraparound and in their specific roles. Please see 9.6c Wraparound Annual Trainings.
(d) Clinical Supervisors and HFW Supervisors/Managers attend general Wraparound training as well as receive initial, ongoing, and booster trainings specific to their leadership/supervisory role. Please see 9.6d Wraparound Program Supervisor Trainings.
(e) All staff receive ICWA and Tribal sovereignty training and mechanisms are in place to identify and provide training that supports populations with specific and unique needs as needed. Please see 9.6e Wraparound Trainings for ICWA and Unique Needs.
9.7 Community-based Training Program
Five Acres administer the training plan in collaboration with community members and families with HFW experience as part of the training team. Ensure efforts are inclusive of and promoted to system and community partners to ensure comprehensive support within the Children’s System of Care and that team members from other systems have a context for HFW participation.
(a) Youth, families and peer partners with current or prior Wraparound experience are meaningfully incorporated into the delivery of required Wraparound trainings. Please see 9.7ab Community-Based Training Program and Wraparound Policies and Procedures Manual (Pg.22).
(b) Community partners are invited to attend Wraparound trainings or are offered trainings on Wraparound to strengthen their participation on HFW teams or to strengthen their role in supporting HFW within the System of Care. Please see 9.7ab Community-Based Training Program and Wraparound Policies and Procedures Manual (Pg.22).
9.8 Coaching and Supervision
Programs provide team members with initial apprenticeship and ongoing coaching that emphasizes Wraparound values, principles, phases and activities, as well as the effective use of flex funds to meet family needs. Leaders will ensure that staff have access to coaching and supervision 24/7, reflective of the flexible scheduling and crisis response needs of families and the community.
(a) All staff are provided with an initial apprenticeship that covers values, skills, and knowledge related to HFW principles, phases and activities, and the effective use of flex funds to meet a family’s needs. Please see 9.8ab Coaching and Supervision and Wraparound Policies and Procedures Manual (Pg.20, 27, 46).
(b) Staff have access to supervision or coaching 24/7 as needed. Please see 9.8ab Coaching and Supervision and 9.8b CBS Division- Crisis Response Protocol.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
By integrating data into every facet of its operations, from clinical practice to workforce development, community collaboration, and organizational strategy, Five Acres cultivates a resilient, adaptive, and outcomes-focused service model. This commitment to data-driven excellence ensures that youth and families receive the highest quality care in a compassionate, responsive, and continuously improving environment.
(a) Data is utilized to improve practice with youth and families, including giving staff timely feedback from data or reports relevant to their service provision and using data to identify staff training needs. Please see 10.2abc Evaluation Metrics & Outcomes.
(b) Data is utilized to identify and address program needs to better serve families and improve overall program effectiveness. Please see 10.2abc Evaluation Metrics & Outcomes.
(c) Data is utilized to identify and communicate system barriers to the Community Leadership Team which impacts the HFW implementation. Please see 10.2abc Evaluation Metrics & Outcomes.
Fidelity Indicators
1.1 Timely Engagement and Planning
Penny Lane Centers ensures High-Fidelity Wraparound (HFW) staff engage families early, consistently, and in alignment with required timelines through clearly defined policies, structured phase-based service delivery, supervision oversight, and continuous quality improvement mechanisms. Engagement begins immediately upon referral and reflects a family-driven, culturally responsive approach, including collaboration with Tribes when serving an Indian child.
Timely Engagement (Within 10 Calendar Days of Referral):
Upon receipt of a referral including AAP eligible self-referrals, the assigned Facilitator initiates contact as soon as possible, but no later than 10 calendar days. Engagement efforts are documented and may include in-person outreach, phone contact, electronic communication (with consent), and coordinated care with referring systems. When serving an Indian child, culturally responsive practices include collaboration with Tribal representatives consistent with agency policy.
Plan of Care Completion (Within 30 Calendar Days):
Through Phase One (Engagement and Family Preparation) and Phase Two (Plan Development), the Child and Family Team (CFT) develops a strengths-based, needs-driven Wraparound Plan of Care within 30 calendar days from the start of services. The Plan reflects family voice and choice, measurable outcomes, crisis/safety planning, and coordinated service strategies.
Ongoing Plan Review (Every 30–45 Days):
The Plan of Care is reviewed within the context of a formal Child and Family Team meeting at least every 30 calendar days. During these reviews, the team evaluates progress, addresses barriers, and refines strategies using structured outcome tools such as CANS, TOM, and LOCUS when applicable.
Formal Plan Updates (At Least Every 90 Days):
The Plan of Care is updated at minimum every 90 calendar days, or more frequently as clinically indicated. Updated plans are distributed to all team members and documented in the youth’s clinical record to ensure coordinated implementation and accountability.
Supervision & CQI Oversight:
Supervisors and QA/QI leadership monitor compliance with engagement and documentation timelines through structured supervision, internal HFW case reviews, performance improvement processes, and outcome monitoring systems. Staff receive feedback regarding timeliness and adherence to HFW standards, and trends are incorporated into agency-wide continuous quality improvement efforts.
Training & Engagement Strategies:
All staff receive HFW aligned training on timely engagement strategies, culturally responsive practice, and alternative outreach approaches when families are difficult to reach. This includes flexible scheduling, field-based engagement, collateral collaboration, and coordinated system outreach to prevent delays in service initiation and plan development.
Collectively, these procedures ensure compliance with HFW standards while reinforcing Penny Lane’s commitment to family-centered, culturally responsive, and outcome-driven service delivery.
Policy & Appendix References:
Engagement & Intake
401 Referral and Intake Process
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
210 Language Access & Cultural and Linguistic Responsiveness
Plan Development & Review
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery
Plan Updates & Documentation
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment
Supervision & CQI
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI
Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#1 Welcome to Penny Lane’s HFW
#2 Wraparound Family Guide
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#22 Safety and Crisis Plan
#26 Wraparound Fidelity Index
#34 Supervisor Review Tool (SPRT)
#43 CANS
#36 TOM
#44 Penny Lane Internal Referral Request HFW
1.2 Led by Youth and Families
Penny Lane Centers operationalizes Principle 1: Family Voice and Choice as a foundational expectation of High-Fidelity Wraparound (HFW) practice. The youth and family are recognized as the primary drivers of the Wraparound process, and their perspectives, culture, strengths, and lived expertise shape all planning, decision-making, and problem-solving. In the case of an Indian child, Tribal representatives are engaged as equal and essential members of the Child and Family Team (CFT), ensuring culturally grounded and legally compliant partnership.
From initial engagement through transition, staff intentionally elicit and elevate the youth and family’s values, vision, preferences, and goals. The Family Vision Statement and Team Mission Statement are developed collaboratively during Phase One and Phase Two and formally documented within the Plan of Care. These statements guide the development of strategies and supports and serve as the anchor for all team decisions.
Strengths including cultural identity, community connections, capabilities, interests, traditions, and natural supports, are comprehensively assessed and clearly documented in the clinical record. This strengths-based foundation informs the selection of interventions, service mix, crisis planning, and natural support integration.
For Indian children, Penny Lane ensures Tribal voice is prioritized and treated as equal within the team structure. Tribal participation is incorporated into coordinated care and CFT processes, and cultural identity and Tribal values are integrated into planning and service delivery consistent with agency policy and HFW standards.
Supervisory oversight reinforces fidelity to Family Voice and Choice. Supervisors and Wraparound Coaches routinely review documentation, observe team meetings when appropriate, and utilize structured fidelity tools to ensure youth and family voice is authentically represented. Feedback is provided through supervision, internal case reviews, and performance improvement processes to strengthen staff competency and confidence.
Additionally, Penny Lane systematically gathers direct feedback from families regarding their Wraparound experience. Tools such as the Wraparound Fidelity Index (WFI), Team Observation Measure (TOM 2.0), satisfaction surveys, and quality assurance follow-up calls are utilized to capture the family’s perception of voice, partnership, and empowerment within the process. This feedback is reviewed as part of the agency’s Continuous Quality Improvement (CQI) structure and informs practice enhancement efforts.
Through structured engagement, documented vision and strengths integration, supervisory oversight, fidelity monitoring, and routine family feedback, Penny Lane ensures Family Voice and Choice is not aspirational but embedded in daily HFW practice.
Policy & Appendix References:
Engagement & Family Voice
401 Referral and Intake Process
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
409 Child and Family Team (CFT) Meetings
210 Language Access & Cultural and Linguistic Responsiveness
Plan Development & Documentation
404 Phase Two – Plan Development
405 Phase Three – Implementation
413 High-Fidelity Wraparound Service Delivery
502 Progress Notes and Service Documentation
Supervision & Fidelity Oversight
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI
Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#1 Welcome to Penny Lane’s HFW
#2 Wraparound Family Guide
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#22 Safety and Crisis Plan
#26 Wraparound Fidelity Index
#36 TOM
#34 Supervisor Review Tool (SPRT)
1.3 Strength-Based
Penny Lane Centers ensures that functional strengths of the youth, family, team members, and the broader community are intentionally identified, documented, reviewed, and operationalized throughout the High-Fidelity Wraparound (HFW) process. Strengths are not abstract qualities; they are defined in functional, actionable terms and directly inform decision-making, strategy development, and service planning.
From the onset of engagement, Facilitators conduct structured strengths discovery conversations that culminate in a documented Strengths Inventory. This inventory includes youth competencies, caregiver capabilities, cultural assets, natural supports, team member contributions, and community-based resources. Strengths are reviewed at each Child and Family Team (CFT) meeting and are visibly integrated into the Plan of Care to drive interventions and solutions.
The Integrated Practice Child and Adolescent Needs and Strengths (IP-CANS) assessment is a required and foundational tool in the strengths identification process. Strength domains identified through IP-CANS are incorporated into the Strengths Inventory and embedded into the Plan of Care as leverage points for goal attainment. Identified strengths extend beyond the IP-CANS to include individualized cultural, relational, experiential, and environmental assets.
HFW teams maintain a solution-focused orientation, emphasizing resilience, capacity building, and progress. Team discussions are structured to redirect focus toward actionable strategies and measurable growth rather than dwelling on past negative events. Supervisors and Wraparound Coaches reinforce strengths-based practice through observation of team meetings, review of Plans of Care, and structured case reviews.
Staff receive ongoing coaching and formal training in strengths-based and solution-focused service delivery, including integration of IP-CANS findings into planning. Fidelity tools such as the Wraparound Fidelity Index (WFI) and Team Observation Measure (TOM 2.0), along with satisfaction surveys and QA follow-up calls, are utilized to routinely elicit family feedback regarding their experience of strengths-based services. Feedback data informs staff coaching, performance improvement planning, and agency-wide continuous quality improvement initiatives.
Through these integrated procedures, Penny Lane ensures that strengths-based practice is consistently embedded in documentation, service delivery, supervision, and fidelity monitoring, reinforcing a culture of empowerment and solution-focused care.
Policy References:
Strengths Identification & Engagement
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
404 Phase Two – Plan Development
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery
Documentation & Planning
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI
Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
718 Wraparound 101 – HFW Foundational Training
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#26 Wraparound Fidelity Index
#36 TOM
#34 Supervisor Review Tool (SPRT)
#43 CANS
1.4 Needs Driven
Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) services are anchored in the identification and prioritization of the youth and family’s high-priority underlying needs. The HFW process emphasizes needs-driven planning rather than behavior-focused or service-driven interventions. Needs statements are developed to reflect the underlying reasons why problematic situations or behaviors are occurring, avoiding language framed solely as deficits, diagnoses, or compliance issues.
During Phase One (Engagement and Family Preparation) and Phase Two (Plan Development), Facilitators guide the Child and Family Team (CFT) through structured conversations to identify and prioritize needs before establishing goals or selecting strategies. These needs statements are documented clearly in the Plan of Care and serve as the foundation for measurable goals and coordinated interventions.
The Integrated Practice Child and Adolescent Needs and Strengths (IP-CANS) assessment is required and central to the identification process. IP-CANS domains are used to inform individualized needs statements and to ensure clinical accuracy and consistency in prioritization. However, needs identification extends beyond IP-CANS scoring and includes culturally contextualized, relational, environmental, and systemic factors identified through family engagement and team collaboration.
Staff receive ongoing training and supervisory coaching to strengthen their ability to formulate clear, functional needs statements and to shift planning conversations from symptom management to underlying need resolution. Supervisors and Wraparound Coaches review Plans of Care through structured tools and internal case reviews to ensure needs are appropriately articulated prior to goal and strategy development.
The HFW process continues until the team, youth, and family collectively determine that prioritized needs are sufficiently met. Transition planning is based on measurable progress toward needs resolution rather than time-limited service delivery. Formal transition and graduation occur only when the team agrees that sustainable supports and capacity have been established to maintain progress.
Through structured planning, required IP-CANS integration, supervisory oversight, and fidelity monitoring, Penny Lane operationalizes needs-driven practice as a core standard of HFW service delivery.
Policy References:
Needs Identification & Planning
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
404 Phase Two – Plan Development
405 Phase Three – Implementation
406 Phase Four – Transition
413 High-Fidelity Wraparound Service Delivery
Documentation & Transition
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment
419 Graduation and Disenrollment
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI
Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#22 Safety and Crisis Plan
#26 Wraparound Fidelity Index
#34 Supervisor Review Tool (SPRT)
#43 CANS
1.5 Individualized
Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) services are highly individualized, flexible, and creatively tailored to the unique needs, strengths, values, culture, and preferences of each youth and family. The HFW Plan of Care is not formulaic; it is intentionally customized to reflect the family’s lived experience, community context, and natural supports. Strategies are designed to reduce harm over time, build sustainable capacity, and leverage the assets within the youth’s family, informal networks, and community. In the case of an Indian child, individualized planning explicitly includes Tribal collaboration and recognition of the Tribe as a culturally essential and equal partner in planning and implementation.
Agency documentation templates, including the Plan of Care and CFT meeting forms are structured to allow narrative flexibility and individualized strategy development rather than checkbox-driven planning. Strengths, needs, and outcome statements are written uniquely for each family and are directly linked to customized strategies that reflect cultural identity, community assets, and family preference.
Staff receive ongoing training and coaching in flexible and creative service delivery. Facilitators receive specialized coaching in leading Child and Family Teams (CFTs) to think beyond traditional service menus and develop tailored strategies that reflect informal supports, faith-based connections, educational partnerships, cultural practices, and other community-based resources. Supervisors and Wraparound Coaches routinely review Plans of Care and observe team meetings to ensure individualized strengths, needs, outcomes, and strategies are evident and not standardized across cases.
Family experience is continuously evaluated through satisfaction surveys, fidelity tools such as the Wraparound Fidelity Index (WFI) and Team Observation Measure (TOM), and quality assurance follow-up calls. Feedback is incorporated into performance improvement processes and workforce coaching to strengthen individualized practice across teams.
Through flexible documentation, structured coaching, fidelity monitoring, and feedback loops, Penny Lane operationalizes individualized planning as a measurable HFW standard rather than a philosophical ideal.
Policy & Appendix References:
Individualized Planning & Service Delivery
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery
312 Flex Funds
Documentation & Plan Review
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI
Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS
#29 Flex Fund Request Form
#34 Supervisor Review Tool (SPRT)
1.6 Use of Natural and Community Based Supports
Penny Lane Centers ensures that natural supports and community-based resources are integral components of the High-Fidelity Wraparound (HFW) process. HFW teams are intentionally structured to include individuals identified by the youth and family as meaningful, supportive, and sustainable connections. These may include extended family members, faith leaders, mentors, educators, neighbors, coaches, Tribal representatives (when applicable), and other informal supports.
From the onset of engagement, Facilitators develop a Natural and Community Supports Inventory that identifies existing relational assets and potential informal resources within the family’s network and local community. This inventory is updated throughout service delivery and actively referenced during Child and Family Team (CFT) meetings to ensure strategies leverage natural supports rather than defaulting to formal service systems.
The HFW Plan of Care prioritizes strategies that occur within the family’s community context and are supported by informal networks whenever clinically appropriate. This approach reduces reliance on formal supports over time and strengthens long-term sustainability. Community-based interventions may include school partnerships, faith-based supports, peer networks, recreational programs, cultural organizations, and Tribal engagement in the case of an Indian child.
Staff receive ongoing training and supervisory coaching in identifying, engaging, and integrating natural supports into the HFW process. Facilitators are coached to shift team discussions from service-based solutions to relationship-based and community-based solutions. Supervisors and Wraparound Coaches routinely review Plans of Care and observe CFT meetings to assess whether natural supports are meaningfully included in team composition, strategy assignment, and action steps.
Family feedback regarding the integration and effectiveness of natural supports is routinely elicited through satisfaction surveys, fidelity tools such as the Wraparound Fidelity Index (WFI) and Team Observation Measure (TOM 2.0), and quality assurance follow-up calls. Feedback trends are incorporated into Continuous Quality Improvement (CQI) initiatives and inform targeted staff coaching and training to strengthen community-based practice.
Through structured documentation, workforce development, fidelity monitoring, and feedback systems, Penny Lane operationalizes Natural Support and Community-Based principles as measurable and sustained components of HFW service delivery.
Policy & Appendix References
Natural Support Identification & Engagement
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
409 Child and Family Team (CFT) Meetings
411 Coordinated Care
413 High-Fidelity Wraparound Service Delivery
210 Language Access & Cultural and Linguistic Responsiveness
Community-Based Strategy Implementation
405 Phase Three – Implementation
312 Flex Funds
421 Home Visits
425 Youth Education Services (HFW Alignment)
Documentation & Plan Review
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI
Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS
#29 Flex Fund Request Form
#34 Supervisor Review Tool (SPRT)
1.7 Culturally Respectful and Relevant
Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) teams recognize and elevate a family’s traditions, values, cultural identity, and heritage as essential sources of strength throughout the Wraparound process. Cultural discovery is not treated as a secondary consideration but as a foundational component of engagement, needs identification, strategy development, and transition planning.
Prior to the development of the HFW Plan of Care, Facilitators complete a comprehensive strengths, needs, and culture discovery process. This includes exploration of cultural identity, spiritual beliefs, family traditions, language preferences, community affiliations, lived experiences, and historical factors that influence family functioning. Cultural information is clearly documented in the youth’s case file and directly integrated into the Family Vision, needs statements, strengths inventory, and intervention strategies.
HFW teams design strategies that are relevant to and respectful of the youth and family’s cultural context. This may include engagement with culturally aligned mentors, faith-based organizations, community groups, bilingual supports, culturally informed therapeutic approaches, and, when serving an Indian child, formal collaboration with Tribal representatives as equal and essential partners in planning. Cultural responsiveness extends into transition planning, where teams intentionally connect families to culturally relevant community supports to sustain progress beyond formal HFW services.
Staff receive ongoing training and supervisory coaching in eliciting cultural information respectfully and integrating it meaningfully into service planning. Cultural humility, bias awareness, and culturally responsive engagement are reinforced through workforce development, supervision, and fidelity monitoring. Supervisors and Wraparound Coaches review documentation and observe team meetings to ensure cultural factors are actively influencing decision-making rather than being documented without application.
Family feedback regarding culturally respectful and relevant services is routinely collected through satisfaction surveys, Wraparound Fidelity Index (WFI), Team Observation Measure (TOM), and quality assurance outreach calls. Feedback data is analyzed through Continuous Quality Improvement (CQI) processes and used to inform targeted coaching, training enhancements, and practice refinement.
Through structured cultural discovery, documentation standards, workforce development, and feedback integration, Penny Lane operationalizes culturally respectful and relevant practice as a measurable and sustained HFW standard.
Policy & Appendix References:
Cultural Discovery & Engagement
210 Language Access & Cultural and Linguistic Responsiveness
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
409 Child and Family Team (CFT) Meetings
415 Parent Support & Advocacy (HFW-Aligned)
Plan Development & Transition
404 Phase Two – Plan Development
405 Phase Three – Implementation
406 Phase Four – Transition
413 High-Fidelity Wraparound Service Delivery
503 Aftercare, Graduation, and Disenrollment
Documentation & Review
502 Progress Notes and Service Documentation
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI
Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#1 Welcome to Penny Lane’s HFW
#2 Wraparound Family Guide
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS
#34 Supervisor Review Tool (SPRT)
1.8 High-Quality Team Planning and Problem Solving
Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) teams are intentionally structured to include both formal service providers and natural supports across the Children’s System of Care. Teams function as shared decision-making bodies responsible for developing, implementing, and monitoring an individualized Plan of Care that reflects the youth and family’s prioritized needs. Collaboration is not symbolic; it is operationalized through shared task ownership, clearly assigned action steps, and structured follow-through mechanisms.
Each HFW team establishes documented Team Agreements that outline shared expectations, communication norms, confidentiality standards, attendance commitments, and accountability structures. These agreements reinforce mutual respect, collective responsibility, and solution-focused engagement. The Child and Family Team (CFT) meeting structure promotes inclusive dialogue, ensuring all voices, including youth, caregivers, natural supports, system partners, and, when applicable, Tribal representatives, contribute meaningfully to planning and problem-solving.
Plans of Care and CFT meeting minutes clearly assign strategies and action items to specific team members, reinforcing shared ownership and follow-through. Facilitators monitor completion of tasks and revisit progress at subsequent meetings to ensure accountability and sustained collaboration. Supervisors and Wraparound Coaches routinely review documentation and observe meetings to assess evidence of shared responsibility, cross-system coordination, and authentic collaboration.
Family and team member feedback regarding their experience of team engagement, collaboration, optimism, and commitment is routinely elicited through satisfaction surveys, fidelity tools such as the Wraparound Fidelity Index (WFI) and Team Observation Measure (TOM 2.0), and quality assurance follow-up calls. Observational data from internal case reviews further assesses team dynamics and shared ownership of strategies. Feedback findings are incorporated into Continuous Quality Improvement (CQI) processes and used to inform targeted coaching, performance development, and workforce training initiatives.
Through structured team agreements, accountability systems, fidelity monitoring, and integrated feedback loops, Penny Lane operationalizes Team-Based and Collaborative principles as measurable standards that foster shared ownership, collective optimism, and sustained commitment to youth and family success.
Policy & Appendix References
Team Formation & Collaboration
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
409 Child and Family Team (CFT) Meetings
411 Coordinated Care
413 High-Fidelity Wraparound Service Delivery
412 Internal High-Fidelity Wraparound Case Reviews
Documentation & Accountability
404 Phase Two – Plan Development
405 Phase Three – Implementation
502 Progress Notes and Service Documentation
Supervision & Continuous Quality Improvement
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI
Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#4 CFT Meeting Minutes
#17 Plan of Care Template
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS
#34 Supervisor Review Tool (SPRT)
1.9 Outcomes Based Process
Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) services are outcomes-driven, measurable, and continuously monitored to inform real-time decision-making. The HFW Plan of Care is structured to link clearly defined needs statements to measurable outcomes, individualized strategies, and assigned action steps with specified timeframes. Progress is not assumed; it is objectively tracked and reviewed within the context of Child and Family Team (CFT) meetings and supervisory oversight.
Each Plan of Care includes specific, measurable strategies and action items aligned to prioritized underlying needs. Timeframes, responsible team members, and expected indicators of progress are documented. Facilitators track completion of action items between meetings and provide structured updates during CFT meetings to ensure accountability and transparency. When progress is not occurring as anticipated, strategies are adjusted collaboratively, and changes are documented and redistributed to all team members to maintain coordinated implementation.
The Integrated Practice Child and Adolescent Needs and Strengths (IP-CANS) assessment is a required and central component of needs identification and outcome tracking. The assigned Wraparound Facilitator, in collaboration with the clinical supervisor and therapist, is responsible for completing the IP-CANS within required timelines and updating it according to established reassessment schedules. IP-CANS results are shared with the Child and Family Team in a developmentally appropriate and strengths-based manner to support collaborative decision-making.
Data derived from the IP-CANS informs prioritization of needs and helps monitor functional improvement over time. However, IP-CANS data does not replace active tracking of needs resolution, measurable goal attainment, or action item completion. Transition planning is based on objective evidence that prioritized needs have been sufficiently met, demonstrated through measurable progress, consistent strategy implementation, and sustainable support structures, not solely through standardized instrument scores.
Supervisors and QA/QI leadership monitor outcome alignment through internal HFW case reviews, Supervisor Review Tool (SPRT) audits, fidelity measures (TOM, WFI), and structured documentation review. Continuous Quality Improvement (CQI) processes analyze outcome trends to strengthen staff practice, reinforce measurable planning standards, and ensure fidelity to outcomes-based principles.
Through structured documentation, defined assessment responsibilities, measurable planning frameworks, and integrated data review processes, Penny Lane operationalizes outcomes-based practice as a core and measurable standard of High-Fidelity Wraparound.
Policy & Appendix References:
Outcomes-Based Planning & Monitoring
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery
Documentation & Plan Adjustment
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment
Assessment & Standardized Tools
714 CANS
716 LOCUS
715 TOM
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI
Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
Appendix Forms
#4 CFT Meeting Minutes
#17 Plan of Care Template
#34 Supervisor Review Tool (SPRT)
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS
1.10 Persistence
Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) teams approach setbacks, crises, and limited progress as indicators that the Plan of Care requires revision, not as evidence of youth or caregiver failure. The HFW process is designed to remain engaged with families through challenges, maintaining a solution-focused and strengths-based stance while adapting strategies as needed. Persistence is operationalized through structured supervision, access to additional supports, and flexible service delivery mechanisms that reinforce the team’s commitment to sustainable outcomes.
HFW teams continue working with youth and families until prioritized needs are sufficiently met and the team, giving preference to family voice and choice, collectively agrees that services should transition. Setbacks prompt structured review of needs statements, strategy effectiveness, and task completion within Child and Family Team (CFT) meetings. Plans are revised collaboratively, and alternative strategies are implemented to address emerging barriers.
Clear processes are in place to support teams facing challenges. Facilitators may access additional supervision, consultation with Wraparound Coaches, and internal High-Fidelity Wraparound case reviews to problem-solve complex situations. Teams may request flexible funding to remove barriers and implement creative solutions aligned with the family’s needs. Crisis response protocols provide structured guidance for stabilization, post-crisis review, and safety planning, ensuring continuity of engagement rather than service discontinuation.
Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, de-escalation strategies, and advanced facilitation skills to lead effective brainstorming sessions during times of difficulty. Supervisors reinforce persistence by reviewing documentation, observing CFT meetings, and ensuring that plan revisions reflect HFW principles, including family voice, strengths-based practice, and needs-driven planning.
Continuous Quality Improvement (CQI) processes monitor patterns related to setbacks, crisis recurrence, and plan adjustments to strengthen agency-wide practice standards. Through structured escalation pathways, flexible resource access, and reinforced coaching infrastructure, Penny Lane operationalizes Persistence as an embedded and measurable HFW practice standard.
Policy & Appendix References
Crisis Response & Plan Revision
405 Phase Three – Implementation
406 Phase Four – Transition
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery
Flexible Supports & Resource Access
312 Flex Funds
411 Coordinated Care
Supervision & Additional Support
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI
Documentation
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment
Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
Appendix Forms
#22 Safety and Crisis Plan
#10 Immediate Safety and Stabilization Plan
#29 Flex Fund Request Form
#4 CFT Meeting Minutes
#17 Plan of Care Template
#34 Supervisor Review Tool (SPRT)
1.11 Transitions as a part of the Fourth Phase of HFW
Penny Lane Centers ensures that transitions from High-Fidelity Wraparound (HFW) services are intentional, needs-based, and collaboratively planned in advance. Transition occurs only when prioritized underlying needs have been sufficiently met, sustainable supports are established, and the youth and family, through shared decision-making, agree that formal HFW services are no longer required. Transitions are not driven by administrative timelines, funding constraints, or adverse events, but by measurable progress and readiness determined by the Child and Family Team (CFT).
Transition planning begins early in the Wraparound process and is integrated into ongoing Plan of Care reviews. As needs are progressively met, teams focus on strengthening natural supports, building community connections, and reducing reliance on formal services to promote sustainability. When an adverse event occurs, the HFW team responds with plan revision and support stabilization rather than service termination.
To ensure continuity and prevent sudden loss of services, clear internal procedures govern discharge, graduation, and aftercare planning. Transition plans include documentation of resolved needs, remaining supports, crisis response strategies, and linkages to community-based resources. When appropriate, referrals to step-down services or alternative supports are coordinated in advance to ensure seamless continuity.
Transitions are celebrated in alignment with the youth and family’s culture, values, and preferences. Celebrations may include formal graduation ceremonies, culturally meaningful acknowledgments, community gatherings, or individualized recognition activities. Administrative structures support this process by allowing access to flexible funds when appropriate, accommodating staff time for community linkage and celebration planning, and encouraging team participation in transition events.
Supervisors review transition plans to ensure they reflect needs resolution rather than administrative closure. Quality Assurance and Continuous Quality Improvement (CQI) processes monitor discharge trends to ensure fidelity to needs-based transition standards.
Through structured planning, supervisory oversight, flexible administrative support, and culturally responsive celebration practices, Penny Lane operationalizes transition as a strength-based milestone that honors family voice and ensures sustainable outcomes beyond formal HFW services.
Policy & Appendix References:
Transition & Disenrollment
406 Phase Four – Transition
419 Graduation and Disenrollment
503 Aftercare, Graduation, and Disenrollment
Plan Review & Documentation
404 Phase Two – Plan Development
405 Phase Three – Implementation
502 Progress Notes and Service Documentation
409 Child and Family Team (CFT) Meetings
Crisis Safeguards
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
Flexible & Community-Based Supports
312 Flex Funds
411 Coordinated Care
425 Youth Education Services (HFW Alignment)
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI
Training & Workforce Development
703 Workforce Training & Competency Development
719 Wraparound 101 – HFW Foundational Training
Appendix Forms
#8 Disenrollment Summary/Aftercare Plan
#24 Transfer Review and Transition Plan
#17 Plan of Care Template
#4 CFT Meeting Minutes
#29 Flex Fund Request Form
Expected Outcomes
2.1 Youth and Family Satisfaction
Penny Lane Centers maintains formal policies and procedures to systematically record, evaluate, and respond to youth and family satisfaction with their High-Fidelity Wraparound (HFW) experience. Satisfaction is viewed as a critical outcome indicator and an essential component of fidelity to HFW principles. The agency utilizes structured feedback mechanisms to assess families’ perceptions of engagement quality, cultural responsiveness, collaboration, progress toward needs resolution, and overall service experience.
Youth and family satisfaction data is collected through multiple channels, including standardized fidelity tools such as the Wraparound Fidelity Index (WFI) and Team Observation Measure (TOM 2.0), satisfaction surveys, and Quality Assurance (QA) follow-up calls. Feedback is reviewed by supervisors and QA/QI leadership to identify strengths, areas for improvement, and practice trends. Findings are incorporated into Continuous Quality Improvement (CQI) processes and inform targeted coaching, training enhancements, and performance development plans.
In cases involving an Indian child, Tribal representatives are recognized as equal partners in the HFW process. The agency ensures that Tribal perspectives are invited and documented during planning, review, and transition phases. Feedback regarding the Tribe’s experience with collaboration, cultural respect, and shared decision-making is incorporated into quality review processes to ensure Tribal satisfaction is assessed and addressed.
Satisfaction data is not collected for compliance purposes alone; it is actively analyzed and used to refine service delivery, strengthen cultural responsiveness, reinforce Family Voice and Choice, and enhance team collaboration. Supervisors provide direct feedback to staff regarding satisfaction outcomes, and aggregate data trends are reviewed at the program leadership level to inform system-wide improvements.
Through structured documentation, standardized fidelity measures, and integrated CQI review processes, Penny Lane demonstrates clear policies and procedures to record and evaluate youth, family, and Tribal satisfaction with the HFW experience.
Policy & Appendix References:
Satisfaction Monitoring & Evaluation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
412 Internal High-Fidelity Wraparound Case Reviews
Service Delivery & Collaboration
402 High-Fidelity Wraparound Family Assessment & Engagement Process
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery
210 Language Access & Cultural and Linguistic Responsiveness
Documentation
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment
Outcome & Fidelity Tools
715 TOM
714 CANS
716 LOCUS
Appendix Forms
#26 Wraparound Fidelity Index
#36 TOM
#4 CFT Meeting Minutes
#17 Plan of Care Template
2.2 Improved School Functioning
Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) services actively support and monitor improvements in youth educational and vocational functioning. Educational stability, school engagement, and vocational development are treated as core outcome domains within the individualized Plan of Care. HFW teams collaborate with families, schools, and community partners to promote consistent attendance, academic progress aligned with grade-level expectations or Individualized Education Plans (IEPs), and development of age-appropriate vocational skills and experiences.
Educational functioning is assessed during the engagement and needs discovery process and incorporated into prioritized needs statements when relevant. The Plan of Care includes measurable strategies to address attendance barriers, behavioral challenges in school settings, academic support needs, and vocational readiness goals. Interventions may include coordination with school personnel, participation in IEP meetings, linkage to tutoring or mentoring programs, advocacy support, and connection to community-based vocational resources.
Attendance patterns, academic performance indicators, and vocational engagement are documented in progress notes and reviewed during Child and Family Team (CFT) meetings. Youth Education Services and coordinated care processes ensure cross-system collaboration. When applicable, IP-CANS education domain ratings inform planning and progress tracking; however, educational data is also directly monitored through school reports, attendance records, and team review discussions.
Supervisors and QA/QI leadership review documentation to ensure that educational goals are measurable and actively monitored. Outcome trends related to attendance and performance are incorporated into Continuous Quality Improvement (CQI) processes to strengthen practice consistency and cross-system collaboration.
Through structured documentation, cross-system coordination, and measurable educational goal tracking, Penny Lane maintains clear policies and procedures to record and evaluate school attendance, performance, and vocational development outcomes.
Policy & Appendix References:
Educational & Vocational Service Integration
425 Youth Education Services (High-Fidelity Wraparound Alignment)
411 Coordinated Care
413 High-Fidelity Wraparound Service Delivery
402 High-Fidelity Wraparound Family Assessment & Engagement Process
Plan Development & Monitoring
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
Documentation & Outcomes Tracking
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#17 Plan of Care Template
#4 CFT Meeting Minutes
#3 Strengths Assessment
#43 CANS
2.3 Improved Functioning in the Community
Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) services promote measurable improvements in youth community functioning, including reduced justice involvement and increased engagement in pro-social community activities. Community integration, lawful behavior, and positive participation in structured activities are treated as key indicators of stability and long-term sustainability within the individualized Plan of Care.
During the engagement and needs discovery phases, teams assess current justice involvement, probation status (if applicable), peer associations, recreational engagement, and community participation. When justice involvement or limited pro-social engagement is identified as a prioritized need, measurable strategies are incorporated into the Plan of Care. These strategies may include coordinated care with probation or legal partners, mentorship connections, restorative justice participation, structured extracurricular activities, employment readiness programs, and linkage to culturally relevant community organizations.
Justice involvement levels, compliance requirements, and community participation are documented in progress notes and reviewed at Child and Family Team (CFT) meetings. Data sources may include probation updates, school reports, caregiver reports, and youth self-report. IP-CANS domains related to behavioral health, risk behaviors, and functioning inform needs identification and progress tracking; however, direct monitoring of community engagement and justice involvement remains a central planning component.
Supervisors and QA/QI leadership review documentation to ensure measurable goals related to community functioning are established and monitored. Trends in justice involvement and community participation are incorporated into Continuous Quality Improvement (CQI) processes to strengthen system coordination and strategy effectiveness.
Through structured documentation practices, cross-system collaboration, standardized assessment integration, and measurable outcome tracking, Penny Lane maintains clear policies and procedures to record and evaluate justice involvement and engagement in community activities.
Policy & Appendix References:
Community-Based & Justice Coordination
411 Coordinated Care
413 High-Fidelity Wraparound Service Delivery
425 Youth Education Services (HFW Alignment)
402 High-Fidelity Wraparound Family Assessment & Engagement Process
Plan Development & Monitoring
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
Documentation & Outcomes Tracking
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Crisis & Risk Monitoring
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#17 Plan of Care Template
#4 CFT Meeting Minutes
#3 Strengths Assessment
#43 CANS
2.4 Improved Interpersonal Functioning
Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) services promote measurable improvements in youth and family interpersonal functioning. Strengthening relationships, reducing stress and strain within the home, and improving communication and relational stability are core outcome domains embedded in the HFW process. Interpersonal functioning is assessed during engagement, prioritized when identified as a need, and systematically monitored throughout service delivery.
During Phase One (Engagement and Family Preparation), Facilitators conduct strengths and needs discovery conversations that explore family dynamics, relational stressors, communication patterns, peer relationships, and caregiver-child interactions. When interpersonal strain is identified as an underlying need, it is translated into a clearly articulated needs statement and linked to measurable goals within the Plan of Care.
The Plan of Care includes specific strategies designed to improve communication, conflict resolution, emotional regulation, parenting capacity, peer relationships, and relational trust. These strategies may include structured family meetings, skill-building interventions, Parent Partner coaching, therapeutic collaboration, and connection to culturally relevant relational supports. Action items are assigned, tracked, and reviewed during Child and Family Team (CFT) meetings to monitor progress and adjust strategies as needed.
Interpersonal functioning is documented through progress notes, CFT meeting minutes, and standardized tools such as the IP-CANS, which includes domains addressing family functioning, social relationships, and behavioral/emotional regulation. However, IP-CANS data complements, not replaces ongoing monitoring of relational improvements, stress reduction, and observable behavioral changes within the home.
Supervisors and QA/QI leadership review documentation to ensure that interpersonal goals are measurable, linked to underlying needs, and regularly evaluated. Feedback from families regarding relationship improvements and stress reduction is routinely elicited through satisfaction surveys, Wraparound Fidelity Index (WFI), Team Observation Measure (TOM), and QA follow-up calls. This data informs Continuous Quality Improvement (CQI) processes and staff coaching initiatives.
Through structured needs identification, measurable planning, standardized assessment integration, and continuous feedback review, Penny Lane maintains clear policies and procedures to record and evaluate improvements in youth and family interpersonal functioning.
Policy & Appendix References:
Interpersonal Needs Identification & Planning
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery
Documentation & Monitoring
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Family Support & Skill Development
414 Parent Education and Training
415 Parent Support & Advocacy (HFW-Aligned)
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS
2.5 Increased Caregiver Confidence
Penny Lane Centers ensures that families have access to effective, needed services and supports while simultaneously building caregiver capacity, confidence, and long-term self-sufficiency. High-Fidelity Wraparound (HFW) services are designed not only to address immediate needs but to strengthen caregiver skills, increase knowledge of available resources, and foster sustained connectedness to community supports beyond formal service involvement.
During engagement and needs discovery, the HFW team assesses caregiver strengths, stressors, resource awareness, and crisis management capacity. When caregiver confidence or system navigation challenges are identified as underlying needs, they are translated into measurable needs statements within the Plan of Care. Strategies are then developed to build caregiver competence in advocacy, problem-solving, crisis response planning, and community linkage.
Parent Education and Training, Parent Support & Advocacy, and coordinated care efforts are integrated into service delivery to enhance caregiver skill-building and empowerment. Caregivers are supported in leading team discussions, participating in decision-making, and navigating educational, behavioral health, and community systems. Crisis and Safety Plans are developed collaboratively to ensure caregivers understand prevention strategies, warning signs, and response steps.
Progress toward increased caregiver confidence and resource connectedness is documented in progress notes, reviewed in Child and Family Team (CFT) meetings, and measured through feedback mechanisms such as satisfaction surveys, Wraparound Fidelity Index (WFI), Team Observation Measure (TOM), and QA follow-up calls. IP-CANS domains related to caregiver resources, supervision, and family functioning inform planning and reassessment; however, qualitative and observable indicators of confidence and independence are also actively tracked.
Supervisors and QA/QI leadership monitor documentation to ensure caregiver empowerment goals are measurable and linked to needs resolution. Continuous Quality Improvement (CQI) processes review trends in caregiver confidence outcomes and inform staff coaching and workforce development efforts.
Through structured planning, measurable documentation standards, parent capacity-building services, and integrated feedback systems, Penny Lane maintains clear policies and procedures to record and evaluate caregiver confidence and connectedness to community resources.
Policy & Appendix References:
Caregiver Capacity & Resource Access
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
404 Phase Two – Plan Development
405 Phase Three – Implementation
411 Coordinated Care
414 Parent Education and Training
415 Parent Support & Advocacy (HFW-Aligned)
Crisis & Sustainability Planning
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
406 Phase Four – Transition
Documentation & Monitoring
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#22 Safety and Crisis Plan
#10 Immediate Safety and Stabilization Plan
#17 Plan of Care Template
#4 CFT Meeting Minutes
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS
2.6 Stable and Least Restrictive Living Environment
Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) services are intentionally designed to promote youth permanency and stability within community-based living environments. Preventing placement disruptions, institutional admissions, and residential transitions is a core outcome objective of the HFW model. Teams prioritize stabilization strategies that address underlying needs, strengthen caregiver capacity, enhance safety planning, and leverage natural supports to prevent escalation to higher levels of care.
At intake and throughout service delivery, the HFW team assesses current placement stability, prior placement history, and risk factors for disruption. When placement instability is identified as a concern, measurable needs statements are developed and incorporated into the Plan of Care. Strategies may include intensive safety planning, crisis prevention interventions, caregiver coaching, flexible funding supports, coordination with child welfare or probation, school stabilization efforts, and mobilization of natural supports to reduce stressors within the home.
Placement status and any changes in living arrangements are documented in progress notes and reviewed at Child and Family Team (CFT) meetings. When a placement change occurs, teams conduct structured review discussions to analyze contributing factors and revise the Plan accordingly. Special Incident Reports (SIRs), crisis documentation, and coordinated care updates are utilized when applicable to ensure accurate tracking and systemic response.
Supervisors and QA/QI leadership monitor the frequency and type of placement changes through documentation review, internal HFW case reviews, and outcome monitoring processes. Data regarding institutional admissions (e.g., detention, psychiatric hospitalization, STRTP placement) and residential transitions are analyzed as part of Continuous Quality Improvement (CQI) efforts to strengthen prevention strategies and early intervention practices.
Transition from HFW services is not initiated due to placement disruption alone; rather, the team remains engaged in revising strategies and strengthening supports to re-establish stability whenever possible. Through structured monitoring, crisis response integration, cross-system collaboration, and measurable outcome tracking, Penny Lane maintains clear policies and procedures to record and evaluate placement changes and promote permanency within community-based settings.
Policy & Appendix References:
Placement Stability & Service Delivery
402 High-Fidelity Wraparound Family Assessment & Engagement Process
404 Phase Two – Plan Development
405 Phase Three – Implementation
406 Phase Four – Transition
413 High-Fidelity Wraparound Service Delivery
411 Coordinated Care
Crisis & Incident Monitoring
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
205 Special Incident Reports
Documentation & Outcome Tracking
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
Flexible Supports
312 Flex Funds
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#22 Safety and Crisis Plan
#10 Immediate Safety and Stabilization Plan
#23 Special Incident Report (SIR)
#17 Plan of Care Template
#4 CFT Meeting Minutes
#3 CANS
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) services are structured to promote behavioral health stability and reduce the frequency of psychiatric hospitalizations and emergency room visits. Stabilization is achieved through proactive needs-driven planning, integrated crisis prevention strategies, coordinated care, and ongoing monitoring of behavioral health indicators. Preventing avoidable hospital admissions is a key outcome objective embedded within the individualized Plan of Care.
During engagement and ongoing service delivery, the HFW team assesses the youth’s behavioral health history, prior hospitalizations, crisis triggers, and risk factors. When hospitalization risk is identified as a prioritized need, the Plan of Care includes measurable strategies such as enhanced safety planning, therapeutic coordination, skill-building interventions, caregiver coaching, natural support mobilization, and crisis prevention protocols.
Hospital visits and crisis events are documented in progress notes, Special Incident Reports (SIRs) when applicable, and reviewed during Child and Family Team (CFT) meetings. Post-crisis reviews are conducted to analyze contributing factors and revise strategies to prevent recurrence. The Immediate Safety and Stabilization Plan and Safety and Crisis Plan are updated as needed to reflect new information and reinforce preventive supports.
Standardized tools such as the IP-CANS inform behavioral health needs identification and reassessment; however, hospital utilization tracking includes direct documentation of emergency department visits, psychiatric admissions, and crisis interventions. Supervisors and QA/QI leadership monitor hospitalization frequency through internal HFW case reviews and outcome monitoring processes to identify patterns and strengthen early intervention practices.
Continuous Quality Improvement (CQI) efforts incorporate data related to crisis response and hospital utilization trends to inform staff coaching, service intensity adjustments, and system collaboration improvements. Through structured documentation practices, crisis response protocols, measurable planning standards, and supervisory oversight, Penny Lane maintains clear policies and procedures to record and evaluate the frequency of hospital visits and promote sustained behavioral health stability.
Policy & Appendix References:
Behavioral Health & Crisis Planning
402 High-Fidelity Wraparound Family Assessment & Engagement Process
405 Phase Three – Implementation
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
413 High-Fidelity Wraparound Service Delivery
Documentation & Monitoring
502 Progress Notes and Service Documentation
205 Special Incident Reports
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#22 Safety and Crisis Plan
#10 Immediate Safety and Stabilization Plan
#23 Special Incident Report (SIR)
#17 Plan of Care Template
#4 CFT Meeting Minutes
#43 CANS
2.8 Reduction in Crisis Visits
Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) services build the capacity of youth and their natural supports to prevent, de-escalate, and manage crises with reduced reliance on professional intervention over time. The HFW process is structured to move from professionally driven stabilization toward family-led crisis prevention and response, strengthening long-term sustainability within the home and community.
During engagement and throughout service delivery, the HFW team identifies crisis triggers, early warning signs, protective factors, and existing informal supports. A comprehensive Safety and Crisis Plan is developed collaboratively with youth, caregivers, and team members. The plan clearly outlines prevention strategies, coping skills, de-escalation steps, designated natural support roles, and defined thresholds for professional involvement.
As needs are addressed and caregiver capacity increases, teams prioritize strengthening natural supports’ ability to manage emerging stressors independently. Facilitators track crisis frequency, severity, and level of professional involvement (e.g., team intervention, mobile crisis response, emergency services, hospitalization). Crisis events are documented in progress notes, reviewed in Child and Family Team (CFT) meetings, and formally recorded through Special Incident Reports (SIRs) when applicable.
Crisis reviews focus on identifying contributing factors, reinforcing prevention strategies, and revising the Plan of Care as needed. Supervisors and QA/QI leadership monitor crisis data trends, including the level of professional involvement required, through internal HFW case reviews and outcome monitoring systems. This data informs Continuous Quality Improvement (CQI) initiatives aimed at strengthening prevention planning and enhancing natural support engagement.
Training for Facilitators includes post-crisis debriefing, safety planning, conflict resolution, and facilitation of team-based problem-solving to ensure that crisis events become opportunities for skill-building rather than service dependency. Through structured crisis documentation, measurable tracking, supervisory oversight, and proactive safety planning, Penny Lane maintains clear policies and procedures to record crisis frequency and professional involvement levels.
Policy & Appendix References:
Crisis Prevention & Response
405 Phase Three – Implementation
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
413 High-Fidelity Wraparound Service Delivery
Documentation & Monitoring
502 Progress Notes and Service Documentation
205 Special Incident Reports
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
Training & Workforce Development
703 Workforce Training & Competency Development
719 Wraparound 101 – HFW Foundational Training
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#22 Safety and Crisis Plan
#10 Immediate Safety and Stabilization Plan
#23 Special Incident Report (SIR)
#17 Plan of Care Template
#4 CFT Meeting Minutes
#43 CANS
2.9 Positive Exit from HFW
Penny Lane Centers ensures that youth and families exit High-Fidelity Wraparound (HFW) services based on demonstrated stabilization and sufficient progress toward prioritized underlying needs, not due to adverse events, administrative timelines, funding constraints, or system pressures. Discharge decisions are collaborative, needs-based, and grounded in measurable outcomes and team consensus, with preference given to family voice and choice.
Throughout service delivery, the Child and Family Team (CFT) monitors progress toward needs resolution, strategy effectiveness, caregiver capacity, natural support engagement, and crisis frequency. Transition planning begins well in advance of formal discharge and includes strengthening community connections, reinforcing crisis prevention skills, and ensuring sustainability without intensive professional support.
When considering exit from HFW, the team reviews objective indicators including:
Measurable goal completion
Reduction in crisis frequency and severity
Stabilization of living placement
Improved interpersonal and community functioning
Increased caregiver confidence and resource navigation capacity
Adverse events (e.g., hospitalization, placement change, justice involvement) trigger Plan review and revision, not discharge. Teams remain engaged during crises and implement revised strategies consistent with the Principle of Persistence.
All exits from HFW are formally documented, including the reason for discharge, level of stabilization achieved, and aftercare planning. Disenrollment summaries and transition plans are completed and retained in the clinical record. Supervisors review all discharge documentation to ensure exits are aligned with needs-based criteria. QA/QI leadership monitors discharge patterns and reasons for exit through outcome tracking systems to ensure fidelity to stabilization-driven transition standards.
Through structured documentation, supervisory oversight, measurable outcome review, and CQI monitoring, Penny Lane maintains clear policies and procedures to record and evaluate when and why families exit HFW, ensuring discharges are clinically appropriate and aligned with HFW principles.
Policy & Appendix References:
Transition & Discharge Standards
406 Phase Four – Transition
419 Graduation and Disenrollment
503 Aftercare, Graduation, and Disenrollment
Plan Monitoring & Documentation
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
502 Progress Notes and Service Documentation
Crisis Safeguards & Persistence
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
205 Special Incident Reports
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#8 Disenrollment Summary/Aftercare Plan
#24 Transfer Review and Transition Plan
#17 Plan of Care Template
#4 CFT Meeting Minutes
#23 Special Incident Report (SIR)
Engagement
3.1 Orientation
Penny Lane Centers ensures that every youth and family receives a comprehensive and developmentally appropriate orientation to the High-Fidelity Wraparound (HFW) process at the onset of services. Orientation is embedded within Phase One (Engagement and Family Preparation) and is designed to promote transparency, informed participation, and shared understanding of the Wraparound framework. Families are positioned as equal partners from the beginning, with clarity regarding their role, rights, and responsibilities.
During initial engagement, the assigned Facilitator reviews the HFW model in full, including the guiding principles (Family Voice and Choice, Strength-Based, Individualized, Natural Supports, Community-Based, Culturally Respectful, Team-Based, Collaborative, Outcomes-Based, and Persistence) and the four phases of the Wraparound process (Engagement, Plan Development, Implementation, and Transition). This overview ensures families understand that services are needs-driven, team-based, and time-limited based on stabilization rather than administrative timelines.
Legal and ethical considerations are reviewed as part of the informed consent process. This includes confidentiality and its limits, mandated reporting requirements, documentation standards, information sharing protocols (Release of Information), client rights, grievance procedures, and crisis response expectations. When serving an Indian child, orientation includes recognition of Tribal involvement, collaboration expectations, and the Tribe’s role as an equal voice on the team consistent with culturally responsive and legally informed practice.
The Facilitator clearly explains the role of each team member, including:
The youth as an active participant
The caregiver as decision-maker and expert on their family
Natural supports as integral contributors
Formal system partners (e.g., therapist, probation, school)
The Facilitator as team coordinator
The Parent Partner as peer support advocate
Supervisory and QA oversight structures
Families are provided written materials that reinforce this orientation and are encouraged to ask questions to ensure full understanding. Orientation discussions are documented in the clinical record.
Supervisors review documentation to confirm that orientation occurred and that the family has been adequately informed. Ongoing feedback from families through fidelity tools (WFI, TOM), satisfaction surveys, and QA calls helps evaluate the effectiveness of orientation practices and informs Continuous Quality Improvement (CQI) efforts.
Through structured engagement procedures, documented informed consent processes, written educational materials, and supervisory oversight, Penny Lane ensures that all families are fully oriented to the HFW process, principles, phases, and team roles.
Policy & Appendix References:
Engagement & Orientation
401 Referral and Intake Process
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
409 Child and Family Team (CFT) Meetings
210 Language Access & Cultural and Linguistic Responsiveness
Legal & Ethical Standards
417 Electronic Communications with Clients and Caregivers
205 Special Incident Reports
502 Progress Notes and Service Documentation
Service Delivery Structure
413 High-Fidelity Wraparound Service Delivery
412 Internal High-Fidelity Wraparound Case Reviews
Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
Appendix Forms
#1 Welcome to Penny Lane’s HFW
#2 Wraparound Family Guide
#20 Release of Information – Foster Youth
#21 Release of Information – Non-Foster Youth
#33 Definition of Confidentiality Form
#4 CFT Meeting Minutes
#42 Penny Lane Wraparound 101 Workbook
3.2 Safety and Crisis stabilization
Penny Lane Centers ensures that pressing safety concerns and urgent needs are addressed immediately so that families can fully engage in the High-Fidelity Wraparound (HFW) process. Stabilization is treated as a prerequisite to effective team-based planning. During Phase One (Engagement and Family Preparation), Facilitators assess immediate safety risks, crisis history, and urgent stressors to determine whether an immediate intervention plan is required.
If pressing concerns are identified, the HFW team develops a written Immediate Safety and Stabilization Plan in collaboration with the youth and caregiver. This plan outlines crisis triggers, warning signs, prevention strategies, designated support persons, and clear steps for response. The plan is provided to the family and documented in the clinical record. When necessary, the team mobilizes coordinated care partners or crisis response resources to ensure stabilization.
The Immediate Crisis Response Plan informs, but does not replace, the comprehensive HFW Safety and Crisis Plan developed during Phase Two (Plan Development). Once stabilization is achieved, the Child and Family Team (CFT) integrates crisis prevention strategies into the broader Plan of Care to address underlying needs and reduce recurrence risk. Safety planning remains dynamic and is reviewed and updated during CFT meetings, especially following any crisis event.
All families are provided with clear instructions on how to access 24/7 crisis response services. Penny Lane maintains defined business hours crisis response coverage and structured after-hours protocols to ensure continuous support availability. Families receive written and verbal information regarding emergency contacts, mobile crisis resources, and when to access emergency services.
Supervisors review crisis documentation to ensure immediate safety planning is completed when indicated and that crisis response procedures align with HFW principles. Special Incident Reports (SIRs), crisis documentation, and internal case reviews are utilized to monitor crisis frequency and response effectiveness. Continuous Quality Improvement (CQI) processes evaluate crisis trends and inform workforce training and system coordination improvements.
Through structured engagement screening, documented stabilization planning, 24/7 crisis access protocols, and supervisory oversight, Penny Lane ensures that immediate concerns are addressed promptly while preserving fidelity to the broader HFW process.
Policy & Appendix References:
Crisis Assessment & Immediate Stabilization
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
413 High-Fidelity Wraparound Service Delivery
Safety Planning & Plan Integration
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
Documentation
205 Special Incident Reports
502 Progress Notes and Service Documentation
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI
Appendix Forms
#10 Immediate Safety and Stabilization Plan
#22 Safety and Crisis Plan
#23 Special Incident Report (SIR)
#4 CFT Meeting Minutes
#17 Plan of Care Template
3.3 Strengths, Needs, Culture and Vision Discovery
Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) Facilitators intentionally guide youth and families through structured conversations to identify individual and family strengths, prioritized underlying needs, cultural identity, and a shared vision for a better future. This discovery process occurs during Phase One (Engagement and Family Preparation) and establishes the foundation for needs-driven, strengths-based, and culturally responsive planning.
During engagement, the Facilitator collaborates with the youth and caregiver to develop a clearly articulated Family Vision statement. The Vision reflects the family’s hopes, long-term goals, and definition of success. This Vision is documented in the youth’s chart and serves as the guiding framework for all subsequent planning and strategy development.
In addition to the Vision statement, a comprehensive Strengths, Needs, and Culture Discovery document is initiated for every youth and family. This document captures functional strengths, cultural traditions, family values, lived experiences, community connections, and identified needs. It is maintained in the clinical record, updated at least every ninety (90) days, and revised whenever new strengths, needs, or cultural considerations are identified during service delivery.
The written summary document serves multiple purposes:
Guides initial Plan of Care development
Ensures all team members understand the youth and family’s strengths and cultural context
Orients new team members as they join the Child and Family Team (CFT)
Reinforces Family Voice and Choice throughout implementation
The document is reviewed and referenced during CFT meetings to maintain alignment between the Family Vision, identified needs, and selected strategies. Supervisors review documentation through internal case reviews and Supervisor Review Tool (SPRT) processes to ensure Vision statements and discovery summaries are present, individualized, and actively integrated into planning.
Through structured documentation, scheduled updates, team dissemination practices, and supervisory oversight, Penny Lane ensures that strengths, needs, culture, and Vision are clearly communicated, regularly refreshed, and foundational to all HFW planning and service delivery.
Policy & Appendix References:
Engagement & Discovery
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
409 Child and Family Team (CFT) Meetings
210 Language Access & Cultural and Linguistic Responsiveness
Plan Development & Implementation
404 Phase Two – Plan Development
405 Phase Three – Implementation
413 High-Fidelity Wraparound Service Delivery
Documentation & Monitoring
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#3 Strengths Assessment
#17 Plan of Care Template
#4 CFT Meeting Minutes
#34 Supervisor Review Tool (SPRT)
#43 CANS
3.4 Engage All Team Members
Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) teams intentionally engage formal service providers, natural supports, and cross-system partners across the Children’s System of Care to support the youth and family. Team composition is driven by Family Voice and Choice and includes individuals who care about the youth and can meaningfully contribute to needs resolution. When serving an Indian child, Tribal representatives are engaged as equal partners and recognized as essential contributors to culturally responsive planning.
During Phase One (Engagement and Family Preparation), Facilitators complete a Natural Supports Inventory with the youth and family. This inventory identifies extended family members, mentors, educators, faith leaders, coaches, community members, and other informal supports. The inventory is documented in the clinical record and updated as new supports are identified.
Facilitators also identify and engage relevant formal Children’s System of Care partners, which may include mental health providers, child welfare staff, probation officers, school personnel, regional center representatives, medical providers, and community-based organizations. Participation is based on the youth’s needs and family preference. Team member roles and responsibilities are clearly defined during orientation and revisited as needed to ensure accountability and collaboration.
The Facilitator leads structured engagement and team-building activities to foster a positive, respectful, and solution-focused team culture. Activities may include establishing Team Agreements, clarifying communication expectations, reviewing the Family Vision, and facilitating collaborative brainstorming. Engagement efforts and team-building processes are documented in meeting minutes and progress notes to reflect active participation and shared ownership.
Supervisors and Wraparound Coaches review documentation and observe Child and Family Team (CFT) meetings to ensure inclusive engagement, role clarity, and cross-system collaboration are evident. Fidelity tools such as the Wraparound Fidelity Index (WFI) and Team Observation Measure (TOM) further assess team engagement quality. Continuous Quality Improvement (CQI) processes incorporate team participation data to strengthen system coordination and collaborative practice standards.
Through structured team identification processes, documented engagement practices, role clarification procedures, and supervisory oversight, Penny Lane operationalizes comprehensive team engagement as a measurable HFW practice standard.
Policy & Appendix References:
Team Engagement & Formation
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
409 Child and Family Team (CFT) Meetings
411 Coordinated Care
413 High-Fidelity Wraparound Service Delivery
210 Language Access & Cultural and Linguistic Responsiveness
Documentation
502 Progress Notes and Service Documentation
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI
Training & Workforce Development
703 Workforce Training & Competency Development
719 Wraparound 101 – HFW Foundational Training
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#26 Wraparound Fidelity Index
#36 TOM
#34 Supervisor Review Tool (SPRT)
3.5 Arrange Meeting Logistics
Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) meetings are scheduled and conducted in ways that prioritize family voice, accessibility, and equitable participation. Meeting logistics are intentionally designed to remove barriers and reflect family schedules, cultural considerations, transportation access, work obligations, trauma history, and communication preferences. The Child and Family Team (CFT) process is structured to adapt to the family, not the reverse.
Facilitators collaborate with youth and caregivers to determine meeting times, locations, and formats that maximize participation and comfort. Meetings may occur in the family’s home, community settings, agency offices, schools, or via telehealth platforms depending on family preference and accessibility needs. When appropriate, teams utilize flexible scheduling, including evenings or alternative hours, to ensure caregiver and natural support participation.
The HFW team proactively arranges meeting logistics, which may include:
Transportation coordination or mileage support
Interpretation or bilingual services
Telehealth access and technical support
Trauma-informed meeting structure and pacing
Accessibility accommodations
Staff are trained to work collaboratively with families and cross-system partners to schedule meetings in alignment with family needs while maximizing team participation. Scheduling decisions are documented in case notes and meeting minutes to reflect family-centered planning practices.
Supervisors and Wraparound Coaches monitor meeting accessibility practices through documentation review and observation of CFT meetings. Feedback from families regarding meeting accessibility and inclusivity is gathered through fidelity tools (WFI, TOM), satisfaction surveys, and QA follow-up calls. Continuous Quality Improvement (CQI) processes analyze feedback trends to strengthen equitable access practices and workforce responsiveness.
Through flexible scheduling policies, trauma-informed planning, logistical coordination, and supervisory oversight, Penny Lane operationalizes accessible and family-centered meeting practices as a core HFW standard.
Policy & Appendix References:
Meeting Logistics & Accessibility
301 Hours of Operation
310 Client Transportation
409 Child and Family Team (CFT) Meetings
210 Language Access & Cultural and Linguistic Responsiveness
417 Electronic Communications with Clients and Caregivers
421 Home Visits
Service Delivery & Coordination
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
413 High-Fidelity Wraparound Service Delivery
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI
Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
Appendix Forms
#4 CFT Meeting Minutes
#25 Transportation Agreement
#1 Welcome to Penny Lane’s HFW
#2 Wraparound Family Guide
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
Penny Lane Centers ensures that, following initial engagement activities, the High-Fidelity Wraparound (HFW) Facilitator intentionally leads the Child and Family Team (CFT) in establishing a strong collaborative foundation prior to development of the Wraparound Plan of Care. This structured groundwork reinforces team cohesion, shared purpose, and alignment with the Family Vision.
Before the Plan of Care is developed during Phase Two (Plan Development), the Facilitator guides the team through three essential activities:
Formal Team Agreements
The team develops documented agreements outlining how members will engage in meetings, communicate respectfully, resolve disagreements, maintain confidentiality, and make decisions. These agreements reinforce shared expectations, psychological safety, and collective accountability.
Team Strengths Inventory
Building upon strengths identified during engagement, the Facilitator leads the team in identifying additional strengths of the youth, caregivers, natural supports, formal providers, and community resources. Strengths are framed functionally and documented in the youth’s case file. The inventory is dynamic and updated as new strengths are discovered.
Team Mission Statement
In alignment with the Family Vision, the team collaboratively creates a written Mission Statement that defines the overall purpose and direction of the HFW team. The Mission operationalizes the Vision by clarifying the team’s shared commitment and approach to supporting the youth and family.
The youth’s and family members’ strengths initially identified during engagement are revisited and expanded as trust deepens and additional assets emerge. These updated strengths are documented and integrated into planning discussions. The Team Agreements, Strengths Inventory, and Mission Statement are retained in the clinical record and referenced during meetings to reinforce alignment and accountability.
Supervisors and Wraparound Coaches review documentation prior to approval of the Plan of Care to ensure that these foundational elements are completed and meaningfully integrated into the planning process. Internal HFW case reviews and Supervisor Review Tool (SPRT) audits further assess compliance and quality. Continuous Quality Improvement (CQI) processes monitor documentation consistency and reinforce practice standards through targeted coaching and workforce development.
Through structured facilitation, required documentation, supervisory oversight, and fidelity monitoring, Penny Lane ensures that Team Agreements, Strengths Inventory, and Mission development are completed prior to Plan of Care development and are foundational to the HFW process.
Policy & Appendix References:
Engagement & Team Formation
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
404 Phase Two – Plan Development
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery
Documentation & Monitoring
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
Training & Workforce Development
703 Workforce Training & Competency Development
719 Wraparound 101 – HFW Foundational Training
Appendix Forms
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#34 Supervisor Review Tool (SPRT)
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
Penny Lane Centers ensures that the High-Fidelity Wraparound (HFW) Facilitator intentionally guides the Child and Family Team (CFT) through a structured, needs-driven planning process prior to finalizing the HFW Plan of Care. This process builds upon the Strengths, Needs, and Culture Discovery completed during engagement and reinforces collaborative, measurable, and individualized planning.
Before the Plan of Care is developed, the Facilitator leads the team in reviewing all underlying needs identified during engagement and invites the youth, caregivers, and team members to identify any additional needs that may have emerged. These needs are written as functional underlying needs statements, reflecting the reasons behaviors or challenges are occurring rather than deficits or diagnoses, and are clearly documented in the youth’s file. The team then prioritizes needs based on urgency, impact, and family preference.
From the prioritized needs, the team collaboratively develops specific, measurable goals and outcomes. Goals are directly linked to the underlying needs and are framed in terms of desired functional improvement rather than symptom suppression or compliance. The youth and family actively participate in defining what success looks like and how progress will be measured.
The Facilitator then engages the team in structured brainstorming to generate multiple creative, individualized strategies before narrowing down selected interventions. Brainstorming emphasizes use of strengths, natural supports, cultural assets, and community resources. Multiple potential strategies are documented in meeting minutes, progress notes, or draft planning materials to preserve creative options and allow for flexibility if revisions are needed.
Selected strategies are then translated into clearly assigned action items with responsible team members and timeframes. These action items are incorporated into the individualized HFW Plan of Care. The planning process is conducted in a team-based, collaborative environment that reinforces shared ownership and accountability.
Facilitators receive ongoing training and supervisory coaching in:
Writing functional underlying needs statements
Developing measurable goals from needs
Leading collaborative prioritization discussions
Facilitating effective brainstorming sessions
Translating strategies into actionable steps
Supervisors review Plans of Care through internal case reviews and Supervisor Review Tool (SPRT) audits to ensure needs prioritization, measurable goal alignment, documented brainstorming, and collaborative development are evident. Continuous Quality Improvement (CQI) processes monitor documentation quality and reinforce planning standards through targeted workforce coaching.
Through structured facilitation, documented needs prioritization, measurable goal development, collaborative brainstorming, and supervisory oversight, Penny Lane ensures that individualized HFW Plans of Care are developed in alignment with HFW principles and team-based practice standards.
Policy & Appendix References:
Needs Identification & Plan Development
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery
Documentation & Monitoring
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#17 Plan of Care Template
#4 CFT Meeting Minutes
#3 Strengths Assessment
#34 Supervisor Review Tool (SPRT)
#43 CANS
4.3 Develop an Individualized Child or Youth and Family Plan
Penny Lane Centers ensures that the High-Fidelity Wraparound (HFW) team develops a comprehensive initial Plan of Care through a structured, collaborative, and principle-driven team process. The Facilitator leads the Child and Family Team (CFT) in integrating prioritized needs, measurable goals, and individualized strategies into a coordinated, strengths-based Plan that reflects Family Voice and Choice. When serving an Indian child, Tribal representatives are engaged as equal partners in the planning process to ensure cultural alignment and shared decision-making.
The Plan of Care is explicitly aligned with the Family Vision and Team Mission Statement and is grounded in the documented strengths, prioritized underlying needs, and cultural context of the youth and family. The planning process elicits multiple perspectives from formal system partners, natural supports, caregivers, and youth, fostering trust, shared ownership, and a unified direction.
The Plan addresses needs across multiple life domains, including behavioral health, education, family functioning, community integration, safety, permanency, and vocational development—as identified and prioritized by the HFW team. Goals and objectives from Children’s System of Care partners (e.g., mental health, child welfare, probation, education, regional center) are integrated into a single coordinated Plan to reduce fragmentation and duplication.
Strategies and action items are clearly documented with:
Assigned responsible team members
Established due dates
Defined measurable outcomes
Shared understanding of roles
Strategies are culturally relevant and intentionally balanced across formal services, natural supports, community resources, and family-driven interventions. Over time, the Plan is designed to increase reliance on natural supports and reduce dependence on formal systems.
Services are delivered within the youth and family’s community and scheduled in alignment with family preferences, accessibility needs, trauma-informed considerations, and equitable participation standards. Natural supports and sustainable community resources are embedded in the Plan, or strategies are included to identify and develop these supports prior to transition.
Transition planning is embedded throughout implementation. The Plan sets benchmarks for moving toward less restrictive, less intrusive, and less formal supports, while honoring the family’s pace and readiness. Graduation occurs based on stabilization and needs resolution, not administrative requirements.
Facilitators receive ongoing training and supervisory coaching to lead high-quality planning processes that demonstrate HFW principles. Supervisors and Wraparound Coaches review Plans of Care through structured internal case reviews and Supervisor Review Tool (SPRT) audits to ensure all required components are present and of high quality. Plans are documented in the clinical record and distributed to all team members to ensure coordinated implementation.
Continuous Quality Improvement (CQI) processes analyze Plan quality, documentation trends, cross-system integration, and fidelity data (WFI, TOM, CANS, LOCUS) to inform workforce development and strengthen planning consistency across teams.
Through structured facilitation, cross-system coordination, documented accountability, supervisory oversight, and CQI review, Penny Lane operationalizes comprehensive Plan of Care development as a measurable and sustainable HFW practice standard.
Policy & Appendix References:
Plan Development & Implementation
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
411 Coordinated Care
413 High-Fidelity Wraparound Service Delivery
406 Phase Four – Transition
Documentation & Distribution
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#17 Plan of Care Template
#4 CFT Meeting Minutes
#3 Strengths Assessment
#34 Supervisor Review Tool (SPRT)
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS
4.4 Develop a Crisis and Safety Plan
Penny Lane Centers ensures that the High-Fidelity Wraparound (HFW) Facilitator leads the Child and Family Team (CFT) in developing a comprehensive, individualized Crisis and Safety Plan that prioritizes safety needs, anticipates high-risk situations, and outlines proactive and reactive strategies. Crisis planning is strengths-based, culturally responsive, and family-driven, ensuring that strategies are chosen by the youth and caregivers and reflect their preferences, lived experience, and cultural values.
During Phase Two (Plan Development), the team collaboratively identifies potential triggers, escalation patterns, environmental stressors, and safety vulnerabilities. The Crisis and Safety Plan clearly documents:
Potential safety risks and high-risk scenarios
Early warning signs
Proactive prevention strategies
Reactive intervention steps in progressive order
Designated natural supports and formal contacts
24/7 crisis response information
Strategies emphasize the use of natural supports wherever possible and prioritize family-led prevention and de-escalation before professional intervention is required. The plan includes clear instructions regarding who to contact for support at any time, ensuring families understand how to access crisis response resources when needed.
The development of the Crisis and Safety Plan occurs within a team-based, collaborative environment. Facilitators receive ongoing training and supervisory coaching in trauma-informed crisis planning, cultural humility, de-escalation techniques, and facilitation of structured safety discussions. Supervisors and Wraparound Coaches review Crisis and Safety Plans to ensure they reflect individualized, culturally relevant, and progressive strategies rather than generic templates.
Crisis and Safety Plans are reviewed during Child and Family Team meetings, especially following crisis events, and are revised as needed to strengthen prevention efforts. Internal case reviews and Continuous Quality Improvement (CQI) processes evaluate plans for evidence of individualized strategy progression, meaningful natural support integration, and cultural alignment. Feedback is incorporated into staff coaching and workforce development efforts to reinforce high-quality crisis planning practices.
Through structured team facilitation, documented individualized planning, supervisory oversight, and CQI review mechanisms, Penny Lane operationalizes crisis and safety planning as a measurable HFW standard that strengthens prevention, safety, and long-term stabilization.
Policy & Appendix References:
Crisis & Safety Planning
404 Phase Two – Plan Development
405 Phase Three – Implementation
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery
Documentation
502 Progress Notes and Service Documentation
205 Special Incident Reports
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Training & Workforce Development
703 Workforce Training & Competency Development
719 Wraparound 101 – HFW Foundational Training
Appendix Forms
#22 Safety and Crisis Plan
#10 Immediate Safety and Stabilization Plan
#23 Special Incident Report (SIR)
#17 Plan of Care Template
#4 CFT Meeting Minutes
Implementation
5.1 Implement The Plan of Care
Penny Lane Centers ensures that the High-Fidelity Wraparound (HFW) team actively implements the initial Plan of Care and systematically monitors progress toward meeting prioritized needs and achieving measurable outcomes. Implementation is conducted in alignment with HFW principles, emphasizing shared ownership, accountability, strengths-based practice, and Family Voice and Choice.
The Facilitator leads the Child and Family Team (CFT) in reviewing strategies and action items at each team meeting. Meeting agendas and minutes include structured sections for:
Review of previously assigned action items
Status updates and completion tracking
Identification of barriers to implementation
Adjustment of strategies as needed
Confirmation of next steps and responsible parties
Individual assignments are tracked, and timelines are reinforced to maintain forward momentum. When strategies are not producing expected outcomes, the team collaboratively revises the Plan in a solution-focused manner consistent with HFW principles. Adjustments are documented and redistributed to all team members to ensure coordinated implementation.
The team intentionally acknowledges and celebrates progress as successes occur, whether small milestones or significant breakthroughs. Celebrations are culturally responsive and aligned with family preferences, reinforcing strengths and sustaining motivation. Recognition may occur within CFT meetings, through written acknowledgments, community-based celebrations, or informal affirmations that honor the youth and family’s growth.
Staff receive ongoing training and supervisory coaching in implementing Plans of Care with fidelity to HFW principles. Training emphasizes strengths-based facilitation, collaborative monitoring, measurable tracking, persistence through setbacks, and the intentional celebration of progress. Supervisors review meeting minutes and Plans of Care through internal case reviews and Supervisor Review Tool (SPRT) audits to ensure action tracking and success recognition are evident.
Continuous Quality Improvement (CQI) processes analyze documentation trends, fidelity tool results (WFI, TOM), and outcome data to reinforce implementation quality and strengthen practice consistency. Through structured monitoring, team accountability, workforce coaching, and intentional celebration of progress, Penny Lane operationalizes Plan implementation as an active, measurable, and principle-aligned HFW standard.
Policy & Appendix References:
Plan Implementation & Monitoring
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery
Documentation & Tracking
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#4 CFT Meeting Minutes
#17 Plan of Care Template
#34 Supervisor Review Tool (SPRT)
#26 Wraparound Fidelity Index
#36 TOM
5.2 Review and Update The Plan of Care
Penny Lane Centers ensures that the High-Fidelity Wraparound (HFW) Facilitator leads a continuous, structured review process to assess progress, evaluate strategy effectiveness, and revise the Plan of Care as needed. The Plan is treated as a dynamic document that evolves in response to measurable outcomes, emerging needs, and team feedback, rather than a static service agreement.
Reviews of strategies, goals, and action items occur within formal Child and Family Team (CFT) meetings. During these meetings, the Facilitator guides the team in:
Reviewing progress toward prioritized needs
Assessing completion of assigned action items
Evaluating the effectiveness of selected strategies
Identifying new or emerging needs
Revising goals or selecting alternative strategies when necessary
When adjustments are required, whether due to success, limited progress, crisis events, or changing circumstances, the team collaboratively updates the Plan. Changes are documented in the youth’s clinical file and reflected in updated Plans of Care. The Plan is formally updated and redistributed to all team members at least every ninety (90) days, and more frequently when clinically indicated.
The Facilitator documents and communicates critical implementation elements through meeting minutes and case documentation, including:
Completion of tasks and assignment of new action items
Team attendance and participation
Use of formal and natural supports
Allocation and use of flexible funds
Updates to strategies, goals, and needs statements
Meeting minutes serve as the primary communication tool to ensure transparency and shared accountability. Updated Plans of Care are distributed to all team members to maintain coordinated implementation across Children’s System of Care partners.
Documentation forms, including the Plan of Care template and meeting minutes are designed to allow flexibility and individualization, enabling updates that reflect the youth and family’s evolving needs, cultural context, and progress trajectory.
Supervisors and Wraparound Coaches review documentation through internal HFW case reviews and Supervisor Review Tool (SPRT) audits to ensure plan updates are timely, individualized, and reflective of team-based decision-making. Continuous Quality Improvement (CQI) processes analyze plan update patterns and documentation quality to inform workforce coaching and practice refinement.
Through structured meeting reviews, dynamic plan adjustments, comprehensive documentation practices, and supervisory oversight, Penny Lane operationalizes ongoing Plan review and revision as a measurable and fidelity-aligned HFW standard.
Policy & Appendix References:
Plan Review & Revision
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery
406 Phase Four – Transition
Documentation & Communication
502 Progress Notes and Service Documentation
312 Flex Funds
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
Training & Workforce Development
703 Workforce Training & Competency Development
719 Wraparound 101 – HFW Foundational Training
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#4 CFT Meeting Minutes
#17 Plan of Care Template
#29 Flex Fund Request Form
#34 Supervisor Review Tool (SPRT)
#26 Wraparound Fidelity Index
#36 TOM
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) Facilitators actively monitor and strengthen team cohesion, trust, and commitment throughout the Wraparound process. Effective collaboration is treated as an essential condition for successful Plan implementation. The Facilitator intentionally cultivates a respectful, solution-focused team culture where all members, including youth, caregivers, formal providers, natural supports, and when applicable, Tribal representatives experience shared ownership and accountability.
Team Agreements are established during initial team formation and are reviewed regularly at Child and Family Team (CFT) meetings to reinforce communication norms, shared expectations, and decision-making processes. Agreements remain present and visible during meetings to anchor collaboration and promote psychological safety.
Facilitators are trained and coached in advanced team facilitation skills, including conflict resolution, trust-building, collaborative problem-solving, and managing cross-system dynamics. Supervisors and Wraparound Coaches provide ongoing observation and feedback to strengthen facilitation effectiveness and team engagement practices.
The use and integration of natural supports are monitored over time. Facilitators intentionally assess whether natural supports are meaningfully engaged in strategies and action items, and whether reliance on formal supports is gradually decreasing as stability increases. Supervisors review Plans of Care and meeting documentation to ensure natural supports are actively utilized. Feedback regarding natural support engagement is incorporated into coaching and Continuous Quality Improvement (CQI) processes.
When new team members are added, whether formal partners or natural supports, the Facilitator conducts a structured orientation process. Orientation includes:
Explanation of the HFW principles and phases
Review of the Family Vision and Team Mission
Summary of prioritized needs and current strategies
Clarification of roles and responsibilities
Engagement in team-building discussions to integrate the new member into the team culture
This process ensures continuity, alignment, and sustained collaboration despite team composition changes.
Through structured Team Agreements, workforce training, supervisory oversight, monitored natural support integration, and formal orientation procedures, Penny Lane operationalizes team cohesion and collaborative functioning as measurable HFW practice standards.
Policy & Appendix References:
Team Development & Engagement
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
409 Child and Family Team (CFT) Meetings
411 Coordinated Care
413 High-Fidelity Wraparound Service Delivery
Documentation
502 Progress Notes and Service Documentation
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#4 CFT Meeting Minutes
#17 Plan of Care Template
#3 Strengths Assessment
#34 Supervisor Review Tool (SPRT)
#26 Wraparound Fidelity Index
#36 TOM
Transition
6.1 Develop a Transition Plan
Penny Lane Centers ensures that transition from High-Fidelity Wraparound (HFW) services is purposeful, collaborative, and based on measurable benchmarks indicating sufficient progress toward the Family Vision, Team Mission, and prioritized needs. Transition planning is not event-driven or administratively imposed; it is initiated when the youth, family, and team collectively determine readiness based on monitored outcomes and stabilization indicators.
Throughout implementation, the Child and Family Team (CFT) tracks measurable progress, natural support engagement, caregiver confidence, reduced crisis frequency, and improved functioning across life domains. When pre-determined benchmarks are achieved, the Facilitator leads the team in formally identifying readiness for transition. Family voice and choice guide this determination.
Once readiness is established, the Facilitator leads the development of an individualized Transition Plan within a team-based meeting. The Transition Plan:
Identifies remaining needs, if any
Specifies ongoing services and natural supports
Clarifies how formal HFW supports will be tapered or transferred
Establishes sustainability strategies
Includes crisis response continuity planning
Documents timelines and responsible parties
The individualized Transition Plan is documented in the youth’s clinical file and distributed to all team members to ensure coordinated follow-through. Transition planning includes verification that identified services and supports will persist beyond formal HFW involvement and that the family understands how to access them independently.
For adoptive families utilizing Adoption Assistance Program (AAP) funding, families are specifically educated regarding available post-adoptive services and community-based resources that can provide continued support. This education is documented and integrated into the transition planning process to ensure continuity and stability.
Facilitators receive ongoing training and supervisory coaching in leading effective transition discussions, identifying sustainability indicators, and supporting graduated movement toward less restrictive and less formal services. Supervisors review Transition Plans through internal case reviews and Supervisor Review Tool (SPRT) audits to ensure benchmarks, sustainability planning, and family readiness are clearly documented.
Continuous Quality Improvement (CQI) processes monitor transition trends and outcomes to reinforce needs-based discharge practices and long-term sustainability standards.
Through structured readiness assessment, individualized transition documentation, coordinated team collaboration, and supervisory oversight, Penny Lane operationalizes transition planning as a measurable and fidelity-aligned HFW standard.
Policy & Appendix References:
Transition Planning & Sustainability
406 Phase Four – Transition
419 Graduation and Disenrollment
503 Aftercare, Graduation, and Disenrollment
413 High-Fidelity Wraparound Service Delivery
Plan Monitoring & Benchmark Review
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Coordinated Care & Ongoing Supports
411 Coordinated Care
312 Flex Funds
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
Training & Workforce Development
703 Workforce Training & Competency Development
719 Wraparound 101 – HFW Foundational Training
Appendix Forms
#8 Disenrollment Summary/Aftercare Plan
#24 Transfer Review and Transition Plan
#17 Plan of Care Template
#4 CFT Meeting Minutes
#34 Supervisor Review Tool (SPRT)
6.2 Develop a Post-Transition Safety Plan
Penny Lane Centers ensures that, prior to the conclusion of formal High-Fidelity Wraparound (HFW) services, the Facilitator leads the Child and Family Team (CFT) in developing or revising a comprehensive Crisis and Safety Plan specifically tailored to the post-transition period. This transition-focused planning ensures that youth and families are equipped with individualized, culturally relevant, and sustainable strategies to manage potential future crises without reliance on formal HFW support.
As part of Phase Four (Transition), the team reviews the existing Crisis and Safety Plan and updates it—or develops a new transition-focused plan—to reflect the youth and family’s anticipated needs after HFW concludes. The updated plan:
Identifies potential crisis situations that may arise post-transition
Defines early warning signs
Outlines proactive prevention strategies
Specifies reactive, stepwise intervention strategies
Identifies natural and community supports who will remain engaged
Provides clear 24/7 contact guidance when professional services are necessary
The youth and caregivers play a central role in identifying preferred strategies, selecting trusted natural supports, and ensuring cultural relevance of prevention and response approaches. Emphasis is placed on maximizing natural and community supports, strengthening caregiver-led crisis management capacity, and reinforcing informal networks to promote long-term sustainability.
The development of the transition-focused Crisis and Safety Plan occurs in a team-based, collaborative meeting environment. Facilitators receive ongoing training and supervisory coaching in trauma-informed crisis planning, culturally responsive facilitation, and post-transition sustainability strategies. Supervisors and Wraparound Coaches review documentation to ensure plans reflect individualized strategy progression and meaningful natural support integration.
Structured review processes, including internal HFW case reviews and Continuous Quality Improvement (CQI) audits, assess crisis and safety plans for:
Individualization and specificity
Clear proactive-to-reactive strategy progression
Cultural relevance
Natural support integration
Alignment with transition benchmarks
Feedback from these reviews informs workforce training and coaching efforts to strengthen transition readiness and crisis prevention practices agency-wide.
Through structured transition planning, documented individualized crisis strategies, collaborative team processes, and supervisory oversight, Penny Lane operationalizes post-transition safety planning as a measurable and fidelity-aligned HFW standard.
Policy & Appendix References:
Crisis & Transition Planning
406 Phase Four – Transition
405 Phase Three – Implementation
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery
Documentation
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Training & Workforce Development
703 Workforce Training & Competency Development
718 Wraparound 101 – HFW Foundational Training
Appendix Forms
#22 Safety and Crisis Plan
#10 Immediate Safety and Stabilization Plan
#8 Disenrollment Summary/Aftercare Plan
#24 Transfer Review and Transition Plan
#4 CFT Meeting Minutes
#17 Plan of Care Template
6.3 Create a Commencement and Celebrate Success
Penny Lane Centers ensures that the conclusion of formal High-Fidelity Wraparound (HFW) services is intentionally celebrated as a positive milestone reflecting growth, resilience, and progress. Transition is framed as an achievement aligned with the Family Vision and Team Mission, not simply the end of services. Celebrations are designed to be meaningful, culturally relevant, and reflective of the youth and family’s preferences, values, and traditions.
During Phase Four (Transition), the Facilitator collaborates with the youth and family to determine how they would like to mark the conclusion of HFW involvement. Celebrations may include formal graduation meetings, culturally significant ceremonies, community-based gatherings, recognition during a final Child and Family Team (CFT) meeting, written affirmations of progress, or other family-preferred acknowledgments. The format, tone, and level of visibility are determined by the youth and family.
Administrative structures support celebratory transitions by allowing:
Access to flexible funds when appropriate
Allocation of staff time for celebration planning and participation
Engagement of community partners and natural supports
Development of commemorative materials or recognition documents
These structures reinforce that celebration is an integral component of strengths-based practice and persistence, not an optional activity.
Supervisors review transition documentation to ensure that discharge reflects stabilization and includes recognition of progress. Transition summaries document celebration activities and family participation. Continuous Quality Improvement (CQI) processes monitor discharge practices to ensure transitions are needs-based and positively framed.
Through structured transition planning, culturally responsive celebration practices, administrative support mechanisms, and supervisory oversight, Penny Lane operationalizes celebration of transition as a fidelity-aligned and strengths-driven HFW standard.
Policy & Appendix References:
Transition & Discharge
406 Phase Four – Transition
419 Graduation and Disenrollment
503 Aftercare, Graduation, and Disenrollment
Plan Monitoring & Closure
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
502 Progress Notes and Service Documentation
Flexible & Community-Based Supports
312 Flex Funds
411 Coordinated Care
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Appendix Forms
#8 Disenrollment Summary/Aftercare Plan
#24 Transfer Review and Transition Plan
#17 Plan of Care Template
#4 CFT Meeting Minutes
#29 Flex Fund Request Form
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
Penny Lane Centers ensures that youth and family voice extends beyond individual case planning and meaningfully informs all levels of High-Fidelity Wraparound (HFW) implementation. Youth and caregiver feedback is systematically incorporated into service planning, policy refinement, workforce development, and Continuous Quality Improvement (CQI) processes. Family Voice and Choice is operationalized not only at the team level but also at the organizational level.
At the service delivery level, youth and caregivers are primary decision-makers within the Child and Family Team (CFT). Their preferences, priorities, and satisfaction directly influence strategy selection, Plan revisions, and transition planning. At the program level, structured feedback mechanisms, including Wraparound Fidelity Index (WFI), Team Observation Measure (TOM), satisfaction surveys, and Quality Assurance (QA) follow-up calls, collect data on the family experience across multiple domains.
Mechanisms are in place for families to participate in local HFW implementation decisions. This may include participation in advisory discussions, structured feedback forums, satisfaction surveys, or quality improvement initiatives designed to capture lived experience input. Feedback themes are aggregated and reviewed by leadership and QA/QI teams to inform:
Policy and procedure revisions
Workforce training priorities
Cultural responsiveness improvements
System coordination practices
Family feedback trends are analyzed as part of CQI review cycles. Supervisors and leadership integrate findings into coaching strategies, performance improvement planning, and workforce development initiatives. When feedback identifies gaps in accessibility, engagement, cultural relevance, or collaboration, targeted corrective actions are implemented and monitored.
Documentation processes ensure that feedback is not only collected but evaluated and acted upon. QA/QI leadership tracks feedback patterns and presents findings within program oversight structures to ensure continuous learning and improvement.
Through structured feedback systems, family participation mechanisms, leadership review processes, and integrated CQI practices, Penny Lane operationalizes youth and family partnership as a core governance and implementation standard within the HFW program.
Policy & Appendix References:
Family Voice & Service Planning
402 High-Fidelity Wraparound Family Assessment & Engagement Process
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery
Quality Improvement & Feedback Integration
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
Policy & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#26 Wraparound Fidelity Index
#36 TOM
#4 CFT Meeting Minutes
#17 Plan of Care Template
7.2 Community Leadership Team
Penny Lane Centers actively participates in the County-established Community Leadership Team (CLT) to support shared decision-making and systems-level alignment with California Wraparound Standards and High-Fidelity Wraparound (HFW) principles. The agency designates an identified leadership representative, typically at Deputy Director level, who consistently participates in Community Leadership Team meetings and collaborates with Interagency Leadership Teams (ILTs) and other cross-system partners.
Through this representation, Penny Lane contributes to system-level oversight and continuous improvement efforts that include:
Promoting inclusion of Tribes within the region as equal partners in community-level planning
Ensuring child-serving entities across systems (mental health, child welfare, probation, education, regional centers, community-based organizations) have opportunities to participate in CLT discussions
Identifying and addressing interagency barriers that impede coordinated service delivery
Supporting cross-agency training initiatives to strengthen family-centered, culturally relevant practice
Reviewing Wraparound implementation trends and fidelity data
Monitoring flex fund access, utilization patterns, and procedural equity
Participating in community-level review of family plans to ensure alignment with HFW values and principles
Penny Lane’s representative brings agency-level data, quality improvement findings, and practice insights to CLT discussions to inform system refinement. Conversely, CLT guidance and cross-agency initiatives are communicated internally to program leadership and integrated into workforce training, supervision practices, and policy refinement efforts.
At the organizational level, internal processes mirror community-level oversight by reviewing:
Flex fund utilization patterns
Fidelity monitoring data (WFI, TOM)
IP-CANS and outcome trends
Discharge and transition patterns
Cross-system collaboration challenges
These reviews inform Continuous Quality Improvement (CQI) planning and workforce development strategies consistent with county and state HFW standards.
Through active leadership participation, structured communication pathways, cross-system collaboration, and integrated CQI processes, Penny Lane fulfills its responsibility to engage in Community Leadership Team activities and contribute to systems-level fidelity and interagency coordination.
Policy & Appendix ReferencesL:
Interagency Collaboration & Coordinated Care
411 Coordinated Care
413 High-Fidelity Wraparound Service Delivery
412 Internal High-Fidelity Wraparound Case Reviews
Flex Fund Oversight
312 Flex Funds
Performance & Data Review
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Workforce & Cross-System Training
703 Workforce Training & Competency Development
719 Wraparound 101 – HFW Foundational Training
Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#26 Wraparound Fidelity Index
#36 TOM
#29 Flex Fund Request Form
#34 Supervisor Review Tool (SPRT)
7.3 Eligibility and Equal Access
Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) eligibility and referral processes promote adequate, appropriate, and equitable access to services. Youth who meet established eligibility criteria are not excluded based on the severity, complexity, or nature of their needs. The program is structured to serve youth with significant behavioral health challenges, system involvement, placement instability risk, or multi-domain needs requiring intensive, coordinated intervention.
Referral pathways are clearly defined and accessible through interagency partnerships, internal referral mechanisms, and community outreach. Intake procedures ensure timely review of eligibility criteria without imposing additional barriers that would limit access for high-acuity youth. HFW services are publicly communicated through outreach materials, cross-system coordination, and partnership engagement to ensure youth and families who would benefit are informed of availability.
Once enrolled, families receive services designed to address complex and multi-system needs. The HFW model integrates cross-system coordination, crisis response planning, flexible funding support, and 24/7 crisis access to ensure continuity and responsiveness. The program maintains defined business hours crisis coverage and structured after-hours protocols to ensure families have access to support when urgent needs arise.
Staffing structures are intentionally planned to maintain appropriate caseload sizes aligned with HFW intensity standards. Caseload assignments are monitored to ensure staff can provide the frequency of contact, team facilitation, community-based service delivery, and crisis responsiveness required for high-acuity cases. Supervisors monitor workload distribution and adjust assignments as needed to preserve service quality and timely engagement.
Administrative and clinical leadership evaluate staffing ratios, productivity benchmarks, and service utilization patterns to ensure adequate workforce capacity. Continuous Quality Improvement (CQI) processes review referral trends, access data, and service intensity indicators to confirm that eligibility criteria are applied equitably and that program capacity aligns with community needs.
Through equitable referral practices, non-restrictive eligibility criteria, workforce capacity planning, 24/7 crisis access protocols, and structured supervisory oversight, Penny Lane ensures that HFW services remain accessible, intensive, and responsive to youth and families with complex needs.
Policy & Appendix References:
Referral & Eligibility
401 Referral and Intake Process
402 High-Fidelity Wraparound Family Assessment & Engagement Process
44 Penny Lane Internal Referral Request HFW
Service Delivery & Intensity
413 High-Fidelity Wraparound Service Delivery
301 Hours of Operation
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
421 Home Visits
Staffing & Workforce Capacity
713 High-Fidelity Wraparound (HFW) Team Staffing
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
Performance & Capacity Monitoring
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Flexible Supports
312 Flex Funds
Appendix Forms
#14 LA County Referral Form
#44 Penny Lane Internal Referral Request HFW
#27 Wrap Line Flyer
#17 Plan of Care Template
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
Penny Lane Centers ensures that fiscal practices, internal budget planning, and contract implementation are fully aligned with the values and principles of High-Fidelity Wraparound (HFW) and the California Wraparound Standards. Within the structure of county and system-level contracts, the agency strategically allocates resources to sustain fidelity, workforce stability, data integrity, and individualized service delivery.
Fiscal oversight is integrated into program leadership, quality improvement infrastructure, and workforce planning to ensure funding supports both direct services and the operational components required for high-quality HFW implementation.
Alignment of Contracts and Budgeting with HFW Standards-
Penny Lane ensures that contract implementation and internal budget management reflect the full scope of HFW requirements, including:
High-Fidelity Direct Services and Supports-
Agency budgets prioritize the delivery of intensive, individualized, community-based services that meet the immediate and complex needs of youth and families. Fiscal planning supports:
Adequate staffing ratios to maintain manageable caseloads
Community-based engagement and home visits
Child and Family Team (CFT) facilitation
Crisis response infrastructure (business hours and after-hours coverage)
Flexible funding allocations
Coordination across Children’s System of Care partners
Rates are operationalized to ensure service intensity consistent with HFW fidelity expectations rather than minimal compliance.
Required Workforce Development and Staffing-
Budget allocations support required HFW roles and functions, including:
HFW Facilitators
Parent Partners
Youth Partners (as applicable)
Family Specialists
Clinical Supervisors (licensed)
HFW Supervisors/Managers
Fidelity oversight and QA functions
Fiscal planning includes funding for:
Initial apprenticeship training
Ongoing supervision and coaching
Annual booster trainings
ICWA and Tribal sovereignty training
Role-specific workforce development
Leadership development and mentoring programs
Compensation strategies, including bilingual differentials, retention incentives, education reimbursement, and supervision structures, are designed to maintain workforce stability and support fidelity implementation.
Data Collection and Data Management Systems-
Penny Lane allocates funding to ensure robust data collection, documentation, and quality improvement systems consistent with HFW standards. Budgeted infrastructure supports:
Electronic Health Record (EHR) systems
IP-CANS administration and tracking
TOM and WFI fidelity monitoring
LOCUS implementation
QA review processes
Internal case review systems
Data reporting and performance dashboards
Data systems are integrated into supervisory and leadership review processes to support continuous quality improvement and contract compliance.
Fiscal Oversight and Continuous Quality Improvement-
Leadership regularly reviews fiscal performance alongside fidelity and outcome data to ensure alignment between resource allocation and HFW implementation standards. Budget monitoring includes:
Staffing capacity analysis
Caseload distribution review
Flexible fund utilization trends
Training investment tracking
Crisis utilization patterns
Discharge and transition stability indicators
When service needs exceed current allocations, leadership collaborates with funders and system partners to identify funding adjustments or resource reallocation strategies that preserve fidelity and service continuity.
Commitment to HFW Values in Fiscal Practice-
Penny Lane’s fiscal model reflects core HFW values:
Family-driven allocation of flexible resources
Investment in workforce stability and cultural responsiveness
Support for cross-system coordination
Data-informed decision-making
Sustainability of services beyond formal involvement
Budgets are structured not only to fund direct service hours but also to sustain the infrastructure necessary for high-quality Wraparound practice.
Policy & Appendix References:
Fiscal Governance & Flexible Funds
312 Flex Funds
Workforce & Staffing
713 High-Fidelity Wraparound (HFW) Team Staffing
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
Data & Quality Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
Service Delivery & Crisis Infrastructure
413 High-Fidelity Wraparound Service Delivery
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
Fidelity & Outcome Tools
714 CANS
715 TOM
716 LOCUS
Appendix:
#46 Organizational Chart
#29 Flex Fund Request Form
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS
#34 Supervisor Review Tool
#17 Plan of Care Template
8.2 Equitable Funding Across System Partners
8.3 Cost Savings are Reinvested
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
Penny Lane Centers maintains a structured process to ensure families have timely access to flexible funds to address urgent, individualized needs that cannot be met through traditional funding streams or community resources. Flexible funds are embedded within the High-Fidelity Wraparound (HFW) service model as a strategic tool to remove barriers, stabilize placements, strengthen natural supports, and advance the Team Mission and individualized Plan of Care.
Flexible funds are included as part of the HFW funding structure and are accessible to teams when needs align with HFW principles. Requests originate through the Child and Family Team (CFT) process and must demonstrate alignment with the individualized Plan of Care. When serving an Indian child, flexible funds may be utilized to support Tribal services or activities that directly address identified youth and family needs, consistent with culturally respectful practice and collaborative partnership.
The defined approval process ensures that each request is evaluated against established criteria, including whether the proposed expenditure:
Adds value to the Team Mission and supports the individualized Plan of Care
Builds upon documented family strengths
Directly addresses prioritized youth and family needs
Is culturally relevant and responsive
Strengthens natural supports and/or community capacity
Represents a fiscally responsible investment
Includes a sustainability plan when applicable
Requests are submitted through a standardized Flexible Fund Request Form and reviewed by designated program leadership (e.g., Program Manager, Regional Director, or Senior Director) in accordance with county and agency policy. Approval processes are designed to be timely to address urgent needs and prevent service disruption.
If a request is denied, there is a structured communication process to inform the team, youth, and family of the rationale. Teams may revise and resubmit requests with additional justification or explore alternative funding or community-based resources. This process reinforces transparency and shared problem-solving.
Supervisors and QA/QI leadership monitor flexible fund utilization patterns, approval timelines, and alignment with HFW principles through internal case reviews and Continuous Quality Improvement (CQI) processes. Regular review ensures funds are equitably distributed, strategically utilized, and aligned with individualized planning standards.
Through structured funding allocation, defined approval criteria, transparent communication practices, and CQI oversight, Penny Lane operationalizes flexible funds as a responsive, equitable, and fidelity-aligned component of the HFW program.
Policy & Appendix References:
Flexible Funds Governance
312 Flex Funds
413 High-Fidelity Wraparound Service Delivery
411 Coordinated Care
Documentation & Approval
502 Progress Notes and Service Documentation
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Staffing & Administrative Oversight
713 High-Fidelity Wraparound (HFW) Team Staffing
Appendix Forms
#29 Flex Fund Request Form
#17 Plan of Care Template
#4 CFT Meeting Minutes
#34 Supervisor Review Tool (SPRT)
8.5 Collaborative Oversight of Flex Funds
Penny Lane Centers maintains structured collaboration and shared oversight with funders and system partners regarding the availability, allocation, and monitoring of flexible funds within the High-Fidelity Wraparound (HFW) Program. Flexible funds are managed transparently to ensure equitable access, fiscal accountability, and alignment with HFW principles across all families served.
Flexible funds are pooled and held at the program level to ensure that resources are available to meet the individualized needs of all enrolled families rather than being restricted to individual teams or cases. This pooled structure promotes equity, sustainability, and strategic allocation based on prioritized needs.
Each flexible fund request is formally documented through standardized procedures that capture:
Requested amount
Purpose of the request
Linkage to prioritized needs and Plan of Care
HFW team recommendation
Approval or denial decision
Final allocation amount
Documentation ensures that both approved and denied requests are tracked. Denials are recorded along with rationale to promote transparency and learning. This tracking allows program leadership and funders to analyze utilization patterns, identify trends, and assess alignment with funding criteria.
Flexible fund utilization data—including total funds available, amounts allocated, categories of use, and approval rates is reviewed regularly by program leadership and shared with funders as required. This ensures collaborative fiscal oversight and alignment with contractual and county requirements.
Continuous Quality Improvement (CQI) processes review flexible fund patterns to evaluate whether allocations:
Reflect individualized, needs-driven planning
Support natural supports and community-based strategies
Promote sustainability
Demonstrate equitable distribution across families
Supervisors and leadership use utilization data to provide coaching and ensure consistent application of approval criteria across teams.
Through pooled fund management, structured documentation practices, transparent reporting, and collaborative oversight with funders and providers, Penny Lane ensures responsible stewardship and equitable access to flexible funds consistent with HFW standards.
Policy & Appendix References:
Flexible Fund Governance & Oversight
312 Flex Funds
413 High-Fidelity Wraparound Service Delivery
411 Coordinated Care
Documentation & Tracking
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
Staffing & Administrative Oversight
713 High-Fidelity Wraparound (HFW) Team Staffing
Appendix Forms
#29 Flex Fund Request Form
#17 Plan of Care Template
#4 CFT Meeting Minutes
#34 Supervisor Review Tool (SPRT)
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
Penny Lane Centers ensures that the requirements or limitations of any single funding source do not restrict the availability of flexible funds or limit the resources necessary to meet the individualized needs of youth, families, Tribes, and communities served through High-Fidelity Wraparound (HFW). The program operates within a braided funding framework that strategically integrates multiple System of Care funding streams to preserve flexibility, equity, and responsiveness.
Flexible funds and HFW program resources are supported through coordinated use of available funding sources (e.g., BHSA, Title IV-E, CalWORKs, Medi-Cal, county allocations, and other System of Care funding streams). This braided funding structure allows Penny Lane to sustain access to individualized supports without overreliance on a single revenue source.
When limitations exist within a particular funding stream, leadership explores alternate funding mechanisms or increases reliance on other available sources to fill gaps. The approval process ensures that funding source requirements are considered for compliance purposes but do not create barriers to families receiving needed support. In situations where one funding stream cannot cover a request, alternate funding options are reviewed collaboratively to prevent service disruption.
Flexible fund access decisions are based on alignment with the individualized Plan of Care, HFW principles, and identified needs, not solely on funding category restrictions. This ensures that youth and families are not excluded from receiving flexible supports due to administrative constraints tied to a single funding source.
Leadership monitors funding allocations and access patterns through internal fiscal review and Continuous Quality Improvement (CQI) processes. Cross-system collaboration with funders supports shared oversight and strategic resource alignment to maintain equitable access across families served.
Through braided funding strategies, fiscal oversight processes, and commitment to HFW principles, Penny Lane ensures that funding requirements do not limit flexible fund availability or undermine individualized, needs-driven service delivery.
Policy & Appendix References:
Flexible Fund Governance
312 Flex Funds
413 High-Fidelity Wraparound Service Delivery
411 Coordinated Care
Fiscal Oversight & Resource Planning
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Staffing & Administrative Oversight
713 High-Fidelity Wraparound (HFW) Team Staffing
Documentation & Tracking
502 Progress Notes and Service Documentation
Appendix Forms
#29 Flex Fund Request Form
#17 Plan of Care Template
#4 CFT Meeting Minutes
#34 Supervisor Review Tool (SPRT)
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) staffing reflects the cultural, racial, and linguistic diversity of the youth, families, and communities served. Workforce planning is intentionally aligned with demographic trends to promote culturally responsive engagement, equitable access, and meaningful representation within service delivery.
The agency monitors the demographic composition of the population served and incorporates this data into recruitment and hiring strategies. Hiring practices prioritize bilingual and bicultural candidates, community-connected staff, and professionals with lived experience reflective of the families served. Recruitment efforts include outreach to diverse professional networks, community-based organizations, and culturally specific institutions to strengthen workforce representation.
When recruitment challenges limit the ability to directly match staff to the cultural, racial, or linguistic needs of a specific family, alternative strategies are implemented. These may include:
Engaging culturally aligned natural supports or community leaders as team members
Partnering with culturally specific organizations
Involving Tribal representatives when serving an Indian child
Leveraging Parent Partners who share lived or cultural experience
When a staff member fluent in the family’s preferred language is unavailable, professional interpretation services are utilized to ensure equitable communication. In certain circumstances, a trusted natural support may assist with language interpretation when appropriate and compliant with confidentiality standards. Language Access policies guide interpretation practices to preserve confidentiality and service quality.
Supervisors and leadership monitor workforce diversity metrics and service access trends through Continuous Quality Improvement (CQI) processes. Workforce development initiatives incorporate cultural humility training, bias awareness education, and culturally responsive facilitation practices to ensure staff are equipped to serve diverse populations effectively.
Through intentional recruitment strategies, demographic monitoring, alternative engagement mechanisms, language access protocols, and ongoing workforce development, Penny Lane operationalizes culturally, racially, and linguistically responsive staffing as a measurable HFW implementation standard.
Policy & Appendix References:
Workforce Recruitment & Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
701 Education, Licensure, Registration, and Certification Verification
702 Verification of Staff Credentials
713 High-Fidelity Wraparound (HFW) Team Staffing
Cultural & Linguistic Responsiveness
210 Language Access & Cultural and Linguistic Responsiveness
413 High-Fidelity Wraparound Service Delivery
402 High-Fidelity Wraparound Family Assessment & Engagement Process
Supervision & Continuous Quality Improvement
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Appendix Forms
#1 Welcome to Penny Lane’s HFW
#2 Wraparound Family Guide
#3 Strengths Assessment
#41 Agency Overview HR
#45 PL MH Flyer
#46 Wraparound Organizational Chart
9.2 Tribally Responsive Workforce
Penny Lane Centers ensures that, in cases involving Indian children, the High-Fidelity Wraparound (HFW) Program prioritizes respect for Tribal sovereignty, traditions, cultural values, and self-determination. The HFW team recognizes the Tribe as an equal and essential partner in planning and service delivery and actively promotes culturally rooted support systems that reflect the youth and family’s Tribal identity.
Staff receive structured training on Tribal sovereignty, traditions, values, and culturally responsive engagement practices. This includes formal annual training under the Indian Child Welfare Act (ICWA) to ensure compliance with federal and state mandates, understanding of Tribal rights, and respectful collaboration standards. ICWA Annual Training reinforces:
Legal foundations of Tribal sovereignty
Requirements for Tribal notification and participation
Culturally respectful communication practices
The importance of Tribal voice as equal decision-makers
Advocacy responsibilities when serving Indian children
When serving an Indian child, the HFW team actively builds partnerships with Tribal representatives and ensures they are invited and supported as equal voices on the Child and Family Team (CFT). The team works collaboratively to:
Align the Plan of Care with Tribal values and traditions
Encourage participation in Tribal ceremonies, practices, and community life
Identify culturally rooted services and supports available through the Tribe
Integrate Tribal resources into crisis planning, transition planning, and long-term sustainability strategies
Advocate for culturally aligned interventions and system coordination
Plans of Care reflect culturally relevant strategies that prioritize Tribal and natural supports wherever possible. Supervisors and QA/QI leadership monitor documentation to ensure Tribal partnership is meaningful, ongoing, and clearly reflected in case records.
Continuous Quality Improvement (CQI) processes incorporate review of Tribal engagement practices and ICWA compliance indicators. Feedback from Tribal representatives and families is integrated into workforce development and policy refinement efforts to strengthen cultural responsiveness and intergovernmental collaboration.
Through annual ICWA training, structured partnership practices, documented collaboration, and CQI oversight, Penny Lane operationalizes respect for Tribal sovereignty and culturally rooted service delivery as a measurable and fidelity-aligned HFW standard.
Policy & Appendix References:
Cultural & Tribal Responsiveness
210 Language Access & Cultural and Linguistic Responsiveness
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery
Plan Development & Implementation
404 Phase Two – Plan Development
405 Phase Three – Implementation
406 Phase Four – Transition
Workforce Training & Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
718 Indian Child Welfare Act (ICWA) Annual Training
Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Appendix Forms
#3 Strengths Assessment
#17 Plan of Care Template
#4 CFT Meeting Minutes
#26 Wraparound Fidelity Index
#36 TOM
9.3 Flexible and Creative Work Environment
Penny Lane Centers ensures a high degree of collective responsibility for High-Fidelity Wraparound (HFW) program quality, cohesion, communication, and fidelity to mission. Leadership intentionally creates organizational structures that promote staff engagement, creativity, flexibility, and shared ownership of outcomes. Program quality is not viewed as the responsibility of a single department; rather, it is embedded across all roles, facilitators, supervisors, quality assurance staff, program managers, and executive leadership.
Leadership establishes structured processes to engage staff in program quality and improvement efforts. These include regular supervision sessions, internal HFW case reviews, CQI meetings, performance dashboards, fidelity tool reviews (CANS, TOM, WFI, LOCUS), and structured feedback loops. Staff are encouraged to identify service delivery challenges and propose innovative solutions aligned with HFW principles.
Cohesion is intentionally cultivated through team-based staffing models, structured supervision, cross-role collaboration, and leadership accessibility. Supervisors foster psychologically safe environments that support reflective practice, collaborative problem-solving, and strengths-based recognition of staff contributions. Leadership models HFW values internally by reinforcing respect, shared decision-making, and solution-focused dialogue.
Open communication is promoted through regular staff meetings, cross-level leadership forums, structured email and documentation protocols, and transparent reporting of program data and improvement initiatives. Staff are informed of policy updates, system changes, performance trends, and strategic priorities. Feedback from staff is actively solicited and integrated into program development and policy refinement.
A clear sense of mission and compliance with HFW philosophy is reinforced through ongoing training, onboarding processes, coaching, and fidelity monitoring. Leadership ensures staff understand and operationalize the HFW principles, phases, and activities in daily practice. Internal review tools and fidelity audits reinforce alignment between documented practice and HFW standards. Creative and flexible problem-solving is encouraged when barriers arise, provided solutions remain consistent with HFW values.
Through structured leadership engagement, transparent communication systems, CQI infrastructure, workforce development strategies, and fidelity monitoring processes, Penny Lane operationalizes collective responsibility for quality, cohesion, and mission alignment as a foundational HFW program standard.
Policy & Appendix References:
Performance & Quality Improvement
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
Workforce Development & Mission Alignment
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
718 Wraparound 101 – HFW Foundational Training
718 Indian Child Welfare Act (ICWA) Annual Training
Service Delivery & Fidelity
413 High-Fidelity Wraparound Service Delivery
714 CANS
715 TOM
716 LOCUS
Organizational Structure
103 Penny Lane Wraparound Organizational Chart
713 High-Fidelity Wraparound (HFW) Team Staffing
Appendix Forms
#34 Supervisor Review Tool (SPRT)
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS
9.4 Hiring, Performance Evaluation, and Job Descriptions
Penny Lane Centers maintains rigorous hiring practices and structured performance assessment processes to ensure staff possess the competencies necessary to implement High-Fidelity Wraparound (HFW) with fidelity and integrity. Recruitment, onboarding, supervision, and evaluation processes are intentionally aligned with Wraparound values, principles, phases, and activities.
Rigorous Hiring Practices-
All HFW positions are supported by formal job descriptions that reflect best practices in Wraparound facilitation, family engagement, cultural responsiveness, crisis management, and coordinated care. Recruitment processes include:
Review of relevant education, licensure, and certifications (as applicable)
Behavioral interview questions aligned with HFW competencies
Evaluation of experience in family-centered, strengths-based practice
Assessment of cultural humility and community engagement experience
Background and credential verification in compliance with agency policy
Hiring decisions prioritize alignment with HFW philosophy, demonstrated collaboration skills, crisis responsiveness, and commitment to family voice and choice.
Defined HFW Team Roles-
Job descriptions clearly articulate expectations, required competencies, and performance standards for the following HFW team roles (functions may be fulfilled by designated positions within the program structure):
Youth Partner – Engages youth voice, supports self-advocacy, and promotes youth-driven participation.
Parent Partner – Provides lived-experience advocacy, caregiver support, and reinforces family voice and choice.
HFW Facilitator – Leads the Child and Family Team (CFT), oversees Plan of Care development and implementation, and ensures fidelity to HFW principles.
Family Specialist – Provides skill-building, support, and resource linkage aligned with prioritized needs.
Fidelity Coach – Monitors adherence to HFW standards, provides coaching feedback, and supports fidelity improvement.
Clinical Supervisor (Licensed) – Provides clinical oversight, crisis consultation, documentation review, and compliance monitoring.
HFW Supervisor/Manager (License not required) – Oversees program operations, staffing, quality improvement, and fidelity implementation.
Each role includes clearly defined responsibilities related to engagement, documentation, crisis planning, coordinated care, natural support integration, and data-informed practice.
Performance Assessment & Ongoing Evaluation-
Meaningful performance assessments are conducted through:
Structured supervision and documentation review
Internal HFW case reviews
Fidelity monitoring (CANS, TOM, WFI, LOCUS as applicable)
Evaluation of timeliness and Plan of Care quality
Crisis response documentation review
Feedback from families and team members
Performance evaluations assess both quantitative indicators (timeliness, documentation quality, action tracking) and qualitative competencies (engagement skill, team facilitation, cultural responsiveness, collaboration).
Supervisors provide structured feedback, coaching plans, and professional development recommendations aligned with workforce training standards. Identified performance gaps inform individualized development plans and targeted booster trainings.
Continuous Quality Improvement Integration-
Hiring practices and performance assessment data are reviewed at the leadership level to ensure workforce capacity aligns with program needs and fidelity expectations. Trends inform recruitment priorities, job description refinement, and training enhancements.
Through structured recruitment standards, clearly defined role expectations, rigorous supervision practices, fidelity monitoring tools, and data-informed performance management, Penny Lane operationalizes workforce accountability and excellence as foundational to HFW program quality.
Policy & Appendix References:
Hiring & Credentialing
701 Education, Licensure, Registration, and Certification Verification
702 Verification of Staff Credentials
713 High-Fidelity Wraparound (HFW) Team Staffing
103 Penny Lane Wraparound Organizational Chart
Workforce Training & Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
718 Indian Child Welfare Act (ICWA) Annual Training
Supervision & Performance Oversight
602 Supervisor-Led Continuous Quality & Performance Improvement
601 Performance Improvement (HFW)
412 Internal High-Fidelity Wraparound Case Reviews
Fidelity & Outcome Monitoring
714 CANS
715 TOM
716 LOCUS
Appendix
#45 PL MH Flyer
#41 Agency Overview HR
JD- Facilitator
JD- Child and Family Specialist
JD- Intensive Service Clinical Manager
JD- Intensive Service Program Manager
JD- Parent Partner
JD- Parent Partner Coordinator/ Family Specialist
JD- IS QA Manager/ Fidelity Wraparound Coach
9.5 Workforce Stability
Penny Lane Centers implements comprehensive Human Resources and leadership strategies designed to maintain a stable, engaged workforce and reduce turnover across High-Fidelity Wraparound (HFW) programs. Workforce stability is treated as a strategic priority directly connected to service quality, fidelity, and continuity of care for youth and families.
Human Resources, in partnership with executive and program leadership, utilizes structured recruitment, competitive compensation, workload monitoring, advancement pathways, and employee engagement initiatives to sustain a high-performing and diverse workforce.
Matching Wages to Cost of Living-
Penny Lane offers competitive salaries and comprehensive benefits aligned with the cost of living in Los Angeles County and surrounding service areas. Compensation strategies include:
Market-informed salary benchmarking
Competitive starting wages
Bilingual differential compensation ($5,000 annually)
Retention bonus programs
4-tier service time (billing) incentive program
Education reimbursement (up to $2,000 annually)
Workforce grant stipends (tuition and loan repayment opportunities)
401K with employer match and profit-sharing
These compensation strategies reflect the agency’s commitment to equitable wages and long-term staff retention.
Maintaining Manageable Workloads-
Workforce planning aligns with HFW intensity standards to ensure manageable caseloads and appropriate service frequency. Leadership monitors:
Caseload size relative to acuity
Crisis coverage structures
Service intensity benchmarks
Documentation support systems
Hybrid and flexible work scheduling
Supervisors regularly review workload distribution to ensure staff can meet engagement timelines, conduct community-based services, and maintain high-quality documentation without burnout.
24/7 supervisory access and crisis consultation further support staff in high-acuity situations.
Clear and Accessible Promotion/Advancement Structures-
Penny Lane maintains clearly defined job descriptions for all roles, including Youth Partner, Parent Partner, Facilitator, Family Specialist, Clinical Supervisor, Fidelity Coach, and HFW Supervisor/Manager.
Advancement structures are transparent and accessible, including:
Internal postings for five (5) business days prior to external recruitment
Career ladder pathways across program levels
Master’s practicum placement opportunities
Mentoring Program for new and emerging staff
Leadership development opportunities
Promotion pathways are inclusive and do not exclude individuals with lived experience. Parent Partners and Youth Partners are valued as essential team roles and are provided opportunities for growth and leadership engagement within the organization.
Wage Increases and Leadership Opportunities Without Position Change-
The agency provides mechanisms for financial and professional growth that do not require a formal position change, including:
Retention bonuses
Service time incentive program
Education reimbursement and CEU support
Bilingual pay differential
Specialized group supervision
Participation in committees (e.g., Racial Justice Committee)
Conference presentation and training facilitation opportunities
Peer recognition and incentive programs
These structures allow staff to expand leadership influence, increase earnings, and build expertise without leaving their current role.
Performance Management & Stability Monitoring-
Employee Development Performance (EDP) evaluations occur five months after hire or transfer and annually thereafter. Performance management aligns expectations with job descriptions and supports professional growth planning.
Primary source credential verification, licensure monitoring, and scope-of-practice oversight ensure workforce integrity and regulatory compliance.
Human Resources supports Talent Management, Health & Wellness initiatives, mentoring, and supervision structures that foster belonging, engagement, and retention within a heart-centered culture.
Organizational Culture & Retention-
Penny Lane promotes workforce cohesion and belonging through:
Heart-centered leadership philosophy
Core Gift Process training
Diversity Beyond the Basics training
Joint Commission Certification
Hybrid work models
Flexible scheduling
Recognition programs and incentives
Technology resources (laptop and phone provision)
These initiatives strengthen engagement, reduce burnout, and sustain workforce stability.
Through competitive compensation, structured advancement pathways, manageable workload oversight, professional development incentives, inclusive hiring practices, and leadership accessibility, Penny Lane operationalizes workforce stability as a foundational strategy to ensure sustained HFW fidelity and high-quality service delivery.
Policy & Appendix References:
Human Resources & Hiring
701 Education, Licensure, Registration, and Certification Verification
702 Verification of Staff Credentials
713 High-Fidelity Wraparound (HFW) Team Staffing
103 Penny Lane Wraparound Organizational Chart
Workforce Development & Retention
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
718 Indian Child Welfare Act (ICWA) Annual Training
Performance Management
602 Supervisor-Led Continuous Quality & Performance Improvement
601 Performance Improvement (HFW)
Service Delivery & Workload Oversight
413 High-Fidelity Wraparound Service Delivery
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
Appendix:
#45 PL MH Flyer
#41 Agency Overview HR
9.6 High Fidelity Training Plan
Penny Lane Centers maintains a structured, multi-tiered High-Fidelity Wraparound (HFW) Training Plan designed to ensure staff competency, leadership alignment, and fidelity to California Wraparound Standards. The training framework incorporates initial onboarding, ongoing professional development, annual booster trainings, and role-specific learning pathways for all staff, including Clinical Supervisors and Wraparound Supervisors/Managers.
Initial HFW Training:
All newly hired HFW staff complete formal foundational training prior to assuming independent case responsibility. Penny Lane utilizes structured internal Wraparound 101 training aligned with HFW principles, phases, activities, and fidelity standards. Foundational training includes:
Overview of HFW philosophy, values, and principles
Detailed instruction on the four phases of Wraparound
Child and Family Team facilitation
Strengths-based and needs-driven planning
Crisis and safety planning
Documentation standards
Cultural responsiveness and family voice
New staff also receive shadowing opportunities, supervised field exposure, and coaching prior to carrying a full caseload.
Ongoing General and Role-Specific Training:
All staff participate in ongoing training in both general Wraparound practice and role-specific competencies. Learning modalities include:
Formal in-service trainings
Supervisory coaching
Internal case reviews
Peer shadowing
Team-based learning meetings
Fidelity tool review (CANS, TOM, LOCUS, WFI)
Role-specific development ensures Facilitators, Parent Partners, Clinicians, Supervisors, and QA staff receive targeted skill enhancement aligned with their responsibilities.
Annual Booster Trainings:
At minimum annually, staff receive booster training in general Wraparound principles and in their designated role. Booster trainings reinforce fidelity expectations, address emerging practice trends, integrate policy updates, and respond to identified CQI data trends.
Supervisor & Leadership Development:
Clinical Supervisors and HFW Supervisors/Managers attend general Wraparound foundational training and receive additional leadership-focused training that includes:
Fidelity monitoring and coaching strategies
Reflective supervision practices
Data-driven performance oversight
Crisis management leadership
Workforce development and staff engagement
Quality improvement processes
Leadership development ensures supervisors can model, coach, and reinforce HFW principles consistently across teams.
ICWA, Tribal Sovereignty & Specialized Population Training:
All staff receive training on the Indian Child Welfare Act (ICWA) and Tribal sovereignty, including annual ICWA refresher training. Training reinforces legal compliance, respectful Tribal collaboration, and culturally rooted service delivery.
Mechanisms are in place to identify and provide specialized training responsive to populations with unique needs, including but not limited to:
LGBTQ+ youth
Commercially sexually exploited youth
Justice-involved youth
Youth with complex trauma
Developmental disabilities
Cultural and linguistic minority communities
Training priorities are informed by demographic data, service trends, and CQI findings.
Continuous Evaluation of Training Effectiveness:
Training participation and effectiveness are monitored through supervision feedback, fidelity review outcomes, performance evaluations, and CQI analysis. Identified skill gaps inform future training development and booster priorities.
Through structured onboarding, ongoing skill development, annual reinforcement, leadership training, ICWA compliance education, and responsive population-specific training, Penny Lane operationalizes a high-fidelity workforce development model aligned with HFW standards.
Policy & Appendix References:
Workforce Training & Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
718 Indian Child Welfare Act (ICWA) Annual Training
Supervision & Performance Oversight
602 Supervisor-Led Continuous Quality & Performance Improvement
601 Performance Improvement (HFW)
412 Internal High-Fidelity Wraparound Case Reviews
Fidelity & Outcome Tools
714 CANS
715 TOM
716 LOCUS
26 Wraparound Fidelity Index
Cultural & Linguistic Responsiveness
210 Language Access & Cultural and Linguistic Responsiveness
Appendix Forms
#42 Penny Lane Wraparound 101 Workbook
#40 Wraparound Training Materials
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS
9.7 Community-based Training Program
Penny Lane Centers administers its High-Fidelity Wraparound (HFW) Training Plan in active collaboration with youth, families, peer partners, and community stakeholders to ensure that training reflects lived experience, strengthens system alignment, and promotes authentic Family Voice and Choice. Training delivery is not limited to internal instruction; it is structured as a shared learning environment that integrates multiple perspectives within the Children’s System of Care.
Youth, caregivers, and Parent Partners with current or prior Wraparound experience are meaningfully incorporated into required Wraparound trainings. Their participation may include:
Co-facilitating portions of foundational and booster trainings
Sharing lived experience narratives
Participating in panel discussions
Contributing to scenario-based learning activities
Providing feedback on practice relevance and cultural responsiveness
Their inclusion reinforces the principle that families are equal partners in HFW implementation and strengthens staff understanding of family-centered engagement practices.
Community partners—including representatives from child welfare, probation, education, regional centers, behavioral health, community-based organizations, and when applicable, Tribal representatives are invited to attend Wraparound trainings or are offered targeted training opportunities. These trainings ensure cross-system partners:
Understand HFW principles, phases, and team roles
Clarify expectations for Child and Family Team participation
Strengthen coordinated care practices
Align service planning across systems
Enhance cultural responsiveness within collaborative environments
Outreach efforts are made to promote training opportunities across system partners to support cohesive and comprehensive service delivery. Training invitations are structured to encourage shared learning and reinforce a common understanding of HFW standards.
Supervisors and leadership evaluate training participation, collect feedback from family and community contributors, and integrate insights into Continuous Quality Improvement (CQI) processes. This collaborative training approach strengthens interagency alignment, reinforces family-driven practice, and enhances fidelity across the system of care.
Through meaningful incorporation of youth and families into training delivery, proactive engagement of community partners, and structured cross-system learning opportunities, Penny Lane operationalizes inclusive workforce development as a measurable HFW implementation standard.
Policy & Appendix References:
Workforce Training & Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
718 Indian Child Welfare Act (ICWA) Annual Training
Parent & Family Engagement
414 Parent Education and Training
415 Parent Support & Advocacy (High-Fidelity Wraparound Aligned)
Interagency Collaboration
411 Coordinated Care
413 High-Fidelity Wraparound Service Delivery
Quality Improvement & Feedback
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
Cultural & Community Engagement
210 Language Access & Cultural and Linguistic Responsiveness
Appendix Forms
#40 Wraparound Training Materials
#42 Penny Lane Wraparound 101 Workbook
#26 Wraparound Fidelity Index
#36 TOM
9.8 Coaching and Supervision
Penny Lane Centers utilizes an apprenticeship-based workforce development model to ensure High-Fidelity Wraparound (HFW) staff develop competency in Wraparound values, principles, phases, and activities prior to assuming independent case responsibility. The apprenticeship process emphasizes practical skill development, reflective learning, and application of HFW philosophy within real-world team environments.
Initial Apprenticeship Model-
All newly hired HFW staff participate in a structured onboarding and apprenticeship period that includes:
Foundational Wraparound 101 training
Shadowing experienced facilitators and team members
Participation in Child and Family Team (CFT) meetings
Supervised development of Strengths, Needs, Culture Discovery documents
Guided development of Plans of Care and Crisis & Safety Plans
Training on flex fund utilization aligned with individualized planning standards
The apprenticeship covers core competencies, including family-driven facilitation, strengths-based planning, needs prioritization, crisis planning, coordinated care, and culturally responsive practice. Specific instruction is provided on the appropriate and effective use of flexible funds to meet individualized needs, including approval criteria, sustainability considerations, and documentation requirements.
New staff demonstrate competency through supervised practice, documentation review, and structured supervisory feedback before transitioning to full caseload responsibilities.
Ongoing Coaching and Reflective Supervision-
Ongoing coaching reinforces fidelity to HFW principles and continuous skill development. Supervisors provide:
Regular individual supervision sessions
Case consultation and reflective practice discussions
Real-time crisis consultation
Documentation review and feedback
Fidelity monitoring using tools such as CANS, TOM, and internal review instruments
Coaching emphasizes persistence, collaboration, strengths-based facilitation, and flexible problem-solving consistent with HFW values.
24/7 Supervisory Access-
Recognizing the intensity and crisis-responsive nature of HFW, leadership ensures that staff have access to supervisory support on a 24/7 basis when necessary. This includes:
Defined after-hours escalation protocols-
On-call supervisory structures
Crisis consultation availability
Leadership accessibility for urgent decision-making
This infrastructure reflects the flexible scheduling and crisis response needs of families and supports staff in making timely, aligned, and informed decisions during high-acuity situations.
Continuous Quality Improvement-
Supervisory structures are monitored through Continuous Quality Improvement (CQI) processes to ensure coaching effectiveness, responsiveness, and alignment with HFW standards. Workforce development data informs refinement of apprenticeship components and leadership coaching strategies.
Through structured apprenticeship pathways, ongoing reflective supervision, flex fund competency development, and 24/7 leadership accessibility, Penny Lane operationalizes workforce coaching and support as a foundational HFW implementation standard.
Policy & Appendix References:
Workforce Development & Apprenticeship
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
Flexible Funds Training
312 Flex Funds
Supervision & Coaching
602 Supervisor-Led Continuous Quality & Performance Improvement
412 Internal High-Fidelity Wraparound Case Reviews
713 High-Fidelity Wraparound (HFW) Team Staffing
Crisis Response & 24/7 Access
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
Fidelity & Outcome Tools
714 CANS
715 TOM
716 LOCUS
Appendix Forms
#42 Penny Lane Wraparound 101 Workbook
#29 Flex Fund Request Form
#34 Supervisor Review Tool (SPRT)
#26 Wraparound Fidelity Index
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
Penny Lane Centers ensures that collected data is systematically analyzed and utilized to strengthen practice at the youth and family level, enhance overall program effectiveness, and inform system-level improvements that impact High-Fidelity Wraparound (HFW) implementation. Data is embedded within supervision, leadership oversight, and Continuous Quality Improvement (CQI) processes to promote accountability and ongoing refinement of service delivery.
At the practice level, data from IP-CANS, TOM, WFI, LOCUS, service activity tracking, crisis frequency, placement stability, educational outcomes, and flexible fund utilization is reviewed to assess progress and service alignment. Supervisors provide timely feedback to staff based on case-level data and performance reports. Data trends inform individualized coaching conversations, documentation review, fidelity monitoring, and targeted workforce development planning. Training needs are identified based on performance patterns, outcome gaps, and fidelity findings.
At the program level, aggregate data is analyzed to evaluate service intensity, timeliness of engagement, Plan of Care quality, discharge patterns, crisis utilization, hospitalization frequency, placement stability, and family satisfaction trends. Leadership uses these findings to adjust staffing structures, refine policies, enhance cross-system coordination, and improve access to resources. CQI meetings incorporate quantitative and qualitative data to drive measurable program improvements.
At the system level, data is utilized to identify structural or interagency barriers affecting families. Patterns such as service delays, resource shortages, funding constraints, or cross-system communication challenges are elevated to the Community Leadership Team (CLT) and relevant interagency partners. This ensures that data informs broader system advocacy, cross-agency collaboration, and policy refinement efforts.
Formal processes are in place to review data regularly, communicate findings across leadership and supervisory structures, and integrate feedback into operational planning. Data-informed decision-making reinforces fidelity to HFW principles, strengthens workforce competence, and supports sustainable system improvement.
Through structured data monitoring, supervisory feedback loops, CQI analysis, and system-level communication channels, Penny Lane operationalizes data utilization as a core governance and implementation standard within the HFW program.
Policy & Appendix References:
Outcomes & Data Monitoring
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
714 CANS
715 TOM
716 LOCUS
Performance & Program Improvement
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
412 Internal High-Fidelity Wraparound Case Reviews
Service Delivery & Documentation
502 Progress Notes and Service Documentation
413 High-Fidelity Wraparound Service Delivery
Interagency Collaboration
411 Coordinated Care
Appendix Forms
#26 Wraparound Fidelity Index
#36 TOM
#39/43 CANS
#34 Supervisor Review Tool (SPRT)
Fidelity Indicators
1.1 Timely Engagement and Planning
a. First contact after referral is made by the Facilitator as soon as possible, but no later than 10 calendar days, who then enters information about referrals into the company’s EMR referral module from which data flow for tracking on an Access to Care dashboard anchored to the date of referral and the date of intake. Average time from referral to enrollment is 5.8 business days and 8.5 calendar days, within the state’s HFW standard. AnD 01.11 Initiation and Authorization of Services, pg. 4., SEE ALSO SBHG BA Dashboard Reporting Tool Examples, pg. 1.
b. Initial Plans of Care are completed with child and family team within 30 calendar days from start of services and entered into the SBHG electronic medical record (EMR); thus, they are an integrated part of the client’s record. Families are provided a “hard copy” of the Plan of Care. RPP 1.24 High Fidelity Wraparound Plan of Care Policy and Procedure, pg. 2.
c. HFW teams utilize the Child and Family Team Meetings as a centralized hub to review and update the POC every 30 calendar days to focus attention on emergent needs, celebrate milestone achievements, and revise strategies regarding on-going needs. RPP 1.24 High Fidelity Wraparound Plan of Care, pg. 4.
d. Plan of care updates are completed with the child and family team at least once every 90 days, and more often as needed. The signed off Plan of care is entered into the SBHG electronic medical record (EMR), as well as distributed to the youth and family. RPP 1.24 High Fidelity Wraparound Plan of Care, pg. 2. SEE ALSO SBHG The Wraparound Process, pg. 1.
e. An automated document tracking “pushed report” is sent to the program team (Facilitator, Clinical Supervisor, QA Manager) and shows the service documentations (e.g., Assessments, Plans of Care, Outcome Measurements, etc.) that are coming due per client based enrollment dates and expected and completed forms in the EMR (“Packet Tracking”). SBHG BA Dashboard Reporting Tool Examples, pg. 1.
f. SBHG HFW Training Plan assures staff are trained to timely engagement strategies, including alternate strategies to address when contacting the family is difficult. SBHG HFW Training Plan’, pg. 6.
1.2 Led by Youth and Families
a. Youth and family perspective are gathered and documented using various documents such as Community Natural Supports Survey, Plan of Care, Strengths Discovery Inventory. Additionally, staff support and encourage tribal affiliated families to include a Tribal Representative on their HFW team. RPP 1.24 High Fidelity Wraparound Plan of Care, pg. 1. SEE ALSO, SBHG Facilitator Guide First 30 Days of Wraparound, pg. 1.
b. HFW teams are trained to elicit and prioritize the youth and family’s values, culture, expertise and strengths, capabilities, skills and interests. These aspects are viewed as critical to a successful process and documented using various tools such as the Plan of Care, Community Natural Supports Survey and Strengths Discovery Inventory. Community Natural Supports Survey, pgs. 1-6. and Strengths Discovery Inventory Ages 4 to 21, pgs. 1-4.
c. SBHG utilizes Supervisors and Fidelity Coaches/Specialist to routinely observe HFW team meetings and review documentation to gather and provide feedback to staff to reinforce HFW practice expectations, build and enhance skills and increase overall staff confidence. SBHG Wraparound providers use the University of Washington’s National Wraparound Institute’s (NWI) WRAPStat fidelity monitoring protocols to focus direct observations of Child Family Team meetings (using the Team Observation Measure (TOMS) and interviews with youth, caregivers, and the facilitator (using the Wraparound Fidelity Index (WFI). Additionally, SBHG is piloting use of the Document Assessment and Review Tool (DART) to provide targeted feedback to individual HFW teams and aggregated data to use for programmatic review. Tools TOMs, WFI-EZ, and DART are known to the state, available upon request if needed.
d. To ensure the HFW process is led by youth and families, feedback is routinely elicited using a wide range of tools and instruments. All SBHG agencies’ QAs run a Service Validation Protocol which involves brief phone interviews with caregivers about whether wraparound services are being delivered to expectations. RPP 01.03 Service Validation, pg. 1.
Additionally, there are questions about satisfaction on Consumer Voice and Choice and related “probes” that are part of our Total Quality Management (TQM) system. SBHG TQM Consumer Quality of Life Probes, pgs. 1-3.
As previously mentioned the TOM 2.0 and WFI are utilized during service delivery, while also administering continuous satisfaction surveys as youth/families exit from services, SBHG DC Satisfaction Survey – Outpatient’, pgs. 1-2.
Lastly, staff are trained and supported in the process of Collaborative Documentation so that, as contextually appropriate, staff can review their service contact notes with the youth and/or caregiver directly before such notes are submitted into the EMR. SBHG Collaborative Documentation COACHING Guide’, pgs. 4, 6, 7, 10, 11.
1.3 Strength-Based
a. To identify the functional strengths of the youth and their family, all team members and the family’s larger community, these strengths are gathered and documented via use of the SBHG Strengths Discovery Inventory and the Plan of care. SBHG Strengths Discovery Inventory, pgs. 1-4.
b. Functional, individualized strengths of the youth and family are identified and documented using a Strengths Discovery Inventory, Community & Natural Supports Survey, as well as through the CANS-IP. Furthermore the Plan of Care and Child Family Team Meeting Agenda prompt on-going review of CANS-IP “Strengths” items by the child and family team. Strengths Discovery Inventory’, pgs. 1-4, Community Natural Supports Survey’, pgs. 1-6, CFT Meeting Summary and Action Plan, pg. 2.
c. Staff are trained on all wraparound principles and on how to anchor, organize and implement Plans of Care to address the youth/family’s needs, goals, strengths, resources, and eventual successes across multiple life domains. SBHG HFW Training Plan, pgs. 2-12.
d. Feedback from families is routinely elicited from families regarding their experience of strengths-based Wraparound services through use of the WFI’s, TOM’s, Consumer Voice and Choice and related probes service validation protocols conducted by SBHG Quality Assurance department via brief phone interviews. Feedback from the listed tools are part of the SBHG Total Quality Management (TQM) system, and data is provided via reports to staff, supervisors, and leadership for continuous quality improvement efforts. Tools TOMs, WFI-EZ, and DART are known to the state, available upon request if needed. SBHG HFW Program Statement P&P, pg 5
1.4 Needs Driven
a. Prior to the formation of goals and strategies, underlying needs are identified and prioritized through SBHG’s standardized behavioral health intake tool kit includes: Pain, Health & Nutrition, Life Events Checklist (Joint Commission trauma screener), Dangerous Behaviors, Psychoses (PQB screener and mini-SIPS), and SAFE-T protocols (suicide safe care). The Pediatric Symptoms Checklist (PSC-35) and CANS-IP are also utilized by the team to identify the needs of the youth and family. Additionally, for client care, the overall upshots of the intake process and use of screeners/assessments are recorded by staff on the EMR Problem List which flags the areas or life domains in need of attention, care and problem-solving. SBHG’s Standardized Behavioral Health Intake Tool Kit, pgs. 1, 6, 9, 13.
b. Staff trainings include: a) the administration, interpretation and application of measurement tools, including Praed or county-sponsored CANS certifications of clinicians as well as SBHG’s in-house Measurement Based Care (MBC) Treat to Target (T2T) trainings; b) how to articulate and document needs in basic human ways as expressed by and/or that would be recognizable by children, youth and families; and c) how to think about and apply intervention strategies anchored to meeting needs and leveraging strengths and resources throughout Plan of Care Development, Implementation, and Transition phases of Wraparound. SBHG Incorporating CANS into the CFT Process Booster Workshop, pg 7, 8.
c. Some screenings/assessments, including the CANS-IP and PSC-35, are used as repeat measures to track treatment progress, identify new needs and goals, and (eventually) demonstrate child/family outcomes. Other screeners/assessments can be readministered as new difficulties emerge. SBHG Decision Support Tool-Use of CANS to Guide Outpatient Service Intensity, pg. 2.
d. There are ample opportunities for new needs to surface and for the child/youth/family to shape the focus of care plans until such time as their needs are met and they are preparing for transition. Transitions are planned according to team and family agreement that needs are sufficiently met through use of the Plan of Care, as well as data provided via CANS-IP and PSC-35.
1.5 Individualized
a. The SBHG HFW Plan of Care (POC) template was recently redesigned based on service plans from among SBHG’s wraparound programs to highlight the life domains in focus for the time period of the POC with all POC elements included. The template provides prompts and quantitative information capture (e.g., from relevant assessments) while ample text fields allow for natural language descriptions of each child/youth/family’s mission, goals, circumstances, needs, strategies, etc. SBHG HFW Plan of Care, pgs. 2-11.
b. Staff training launches during New Employee Orientation (NEO) and continues through an ongoing, rotating set of offerings using SBHG Learning Management System (LMS) modules, on-line classes and in-person workshops that focus on the application of our facilitation model. SBHG HFW Training Plan, pgs. 5-6.
c. Training of facilitators and other staffs launches during New Employee Orientation (NEO) and continues through an ongoing, rotating set of offerings using SBHG Learning Management System (LMS) modules, on-line classes and in-person workshops that focus on the application of our facilitation model. We use the framework, principles and practices of “The Facilitator’s Guide to Participatory Decision Making”, Kaner et al (Jossey Bass, 3rd Ed., 2024) to structure facilitation trainings and practices. Multiple individuals (SBHG RPP Dept, Wraparound program leaders, and company trainers) are steeped in the framework, provide consultative guidance, and conduct facilitation workshops. In addition to LMS reports, training completions are tracked and will soon be visible on SBHG’s Training and Practice Fidelity Dashboards. SBHG Facilitator Guide First 30 Days of Wraparound, pg. 1. SEE ALSO Workforce Development and the SBHG HFW Training Plan, pgs. 5-6.
d. SBHG takes a multifaceted approach related to the routine review of HFW plans of care, to ensure all plans are individualized based on needs, strengths, strategies and outcomes. HFW Supervisors provide review and provide feedback to guide teams and align Plans of Care to HFW standards, such as ensuring the presence of strategies which capitalize on the assets of the family’s community and informal networks. SBHG’s QA Department structures regular audits of service documentation including qualitative reviews of Wraparound POCs. Sampling includes families at different phases of wraparound and yields a robust annual sample. Additionally, Fidelity Specialist utilize the DART to review for evidence of wraparound principles including individualization. SBHG QA Safety Crisis and POC Checklist, pg. 1.
e. All types of feedback covered in this (and other) HFW standards – POC completions, POC quality audits, facilitation training completions and participant feedback, TOMS/WFI results, etc. — are provided to teams as part of SBHG’s 25+ year program of Total Quality Management (TQM) for Continuous Quality Improvement (CQI). Local QA staffs support teams to work on QI initiatives, Rapid Cycle Improvement Processes (RCIPs) and other ‘Plan, Do, Check, Act’ (PDCA) processes to monitor and improve the quality of care provided to children/youth and families to HFW standards. The TQM program centers varied stakeholder input and transparency with stakeholders invited to participate in Quality Councils. SBHG Example Biennial TQM Plan pgs. 1-2.
1.6 Use of Natural and Community Based Supports
a. As services get underway, Child Family Team Meeting agendas, the Community Natural Supports Survey and the Plan of Care among other protocols prompt and/or direct attention to natural and community supports that are available and/or that might be cultivated during the child/youth’s enrollment. Plans of Care include natural and community resources and supports as one category of intervention, which are informed by the Community Natural Supports Survey, and updated at least once every six months. CFT Meeting Summary and Action Plan, pg. 2.
b. Our teams also participate in trainings on Family Search & Engagement (FSE). Since fall 2023, we contracted with the National Center for Permanent Family Connections (NCPFC) for training and consultations, the latter focus both on programmatic and system of care issues, and with team supervisors so they know how to facilitate/support their staffs’ FSE activities. As part of the FSE initiative, current wraparound programs contracted to use the Seneca Search Engine as an aide to identify safe adults who might build a relationship and contribute socially and emotionally to the life of a child/youth in ways that are meaningful. For foster youth and others involved with child welfare, the Child Welfare Worker is always consulted, and they must approve a person’s involvement with the child/youth. We anticipate expanding NCPFC trainings and FSE implementation to all Child/TAY FSPs in CY 2026. SBHG HFW Training Plan, pg. 4(f).
c. SBHG multifaceted approach related to the routine review of HFW plans of care, to ensure all plans include natural support, and that community and natural supports are assigned strategies and action items. HFW Supervisors provide review and provide feedback to guide teams and align Plans of Care to HFW standards, such as ensuring the presence of strategies which capitalize on the assets of the family’s community and informal networks. SBHG’s QA Department structures regular audits of service documentation including qualitative reviews of Wraparound POCs. Sampling includes families at different phases of wraparound and yields a robust annual sample. SBHG QA Safety Crisis and POC Checklist, pg. 1.
d. The prior described HFW fidelity protocols (TOMs, WFI, Service Validations, Quality Audit, etc.) are used to monitor that POCs and service documentation reflect robust attention to, and use of natural community supports; and, that services are respectful and a good fit to the child/youth/family’s culture and preferences. Information and findings from fidelity protocols are available to staff for programmatic review and quality improvement in the context of the aforementioned TQM system and on BA Dashboards. SBHG Example of TQM Quality Council, pg. 5-7.
1.7 Culturally Respectful and Relevant
a. Cultural considerations may come to the fore should a family prefer to include on the team person(s) from specific communities with which they identify, such as a religious/spiritual guide. The addition of community and natural support person(s) is encouraged and reinforced and may change the overall perspective of the team, the direction of goal setting, and the availability of persons who can provide novel intervention strategies. Staff support tribal affiliated families to include a Tribal Representative on their Child Family Team. Family traditions, values, and heritage are evident across several tools and instruments such as the Plan of care and Strengths Discovery Inventory. SBHG High Fidelity Wraparound Plan of Care pg. 1. SEE ALSO SBHG Strengths Discovery Inventory Ages 4 to 21, pg. 2-3.
b. Staff trainings are identified by each team and trainings are coordinated and/or delivered through SBHG’s Training Department, including trainings offered by counties on cultural subgroup(s) in their communities, including American Indian/Native American/First Peoples. PGM 01.01 Cultural Attunement Program, pg. 1-2. SEE ALSO SBHG Cultural Competency Assessment Templates, pgs. 1-2.
c. Along with the University of Washington’s standardized fidelity tools (TOMs, WFI), the elements of this standard are tracked for the POC agenda, CFT minutes, team agreements and service documentation using the protocols described in prior sections – e.g., Packet Tracking, Service Validations and Quality Reviews.
1.8 High-Quality Team Planning and Problem Solving
a. In preparation for planning care, early team meetings involve facilitation of a Team Agreement, review and additions to the Strengths Discovery and the creation of the Family’s Mission Statement. The process involved in the Development and Documentation of these protocols, which become part of the child/youth/young adult’s record in the EMR, provides an early opportunity after intake for the team to form, learn about each other as participants, and set the course for how they will work with each other over time. Competent facilitation that promotes collaboration and drives toward clarity, mutual understanding and shared agreements is essential for the creation of meaningful and robust POCs. SBHG QA Safety Crisis and POC Checklist, pg. 1. SEE ALSO SBHG Facilitator Guide First 30 Days of Wraparound, pg.1.
b. The prior described HFW fidelity protocols (TOMs, WFI, Service Validations, Quality Audit, etc.) are used to monitor and ensure robust attention to, and use of formal and natural community supports working together to develop, implement, and monitor that the POC is individualized; and, that services are respectful and a good fit to the child/youth/family’s culture and preferences. Information and findings from fidelity protocols are available to staff for programmatic review and quality improvement in the context of the aforementioned TQM system and on BA Dashboards.
c. All types of feedback covered in this (and other) HFW standards – POC completions, POC quality audits, facilitation training completions and participant feedback, TOMS/WFI results, etc. — are provided to teams as part of SBHG’s 25+ year program of Total Quality Management (TQM) for Continuous Quality Improvement (CQI). Local QA staffs support teams to work on QI initiatives, Rapid Cycle Improvement Processes (RCIPs) and other ‘Plan, Do, Check, Act’ (PDCA) processes to monitor and improve the quality of care provided to children/youth and families to HFW standards. The TQM program centers varied stakeholder input and transparency with stakeholders invited to participate in Quality Councils. SBHG Example of TQM Quality Councils. SBHG TM CQI 2025(July 2024-June 2025), pgs. 3, 23, 39-47, 56-60, 67.
d. Team members certify their agreement to the individualized POC, by signing and dating each POC. RPP 1.24 High Fidelity Wraparound Plan of Care Policy & Procedure, pg.4.
1.9 Outcomes Based Process
a. The HFW Plan of Care articulates strategies and action items in the SMART format: specific, measurable, action-oriented, realistic, and time-based. Quality reviews at SBHG typically focus both on what we refer to as the “Clinical Loop” or “Golden Thread” – that screenings/assessments shape POCs, POCs articulate needs, strategies and interventions in SMART format, follow-on activities match the plan and are evident in service documentation with redux of this same cycle over the course of care — and specific standards for the practice model of the program (e.g., HFW elements for wraparound). SBHG High Fidelity Wraparound Plan of Care, pg. 4.
b. The Facilitator addresses gaps or lapses in POC follow-ons and in the wraparound process in a direct, candid and kind (non-shaming) way that focuses on constructive barrier busting and solution building so that team members can proceed with POC fulfillment. Facilitators make certain action items are completed, updates are made as needed, and milestones are celebrated along the process. SBHG High Fidelity Wraparound Plan of Care, pg. 4.
c. Communication loops back to team members about progress, results and newly emerging needs and/or flexes sought by family members and/or allied professionals occur at CFT Meetings, in staff preparation meetings (these are called Service Integration Team (SIT) meetings, please see Implementation Section 5.2 for more information), and during group and individual supervision of staff where Measurement Based Care (MBC) data are reviewed (for individual cases and/or in aggregate). SBHG High Fidelity Wraparound Plan of Care, pg. 4.
d. HFW teams rely upon the Mental Health Specialist (MHS) to complete the CANS_IP and disseminate data from the CANS-IP to the HFW team, including youth and family. SBHG provides practice guidance on the use of the CANS (see SBHG Decision Support Tool – Use of CANS to Guide Outpatient Service Intensity, Supplemental Documents, pg. X) so that team members recognize how to think about and use the ratings in the context of other information. SBHG Decision Support Tool-Use of CANS to Guide Outpatient Service Intensity, pgs. 1-2.
e. MHS’ and supervisors access and review individual Treat to Target CANS-IP dashboards during 1:1 or group supervision. As previously discussed (1.09(d)) team members are provided guidance on how to think about and use the CANS-IP rating in the context of other information, as well as, to support tracking and team decision-making. SBHG BA Dashboards Landing Page, pg. 2.
1.10 Persistence
a. SBHG service teams fully embrace the principle of Persistence, and they do not frame a child/youth/family’s setbacks or challenges as “failure(s)”. The importance and value of persistence is often expressed in staff testimonials about how they think about their work – e.g., we “do whatever it takes”, we “do not give up” — and in child/youth/caregivers’ comments on satisfaction surveys – e.g., the team “was always there for me, no matter what” and “helps me month after month to pick back up and keep going.” SBHG Facilitator Guide First 30 Days of Wraparound, pg.1.
b. Setbacks and challenges are a regular topic in Child Family Team (CFT) meetings, and CFT meeting notes are reviewed by the supervisor prior to claiming approval (CFT and ICC Progress Notes), to (among other things) make sure the ethos of persistence is upheld in the planning process. Additionally, persistence is a feature that is looked for and noted during QA service documentation quality reviews. PGM 1.49 Case Review and Consultation for Challenging Cases, pgs. 1-2.
c. Team members are educated about varied support processes available through their agency leadership and from SBHG’s Clinical Services Team and Clinical Steering Committee. These include asking for more feedback/guidance/coaching from their supervisor, practice consultations and workshops provided by others in the company who have long tenure with wraparound, and a formal protocol for seeking case consultations for difficult/stuck situations. PGM 1.49 Case Review and Consultation for Challenging Cases, pgs. 1-2.
1.11 Transitions as a part of the Fourth Phase of HFW
a. HFW teams utilize various tools and processes to provide adequate transitions for youth and families. The listed methods are designed to minimize pre-mature discharges and loss of services due to adverse events or due to administrative requirements. Furthermore, the methods ensure a smooth transition with proper aftercare and safety planning. AnD 05.10 Discharge Discharge Criteria and Process, pgs. 1-3.
b. Teams celebrate success! They do so continuously during services when milestones and/or other accomplishments are acknowledged during CFT Meetings; and they plan and carry off a celebration event for each child/youth/family as they move into transition and near discharge. Transitions and celebrations are documented in service notes (auditable) and they are typically very personal/individualized with mementos, cards, food treats, rituals and most importantly – testimonials and comments from team members about the strengths, resiliencies and gains made by the child/youth/young adult and family during their wraparound enrollment. A good celebration is anchored to real accomplishments and expresses folks’ confidence and respect for the child/youth/family’s hard work and future endeavors. Additionally, some clients/families agree to present their stories at SBHG’s Annual Quality Councils, which is an auspicious meeting process that involves the agency, program, SBHG leadership and staffs, and external stakeholders in a formal review of the program’s year of providing services, abiding practice standards, operating within regulations and policy, and achieving outcomes. These testimonials bring much life to the efforts involved in human service delivery and are often accompanied by digital forms of storytelling (audio, video, etc.) which staff develop with the child/youth/young adult and their family members. The digital story, handed off to the client/family, becomes a meaningful celebration and remembrance of their journey through wraparound. SBHG Example of TQM Quality Council, pgs. 39-44.
Expected Outcomes
2.1 Youth and Family Satisfaction
To ensure youth and families are satisfied with their HFW experience and progress, SBHG implements Service Validations using a random monthly sampling, with the the caregiver providing the rating. SBHG’s HFW relevant programs (along with all other outpatient teams) historically contributed to (and continue to participate in) the state’s Performance Outcome and Quality Improvement (POQI) aka Consumer Perception Survey (CPS) process, and we made the transition a few years back to using UCLA’s CPS portal for clients/families to complete such, which occurs once a year in the spring (one week, annual cross-sectional survey). We administer the DCOSS Satisfaction survey at or near discharge, to either the youth or caregiver. SBHG also administers the WFI-EZ (Items C1-4) on a quarterly basis using the WrapStat system to generate random samples. The WFI-EZ is administered to youth and caregivers (also provided to facilitators). SBHG HFW EvalPlan, pg. 3, section Expected Outcomes 2.1 Youth and Family Satisfaction.
2.2 Improved School Functioning
Measurements to assess Improved School Functioning are currently tracked using CANS-IP (Life-Functioning domain, School Functioning). The CANS-IP is administered at intake, at 6 month intervals and at discharge from HFW. The WFI-EZ items (D4, D7) are used to monitor school functioning on a quarterly basis and administered to the youth and caregiver, and reported into the WrapStat system. POC (Life Domain- Educational and Vocational) is used and measured at intake (initial plan development), 6 month intervals, and as often as needed. The facilitator takes the lead in ensuring this area is discussed and tracked within the HFW process. The Pediatric Symptom Checklist (PSC-35) schooling items (Q’s 5, 6, 17, 18-relevant only for clients younger than 18yrs. old) is administered at intake, 6 month intervals and discharge and rated by the Caregiver. Lastly, the SBHG DC Status Form contains information related to school functioning, and is administered at/near discharge. SBHG HFW EvalPlan, pg. 3, section Expected Outcomes 2.2 Improved school functioning. ALSO SEE SBHG Discharge Status Form pgs. 5-6.
2.3 Improved Functioning in the Community
Measurements to assess Improved Functioning in the Community are currently tracked using CANS-IP (Life-Functioning domain, multiple items). The CANS-IP is administered at intake, at 6 month intervals and at discharge from HFW. The WFI-EZ items (B19, D3, D9) are used to monitor functioning in the community on a quarterly basis and administered to the youth and caregiver, and reported into the WrapStat system. POC (Life Domain- Daily Living and Life Skills; Legal) is used and measured at intake (initial plan development), 6 month intervals, and as often as needed. The facilitator takes the lead in ensuring this area is discussed and tracked within the HFW process. SBHG HFW EvalPlan, pg. 3, section Expected Outcomes 2.3 Improved Functioning in the Community. CANS and WFI-EZ known to the state, available upon request if needed.
2.4 Improved Interpersonal Functioning
Measurements to assess Improved Interpersonal Functioning are currently tracked using CANS-IP (Strengths and Family Functioning domains). The CANS-IP is administered at intake, at 6 month intervals and at discharge from HFW. The WFI-EZ item (D8) is used to monitor Interpersonal functioning on a quarterly basis and administered to the youth and caregiver, and reported into the WrapStat system. POC (Life Domain- Family & Relationships, Daily Living & Life Skills, Social & Recreational) is used and measured at intake (initial plan development), 6 month intervals, and as often as needed. The facilitator takes the lead in ensuring this area is discussed and tracked within the HFW process. The Pediatric Symptom Checklist (PSC-35) items (Q’s 2, 15, 16, 31, 32, 33, 34 -relevant only for clients younger than 18yrs. old) is administered at intake, 6 month intervals and discharge and rated by the Caregiver. Lastly, the SBHG DC Status Form contains information related to school functioning, and is administered at/near discharge. SBHG HFW EvalPlan, pg. 3-4(top of pg. 4), section Expected Outcomes 2.4 Improved Interpersonal functioning. ALSO SEE SBHG DISCHARGE STATUS FORM, pg. 6- #33 & 34. “CANS, WFI-EZ, and PSC known to the state, available upon request if needed”
2.5 Increased Caregiver Confidence
Measurements to assess Increased Caregiver Confidence are currently tracked using CANS-IP (Caregiver domain). The CANS-IP is administered at intake, at 6 month intervals and at discharge from HFW. The WFI-EZ item (B19, B24, C4) is used to monitor increased caregiver confidence on a quarterly basis and administered to the youth and caregiver, and reported into the WrapStat system. Lastly, caregiver’s responses to Discharge Satisfaction Survey items which will be up-tuned to include more HFW items. The Discharge Satisfaction Survey (caregiver responses) is administered at/near discharge to the caregiver. SBHG HFW EvalPlan, pg. 4, section Expected Outcomes 2.5 Increased Caregiver Confidence. ALSO SEE SBHG DC Satisfaction Survey, pg. 1.
2.6 Stable and Least Restrictive Living Environment
Measurements to assess Stable and Least Restrictive Living Environment are currently tracked using the CANS-IP (Caregiver domain, Residential Stability). The CANS-IP is administered at intake, at 6 month intervals and at discharge from HFW. The WFI-EZ item (D1) is used to monitor if a stable and least restrictive living environment on a quarterly basis and administered to the youth and caregiver, and reported into the WrapStat system. POC (Life Domain-Home and Place to Live) is used and measured at intake (initial plan development), 6 month intervals, and as often as needed. The facilitator takes the lead in ensuring this area is discussed and tracked within the HFW process. Lastly, the SBHG DC Status Form contains information corresponding to stable and least restrictive living environment, and is administered at/near discharge. There is also residential placement data (types of living situations, types of placements, placement changes, etc..) captured on MHSA DCR forms, and we look forward to clarification about whether these tools are required for all HFW programs. SBHG HFW EvalPlan, pg. 4, section Expected Outcomes 2.6 Stable and Least Restrictive Living Environment. ALSO SEE SBHG Discharge Status Form pg. 2-(#7, 8, 9, 10) and pg. 3 (#11).
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Measurements to assess reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits are currently tracked using the WFI-EZ item (D1 & D2) is used to monitor Inpatient, Emergency Department Admission for Behavioral Health Visits on a quarterly basis and administered to the youth and caregiver, and reported into the WrapStat system. The SBHG DC Status Form contains information related to reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits, and is administered at/near discharge. SBHG HFW EvalPlan, pg. 4, section Expected Outcomes 2.7 Inpatient, Emergency Department Admission for Behavioral Health Visits. ALSO SEE SBHG Discharge Status Form pg. 2-(#7, 8, 9, 10) and pg. 3 (#11).
2.8 Reduction in Crisis Visits
The measurement to assess Reduction in Crisis Visits are currently tracked using the SBHG DC Status Form which contains information related to crisis visits, and is administered at/near discharge. SBHG HFW EvalPlan, pg. 4, section Expected Outcomes 2.8 Reduction in Crisis Visits. ALSO SEE SBHG Discharge Status Form pg. 3 (#14).
2.9 Positive Exit from HFW
Measurements to assess Positive Exits from HFW are currently tracked on SBHG’s Discharge Status Form. At this juncture most counties expect that a positive exit is program completion with most/all treatment goals (aka wraparound POC goals) met. We believe we have sufficient data capture with these items and “other circumstances related to discharge” to report on the nature of exits should counties refine their contract Key Performance Indicators (KPIs) in the future. We maintain an ongoing EMR Data Capture workgroup to sort through and update EMR forms as new data capture needs arise for the KPIs articulated in our contracts. SBHG Discharge Status Form pg. 1 (#1), pg. 2(#5-6), pg. 5(#28).
Engagement
3.1 Orientation
a. SBHG’s HFW programs approach engagement, and specifically orientation, as a ‘layering in’ and ‘mattering’ process, with repetition of key orienting information during early contacts that provide opportunities for youth, families, natural supports & allied professionals to have their questions answered in ways and at a pace that allows information to sink in. During the engagement phase it is often best to “go slow to go fast”: subsequent service processes can unfold with much less (or no) misunderstanding and hesitation when participants feel prepared and they feel heard with their inquiries promptly addressed by staffs. At the individual case level, once a referral packet is received, Wraparound Facilitators contact the county designee (CSW or Probation Officer) to notify about the receipt of the referral and the first appointment date. Brochures are provided, and some teams use a short and engaging video to further client/family understanding of the wraparound process, including what is meant by the program’s ethos of doing ‘whatever it takes’, centering client/family ‘voice and choice’ and how services are ‘individualized’. SBHG Facilitator Guide First 30 Days of Wraparound, pgs.1-2. SEE ALSO SBHG Examples of Family Search & Engagement Practices, pgs. 11-13.
b. Participants sign acknowledgements, informed consents and related legal documents; commence screenings and assessments; learn about staff types and roles; and review the ways they — the client/family – can responsibly participate and contribute to good results. Intake covers wraparound principles, phases, service intensity and processes (incl. how Child Family Team meetings work and meeting frequency), legal and ethical considerations (e.g., mandated reporting, safety protocols, etc.), fidelity, progress and outcome monitoring. The overall intake process is a balancing act: providing information without overwhelming people, moving through required steps while building rapport, reassuring that helpful services to meet important client/family needs will be forthcoming whilst also communicating that services are time limited. Safe and healthy client/family functioning within an active natural support system is an overarching goal. SBHG Informed Consent, pg. 1. SEE ALSO SBHG The Wraparound Process, pg. 1.
c. Participants learn about staff types and roles; and review the ways they — the client/family – can responsibly participate and contribute to good results. For tribal affiliated youth, representatives from Tribes are included in the wraparound process. SBHG The Wraparound Process, pg. 1. SEE ALSO SBHG Facilitator Guide First 30 Days of Wraparound, pg.1.
3.2 Safety and Crisis stabilization
a. The client/family’s initial urgencies are identified among information provided by the person making a referral, first contacts with the client/family and during the intake process (throughout Engagement), including through standardized wraparound and behavioral health screening and assessment tools: Pain, Health & Nutrition, Life Events Checklist (Joint Commission trauma screener), Dangerous Behaviors, Psychoses (PQB screener and mini-SIPS), and SAFE-T protocols (suicide safe care). Across many counties wherein SBHG operates, clinicians (Mental Health Specialist) are required to be LPS certified to provide immediate intervention in crisis situations, including writing psychiatric holds. SBHG Standardized Behavioral Health Intake Tool Kit, pgs. 1, 6, 14, 15.
b. The SBHG HFW Safety Plan is completed at this early stage, and later additional safety/crisis plan information is included on the POC – both of these documents are shared with the client/family. High risk behavioral incidents among other types of risky occurrences are tracked in SBHG’s incident reporting module in the EMR from the point of enrollment through discharge. SBHG HFW Safety Plan, pg. 1.
c. As part of the SBHG process, HFW teams ensure youth and families are provided a copy of the written plan, as well as subsequent updates. Both during the development and within subsequent plans, families are provided information regarding how to access 24/7 crisis response when needed. Additionally, many of our HFW programs operate in counties/communities in which the SBHG agency also operates crisis stabilization units, mobile crisis services, and/or psychiatric health facilities and all staffs across outpatient programs are trained on how to access, refer and support clients/families into crisis services (whether operated by SBHG or elsewise). The written plan and service notes related to urgencies/crisis are documented in the client record for enrolled persons. High risk behavioral incidents among other types of risky occurrences are tracked in SBHG’s incident reporting module in the EMR from the point of enrollment through discharge. The SBHG HFW Safety Plan, pg 1 is completed at this early stage, and later additional safety/crisis plan information is included on the POC – both of these documents are shared with the client/family. Please see SAFE-T Screener, SAFE-T Assessment, SAFE-T Monitoring Tool &PGM 01.14 Suicide Screening and Assessment using the SAFE-T.
3.3 Strengths, Needs, Culture and Vision Discovery
a. SBHG HFW teams place a premium on working with the youth and family to complete a Family Vision during the Engagement phase. The Family Vision is a central component of the POC, and therefore completed for every youth and their family, and provides a “north star” for the entire HFW throughout the wraparound process. Over the years of operating Wraparound programs (first one opened 2000) and Full Service Partnerships (first one 2006), SBHG teams have used varied types of discovery protocols with clients/families to explore and understand the strengths and resources of the client/family, including their cultural heritage/practices and social support networks, as well as the current challenges and issues they are grappling with that speak to underlying needs and personal/familial goals for the future. SBHG Strengths Discovery Inventory Ages 4 to 21, pg. 1.
b. For our HFW implementation, program teams pivoted to uniform use, including 90-day updates, of the following set of protocols that help facilitate plan development: Team Agreement, Strengths Discovery Inventory and a Child/Family Mission Statement in their own words. Additionally, from Engagement and continuing during Plan of Care development (and beyond as needed), team members use discovery strategies for children/youth who can benefit from Family Search and Engagement (FSE) to identify and bring forward safe adult persons into their lives in reliable and meaningful ways. Our teams are trained on FSE by the National Institute of Permanent Family Connections (NIPFC) to enhance youth’s natural and community supports, which requires intentional effort over time with subsets of those served. SBHG Facilitator Guide First 30 Days of Wraparound, pg.1. SEE ALSO SBHG Examples of Family Search & Engagement Practices, pgs. 1-17.
3.4 Engage All Team Members
a. To be successful, the wraparound process requires the presence and active participation of the child/youth/young adult and their family members, allied professionals assigned to support the client/family, and the family’s selected natural support persons. Community Natural Supports Surveys, pgs. 1-6.
b. Once a referral packet is received, Wraparound Facilitators contact the county designee (CSW or Probation Officer) to notify about the receipt of the referral and the first appointment date. AnD 01.11 Initiation and Authorization of Services, pg.3.
c. Engagement into the process of wraparound with all relevant parties to an individual client’s enrollment is supported by all staffs as they make initial service contacts, including collateral and consultative types of meetings. For examples, Facilitator’s reach out to and coordinate the participation of all Child Family Team members (formal and natural supports and Tribes in the case of an Indian child), including communicating about varied staff roles and providing facilitative leadership of Child Family Team meetings. THE HFW team ensures the family is comfortable and agrees to the role potential supports will play on the team during the process. Community Natural Supports Surveys, pgs. 3-4.
d. In SBHG programs, discrete practices are trained to and applied purposefully to promote and sustain engagement. These include Mattering as described in Engagement Section 3.1 and engagement activities used during Child Family Team meetings. Facilitators training which is based on Kaner, et al, Facilitator’s Guide to Participatory Decision Making, 3rd edition, 2024, is used to enhance the skillset of facilitators to utilize team building activities and other engagement strategies to navigate the wraparound process. Facilitators document their activities in progress notes found within the SBHG EMR. SBHG EMR CFT PN Template, pg. 3.
3.5 Arrange Meeting Logistics
a. To launch and sustain the process, attentive effort — of the Facilitator and other staff members called upon to assist – is applied to coordination and scheduling, starting with and centering the family’s availability, needs and preferences regarding basic logistics (dates, times, locations, transportation, child care supports, etc.). Care is taken to schedule meetings and service sessions in a way that the client/family can meet and sustain in consideration of their other commitments (e.g., caregivers’ work schedules, avoiding disruption of a child/youth’s school day) while also finding times that natural support persons can make, and cross-checking options with busy allied professionals. To ensure meeting logistics are aligned to standard 3.5, a long-standing SBHG TQM practice known as Service Validation, along with other standardized wraparound fidelity tools, is utilized to monitor client/family perceptions about logistics (e.g., convenience). Service Validation Form, pg. 2. SEE ALSO SBHG Facilitator Guide First 30 Days of Wraparound, pg.1.
b. Team members are trained on how to coordinate/schedule (using MS Outlook), broker agreements, trouble-shoot constraints, bridge language/cultural needs, tune in to psychological dynamics, and communicate/reinforce commitments to the process. As many wraparound cases revolve around high acuity needs and circumstances which could impede progress of the wraparound process staff training includes but is not limited to: encouraging flexible use of meeting modalities per the family’s preferences (in-home/field settings, in person at clinic, on-line, etc.), use of apps (e.g., ‘GReminders’) for appointment tracking and reminders), and documenting appointment planning logistics (using MS Outlook) so the information is available to all staff on the team. SBHG HFW Training Plan, pg 6.
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
a. In preparation for planning care, early team meetings involve facilitation of a Team Agreement, review and additions to the Strengths Discovery and the creation of the Family’s Mission Statement. The process involved in the development and documentation of these protocols, which become part of the child/youth/young adult’s record in the EMR, provides an early opportunity after intake for the team to form, learn about each other as participants, and set the course for how they will work with each other over time. (see templates in addendum, the Family Mission Statement is recorded on the Plan of Care). SBHG High Fidelity Wraparound Plan of Care, pg. 2.
b. Competent facilitation that promotes collaboration and drives toward clarity, mutual understanding and shared agreements is essential for the creation of meaningful and robust POCs. Thus, strengths identified during engagement are routinely updated to reflect new/additional discovered strengths, which are then recorded in the child/youth/young adult’s record in the EMR, and appropriate documentation such as the Strengths Discovery. SBHG High Fidelity Wraparound Plan of Care, pg. 2.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
a. Competent facilitation promotes collaboration and drives toward clarity, mutual understanding and shared agreements as being essential for the creation of meaningful and robust POCs. Prior to the development of the POC, the team identifies and prioritizes needs for youth and family, and clearly documents in the youth’s file located in the SBHG EMR. SBHG Facilitator Guide First 30 Days of Wraparound, pgs.1. SEE ALSO SBHG High Fidelity Wraparound Plan of Care, pgs.3-10.
b. The wraparound team ensures identified needs are utilized to formulate measurable goals and outcomes. Identified needs are collaboratively prioritized by the team across life domains, with goals and expected outcomes based on priority needs that emphasize strengths and resources over behaviors and deficits. Teams are encouraged and trained to approach formulation of goals and outcomes from a strength-based perspective opposed to deficit-based goal development. The POC prompts for articulating and specifying creative approaches, strategies and action items. SBHG High Fidelity Wraparound Plan of Care, pgs.3-10.
c. These goals and outcomes found in the Plan of Care are developed collaboratively during Child and Family Team meetings. Our Plan of Care process also cascades to intervention planning by the program’s Certified Peer Staff who confers with the youth/family/team and writes out the interventions they will be using in a Peer Interventions Plan that is adjunctive to the SBHG HFW Plan of Care (template attached). Only a certified Peer Staff can complete such a plan which dovetails with POC action items to be carried out by Peer Staff. SBHG Certified Peer Interventions POC, pg. 3.
d. Identified strategies are located across a broad range of documents such as progress notes, Plan of Care, Child and Family Team Meeting minutes, and Strengths Inventory.
e. Facilitators role model and apply multiple, varied facilitative methods learned during SBHG trainings anchored to ‘The Facilitator’s Guide to Participatory Decision-Making’. These methods involve, but are not limited to, Active Listening, Brainstorming, Chart Writing, Open Discussion, Soliciting Divergent Opinions, Stacking/Tracking, Managing Difficult Dynamics, Transparent Decision Rules, and Building Sustainable Solutions. Our program’s wraparound facilitators are consistently endorsed as being effective (e.g., 93% to 100% adherence in FY 24-25) per TOMs CFT observations. SBHG BA Dashboard Reporting Tool Examples, pg. 4.
f. The resulting POC template identifies needs that are collaboratively prioritized by the team across life domains, with goals and expected outcomes based on priority needs. SBHG High Fidelity Wraparound Plan of Care, pgs.3-11.
4.3 Develop an Individualized Child or Youth and Family Plan
a. Competent facilitation promotes and elicits collaboration built upon multiple perspectives. Facilitators receive on-going coaching and training on building trust and shared vision and demonstrates the HFW principles. SBHG HFW Training Plan, pg. 8 section Customer Service and Collaboration.
b. Facilitators and the overall HFW team are cognizant of various goals and objectives identified by Systems of Care partners, and ensure these are comprehensively integrated into the Plan of Care. For example, child welfare, juvenile probation, legal, housing and educational prerogatives and the demands of such system involvements (looming court dates, pending placements, needed persistence with advocacy, etc.) will focus the team on supporting the family to understand, navigate and prepare for the decisions that unfold when interacting with such systems, including opportunities and constraints, and system resources that may (or may not) be available. SBHG Facilitator Guide First 30 Days of Wraparound, pgs. 1-2.
c. POCs are shared documents that align well with SBHG’s initiative for Collaborative Documentation. Plans are entered into the client EMR and can be printed/shared with the child/youth/young adult and family. Topical highlights and areas in focus on the POC are posted in the CFT meeting agenda that is visible to all participants during the meeting. SBHG EMR CFT PN Template, pgs. 2-4.
d. SBHG has implemented several procedures to ensure Plans of Care meet criteria defined in the above items (1-6). These procedures also allow for review of Plans of Care for continuous quality improvement. Wraparound staff participate in Service Integration Team (SIT) meetings, and supervisions wherein the Plan of Care is reviewed. Teams and supervisors receive feedback from TOM’s debriefs as well as the DART. These reviews account for the inclusion of natural/community support, individualized proactive and reactive strategies for youth and family, and cultural relevancy. HFW teams are coached and provided feedback on strategies to ensure a comprehensive initial Plan of Care based on prioritized needs, goals, and strategies of the family and youth. In addition, Plans of Care are reviewed for inclusion of natural supports, addresses goals identified by Children’s System of Care partners, and benchmarks are set to move the family towards graduation and transition out of HFW, considering the families ability to move through the process at their own pace. SBHG QA Safety/Crisis Plan & Plan of Care Checklist, pg 1. SEE ALSO SBHG QA Safety Crisis Plan, pg. 1; Plan of Care, pg. 1.
4.4 Develop a Crisis and Safety Plan
a. HFW staff establish and maintain conversations with the child/youth/caregiver that express care, hope, and responsibility to self and others in order to forge a collaborative approach about safety and managing through acuity. They provide psychoeducation to family members about what works best when helping a loved one with safety risks and during crises and they provide contact information to access immediate help from the program team (staff provide 24/7 access), local call centers, crisis/emergency services, police, etc. From this foundation, specific proactive and reactive strategies for promoting and improving safety and decreasing crisis episodes are individualized and tailored to the child/youth/young adult’s developmental age/stage, cultural background and family/team preferences regarding interventions. As part of the SBHG process, HFW teams ensure youth and families are provided a copy of the written plan, as well as subsequent updates. Both during the development and within subsequent plans, families are provided information regarding how to access 24/7 crisis response when needed. Additionally, all staffs across outpatient programs are trained on how to access, refer and support clients/families into crisis services (whether operated by SBHG or elsewise). The written plan and service notes related to urgencies/crisis are documented in the client record for enrolled persons. SBHG HFW Training Plan, pgs. 2-6.
b. Staff are trained, supervised and coached to increase supportive/monitoring contacts and communications with the child/youth/family when there are safety concerns, unfolding crises and crisis occurrences. As safety concerns and events surface, staff work through the Child Family Team process, and they also receive guidance from their supervisor and SBHG’s ongoing in-services regarding safety and crisis management. SBHG HFW Training Plan, pgs. 2-6
c. As a long-tenured behavioral health provider, our program teams are steeped in safety and crisis planning. SBHG program teams use the Family Safety and Crisis Plan Template, which is accompanied by a written policy and procedure, staff training and coaching, monitoring of plan completion and quality, and other institutional supports described below. staffs participate in Service Integration Team (SIT) meetings, wherein the crisis and safety plan is reviewed. This includes review for the inclusion of natural/community supports, individualized proactive and reactive strategies for youth and family, and cultural relevancy. Teams are coached and provided feedback on strategies to ensure natural supports, via SIT meetings, feedback in TOM’s debriefs, and supervision. Within a larger Quality Assurance context, SBHG HFW programs will mobilize a wide range of tools such as the DART (which is currently being piloted) and probes to mine crisis and safety plans as an area for continuous quality improvement, training and coaching opportunities. SIT Form, pg. 3.
Implementation
5.1 Implement The Plan of Care
a. Facilitators take the lead in focusing the team as they carry out the implementation of the initial plan, and they also ensure the team reviews strategies and action items during the HFW team meeting. Facilitators use the CFT Meeting Agendas to focus attention on follow-ons, feedback and progress regarding action items discussed at prior meeting(s) and summaries of the information are codified ongoingly in CFT Meeting Minutes and in the Facilitator’s service documentation progress notes. Facilitators make certain the process involves acknowledging and celebrating what is working, progress made toward goals, the positive contributions of participants, and arrival to the next phase in the wraparound process (aka service process milestones). Celebratory activities are envisioned, arranged for and carried out by the team and may occur during the CFT Meeting or at other times and other contexts. SBHG EMR CFT PN Template, pg. 3. SEE ALSO SBHG High Fidelity Wraparound Plan of Care, pgs. 3-11; SBHG QA Safety/Crisis Plan & Plan of Care Checklist, pg.1
b. HFW teams train in professional facilitation (Kaner et al, Facilitator’s Guide to Participatory Decision Making, Jossey Bass, 2014), which make them particularly adept at fostering cohesion when trouble-shooting, problem-solving and solution building. Our staff are trained on how to reach out, engage and coordinate with tribes as natural/community supports – e.g., to participate in the CFT process and/or for resource/linkages in fulfillment of individualized Plan of Care / Safety / Transition Plans. Various staff facing meetings such as team meetings, group supervisions, and All Staff Meetings to create a clear sense of mission and alignment to HFW principles. During in-person and online meetings, various hands-on activities are used to develop staff skills and reinforce HFW standards and principles. Coaching also includes a minimum of 12 hours of shadowing which involves supervisors or their designee (e.g., senior staff of the same type as the new employee) accompanying new staffs into the field or to CFT meetings, to help them understand how to apply wraparound principles and practices in an in vivo context. Permission from the client/family is established before shadowing occurs. SBHG HFW Training Plan, pg. 10.
5.2 Review and Update The Plan of Care
a. Facilitators take the lead in the review and update of the Plan of Care. Facilitators ensure review of the Plan of Care is a continual process and updated during HFW team meetings (Child & Family Team meetings). The CFT meeting process results in POC adjustments as new strengths, needs, resources and goals surface, and/or because attempted strategies have not achieved desired outcomes and new approaches are sought.
b. POCs are reviewed and updated at least once every 90 days and the signed off POC is entered in the EMR. High Fidelity Wraparound Plan of Care Policy & Procedure, pg. 4.
c. Facilitation, communication and documentation (meeting agendas, meeting minutes, service documentation progress notes, etc.) of the POC, CFTs and the wraparound service process involve tracking attendance and participation at meetings, monitoring and addressing the need for inclusion of community/natural support persons and/or Family Search and Engagement (FSE) strategies, use of Flex Funds, and tracking that POC action items and interventions are carried out in a timely manner by staff and in ways that are consistent with wraparound principles. SBHG EMR CFT PN Template, pgs. 2-4.
d. The standardized forms used for HFW teams can be updated as needed, and thereby individualized to reflect the youth’s, family’s and team’s changing needs.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
a. A central role of staff, especially the Facilitator of the CFT process, is to build supports while maintaining team cohesiveness and trust. As recognized in this standard, the process of team cohesion starts with the development and revisiting the Team Agreement and Family Vision during CFT Meetings, as these documents provided mutually shared anchors to the ‘why and what’ the team is all about. The Facilitator addresses gaps or lapses in POC follow-ons and in the wraparound process in a direct, candid and kind (non-shaming) way that focuses on constructive barrier busting and solution building so that team members can proceed with POC fulfillment. SBHG High Fidelity Wraparound Plan of Care, pg. 2.
b. Our training/coaching and supervision of staffs emphasize multiple aspects of how to create psychological safety and build strong teams. Our training of Facilitators emphasizes how participants’ attention and capacity for follow-through may be compromised at times due to life’s pressures, families living in poverty, past traumatic life events, disillusionment with “systems” and “help-givers” and newly occurring upheavals/crisis. The Facilitators are coached to remain — and role model — being professional (within role, interpersonal boundaries), positive, proactive and persistent and to attend to building good relationships among team members as good relationships yield better problem solving and mutual accountability. SBHG HFW Training Plan, pgs. 6, 8, 10.
c. Between CFT Meetings, wraparound staffs participate in Service Integration Team (SIT) meetings, during which they sort through current dynamics/issues related to how the staff team is functioning so as to make sure that all staff on a team are oriented, on the same page with the POC and CFT process, leveraging the strengths of each other as a team, completing follow-ons in a timely manner, and abiding wraparound principles in their work with the child/youth/young adult and family members. One constant area of emphasis and review is the inclusion of natural/community support into the wraparound process and integration onto the HFW team. Teams are coached and provided feedback on strategies to ensure natural supports, via SIT meetings, feedback in TOM’s debriefs, and supervision. SIT Form, pgs. 2-6.
d. During the implementation phase, the structure of the CFT process – use of a standard agenda, easily accessible or visual posting of consensus information (e.g., Team Agreement & Family Mission), regularly scheduled cadence of meetings, professional facilitation, engaged participation and meeting documentation – is key to regularizing the experience of wraparound as a cohesive and reliable process. With good structure, participants can learn to know what to expect, how they can contribute, and how the team functions together on the behalf of the child/youth/young adult and their family members. New team members (which would include formal and natural/community supports) are oriented to this cadence and structure, including integration of their strengths, assigning action items to the current plan, and engaging in team building exercises. CFT Meeting Summary and Action Plan pgs 2-3.
Transition
6.1 Develop a Transition Plan
a. Transition planning is carried out in the same way as occurs during other phases of wraparound – through assertive and engaged CFT Facilitation, abiding wraparound principles and standards (e.g., individualized, team based, culturally sensitive, outcomes driven, etc.) and the use of the HFW POC. Program teams take advantage of SBHG’s Measurement Based Care (MBC) system and dashboards to gauge the progress of the child/youth/young adult and family during services. Having easy access to visualizing progress using standardized measurements strengthens the team in their deliberations about whether it is time to move toward Transition and discharge or not. The team will consider a variety of MBC outcomes (e.g., CANS domains), contextual factors, risk issues, and other client/family needs. SBHG BA Dasboards Landing Page, pgs. 1-4.
b. The HFW team collaborates intensely and honestly in making the determination to transition a youth out of services. Once this determination has been made, facilitators lead the team in creating an individualized transition plan. Such decisions are not based on just one CANS Domain, or just the CANs, rather the team will consider a variety of MBC outcomes, contextual factors, risk issues, other client/family needs, and supports which will persist after HFW comes to an end. The transition plan clearly documents current needs and services, while also ensuring the family has built a strong network of natural and community supports which will continue to provide the youth and family support. The transition Plan of Care is documented in the youths file in the SBHG EMR, and a copy of the plan is provided to the youth, family and wraparound team. RPP 1.24 High Fidelity Wraparound Plan of Care, pg. 4.
c. Facilitators ensure to maintain the collaborative nature and environment as the team develops the crisis and safety transition plan and it works well when the plan strongly reflects family members’ collaborative inputs, addresses their fears/worries, and provides information about competent and reliable supports/resources that will help them manage through safety risks and difficulties. To maintain the highest level of fidelity and quality, facilitators (as well as other assigned team members) receive on-going training and coaching on crisis and safety planning. All staffs are trained in Wellness Recovery Action Plan (WRAP) as part of SBHG’ Core Practices curriculum and they can elect to use the evidence based steps of that practice – e.g., when things are breaking down, crisis and recovery — to further explore, augment and support the client/family’s understanding of how to manage health conditions over the life course. WRAP is a self-directed and peer supported process, with versions available for children and teens. SBHG HFW Training Plan, pg. 8.
d. The HFW team works in various capacities to identify services and supports for the youth and family to be included in the transition plan. Once identified, the team is intentional about ensuring these supports will persist past formal HFW. These efforts include making sure the family is able to access them, which entails broad considerations such as financial impact, and proximity and ability to physically access the service or support. Our programs do not receive Adoption Assistance Program (AAP) funding at this time; rather, we collaborate with Adoptive Families and have single-source contracts with them to provide Wraparound services. We don’t use MediCal with them; instead, we contract with DFCS for payment. Otherwise, we proceed with the same wraparound processes when working with adoptive families as with any family, and team members provide information, referrals and linkages to adoption-related resources as such needs are identified during the POC process (initial and updates). AnD 05.10 Discharge Criteria and Process, pg. 3. SEE ALSO SBHG The Wraparound Process, pg. 1.
6.2 Develop a Post-Transition Safety Plan
a. The Post Transition Safety Plan process and the agreements represented by the plan is an important and essential milestone; once achieved it can be acknowledged and celebrated too – “you all have learned a lot about how to handle stressful things that might occur in the future and you built yourself a good safety plan. That’s not easy and you can feel very proud about that – congratulations!”. Staff apply the same screenings/assessment toolkit, practice principles (HFW, SAFE-T, etc.), contextual considerations, service and documentation processes to Develop a Post-Transition Safety Plan. The Post Transition Safety Plan is documented on the SBHG Safety Plan template, and a copy is provided to the child/youth/young adult and family. The key shift in the planning process for post Transition (after discharge) is that the team must carefully consider, talk through, and put into place strategies and resources that will be available in the community and among natural connections (and not the staff team) to meet potential crisis scenarios unique to the child/youth/young adult and family. This includes promoting reliance on the plan’s identified strategies and resources, especially encouraging use of the proactive strategies while also talking through “what happens if” scenarios (reactive strategies) so the family feels confident they can cope through future crisis should such occur. AnD 05.10 Discharge Criteria and Process, pg. 3. SEE ALSO SBHG HFW Safety Plan, pgs. 1-2.
b. Facilitators ensure to maintain the collaborative nature and environment as the team develops the crisis and safety transition plan and it works well when the plan strongly reflects family members’ collaborative inputs, addresses their fears/worries, and provides information about competent and reliable supports/resources that will help them manage through safety risks and difficulties. To maintain the highest level of fidelity and quality, facilitators (as well as other assigned team members) receive on-going training and coaching on crisis and safety planning. All staffs are trained in Wellness Recovery Action Plan (WRAP) as part of SBHG’ Core Practices curriculum and they can elect to use the evidence based steps of that practice – e.g., when things are breaking down, crisis and recovery — to further explore, augment and support the client/family’s understanding of how to manage health conditions over the life course. WRAP is a self-directed and peer supported process, with versions available for children and teens. SBHG HFW Safety Plan, pg. 8.
c. Wraparound staffs participate in Service Integration Team (SIT) meetings, wherein the crisis and safety plan is reviewed. This includes review for the inclusion of natural/community supports, individualized proactive and reactive strategies for youth and family, and cultural relevancy. Teams are coached and provided feedback on strategies to ensure natural supports, via SIT meetings, feedback in TOM’s debriefs, and supervision. Within a larger Quality Assurance context, SBHG HFW programs will mobilize a wide range of tools such as the DART (which is currently being piloted) and probes to mine crisis and safety plans as an area for continuous quality improvement, training and coaching opportunities. SIT Form, pgs. 3-5.
6.3 Create a Commencement and Celebrate Success
a. We expect that every successful graduation results in a celebration and that those CFTs that meet at least some of their goals take the time to acknowledge and reflect upon progress made together as a team, ahead of the planned discharge date. Acknowledgements, commencement and celebration rituals communicate that ‘you matter’ and that we (the staff) are hopeful about your future. The atmosphere is positive and the team ensures the celebration incorporates the family’s culture, values, and preferences. This approach further reinforces and emphasizes the family’s culture and values as foundational strengths which will support the family beyond the end of the Wraparound process. AnD 05.10 Discharge Criteria and Process, pg 3.
b. Staff teams leverage agency resources (e.g., meeting spaces, staff time and attention, scheduling/coordination, etc.), flexible funds (e.g., food, supplies for fun activities, etc.) and the creative ideas, cultural traditions/rituals, and party contributions of CFT participants to create a commencement and celebrate success. In some instances, family’s have agreed to have their story recorded in a graduation video, highlighting their journey through the wraparound process. The teams also reflect briefly on the child/youth/young adults’ and family’s strengths, commitments to well-being, and positive aspects of their engagement with the program. PGM 06.08 Flex Fund Request, pg 1.
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
a. We are actively exploring processes to enhance our capacity to center youth and family as key decision-makers. At the individual client care level, clients/families are part of the CFT process which leverages their inputs and wisdom as decision makers. Additionally, clients/families have historically been engaged to provide feedback and recommendations to programming and agency operations using Focus Groups, surveys, and participation in SBHG’s Quality Councils (see Standard 10 for more information on Council). SBHG Family Focus Group Protocol, pg. 1 (all), pg. 2-section 2 “How will your comments be used.”
b. Family feedback is an instrumental asset and key component to SBHG decision-making regarding service planning and implementation. To ensure youth and families are key decision-makers, feedback is routinely elicited using a wide range of tools and instruments. All SBHG agencies’ QAs run a Service Validation Protocol which involves brief phone interviews with caregivers about whether wraparound services are being delivered to expectations. As previously mentioned, the TOM 2.0 and WFI are utilized during service delivery, while also administering continuous satisfaction surveys as youth/families exit from services. These instruments provide essential data and feedback which is then translated into actionable steps related to quality improvement. Feedback is used to support quality improvement initiatives and projects which are central to SBHG’s TQM program. The TQM program centers varied stakeholder input and transparency with stakeholders invited to participate in Quality Councils. Family feedback is instrumental in developing and updating policies, procedures, and processes to monitor and improve the quality of care provided to children/youth and families to HFW standards. SBHG is also revisiting the establishment and maintenance of a dedicated Consumer Advisory Groups comprised of youth/family representatives. Our current thoughts about how to build such an alliance is to structure Advisory regionally (instead of per program), host meetings online, and figure out how to optimally incentivize participation. Other strategies being discussed include joining established community processes, such as county-run Youth Advisory Boards (which some teams have done in the past); and setting up a communication process (e.g., text messages) with enrolled clients/families to gather their input on particular issues/questions – one topic at a time as such arise. Service Validation Protocol’, pg. 1 section B#4 & section D. SEE ALSO Service Validation; SBHG Example- Biennial TQM Plan, pg. 10 section 12.
7.2 Community Leadership Team
a. Stars Behavioral Health Group’s agency and program leaders have historically participated in and actively supported county-led processes on behalf of system of care development, interagency collaborations, program and practice improvements and promoting positive community relations and will do so to 7.2 standards as invited and/or directed by our county partners. Each SBHG agency assigns at least one HFW program leader to the county’s Community Leadership Team. Indeed, our agency/program leaders have already been participating in county facilitated HFW community and provider planning meetings: for example, in Santa Clara, Michelle Buckely, Starlight Program Director and Maria Nieto, Starlight Operations Coordinator; in Fresno, Jennifer Seidel, Central Star Administrator and Fatima Vasquez, Central Star Program Director; and in Los Angeles, Tina Binda, Star View TEAMMATES Administrator and Lindsey Watson, Star View Assistant Administrator.
7.3 Eligibility and Equal Access
a. Staffs responsible for referral and intakes are trained and supervised to the program’s contractual expectations and written policies and procedures. Staff understand that the company’s mission and ethos is to serve and they “do what it takes” to sort out and resolve eligibility and enrollment issues in a timely way. Furthermore, wraparound teams are trained to address a wide range of needs, ensuring no youth is excluded from receiving services due to severity of those needs. SBHG agencies consistently receive positive feedback (90% or greater endorsements) on Agency Partner Surveys (n=59 respondents, FY 23-24 to current) about their Wraparound and Full Service Partnership programs’ alignment with access to care standards, including prompt referral processing and inclusivity. SBHG HFW Training Plan, pg 12.
b. Staffing plans are a 1:10 staff to client ratio to support the intensity, frequency and crisis interventions needed by those enrolled in an HFW program. The SBHG wraparound team provides 24/7 support to families in crisis, with the additional support of Mental Health Specialist (therapist/clinicians) being LPS certified should a psychiatric hold be required as part of the intervention. ADM 6.31 TEAMMATES_FSP 247 LPS Crisis Coverage 12.30.21, pg 1-2. SEE also SPP – 23 Therapist Increased Caseload Bonus, pg 1
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
a. Funding for HFW is expected to occur through SBHG agencies’ contracts with county departments of behavioral health. SBHG currently successfully provides HFW through these contracts, claiming services to MediCal, Mental Health Services Act and other funding for indigent clients. In Santa Clara and Fresno Counties, HFW for youth and families involved with the child welfare and/or juvenile probation systems is also supported with foster care funding. Budgets developed with counties as part of their solicitations for services or to support ongoing funding include necessary funding for staffing meeting HFW standards, for ongoing training and other workforce development, and for extensive clinical, financial, and human resources data management systems. Contract budgets reflect SBHG’s cost proposals developed when bidding/rebidding on programs and then negotiated/adjusted with the county, and are fully transparent about provider types, rates/salaries, payroll taxes, employee benefits, facility/equipment/IT, operating and financial services (e.g. annual external audits) and any special expense types for a program (e.g., Flex Funds in wraparound and FSPs). All HFW programs provide “flex funding,” which is included in all county contracts for Wraparound, to support the immediate needs of families and youth for services and supports. Staff access credit cards or checks are expedited to support immediate access to these funds.
b. HFW funding is utilized to support the flexible and creative work environment described in Standard 9.3. SBHG actively works to be a trauma informed organization with a focus on having a psychologically safe work environment, positive relationships between staff, and opportunities for open communication and collaboration. Evidence of positive employee relations and workplace culture is SBHG’s certification as a ‘Great Place to Work’ for 9 straight years. You may also see evidence of our positive organizational culture in the example TQM Quality Council slide deck provided under Standard 10.2. SBHG TM CQI 2025 July 2024-June 2025, pgs. 8-9.
c. SBHG’s contracts and budgets explicitly allocate funding for the data collection and data management systems required to support High Fidelity Wraparound practice, fiscal accountability, and contractual compliance. SBHG maintains a mature, fully integrated data infrastructure anchored by a customized EMR (Netsmart MyEvolv) that has been in continuous use for over 15 years and is structured to capture all core Wraparound activities, including referrals, enrollment, assessments, plans of care, progress notes, measurement based care tools, and discharge outcomes in alignment with CA Wraparound Standards. Documentation follows auditable formats that reflect Wraparound principles, is subject to supervisory review and approval, and adheres to established timeliness standards prior to claiming. EMR, finance, and HR data are integrated into SBHG’s Business Analytics system, which provides real time dashboards and reports used by leadership, supervisors, and QA staff to monitor fidelity indicators, service delivery patterns, productivity, and budget performance. This long standing, fully funded infrastructure demonstrates SBHG’s sustained fiscal investment in data systems that support quality assurance, transparency, and consistent fidelity to the CA High Fidelity Wraparound Model across all contracted counties. SBHG EMR Infrastructure Overview, pgs. 1-3. SEE ALSO SBHG BA Dashboard Landing Page Examples pgs. 1-4, SBHG BA Reporting Tool Examples, pgs. 1-8.
8.2 Equitable Funding Across System Partners
8.3 Cost Savings are Reinvested
a. SBHG operates many programs and annually contracts with over 20 counties across California. We calculate and track the financial performance of each of our agencies and programs but we do not always reinvest “cost savings” or surpluses, for those programs that have them, specifically back to those programs. Surplus funds are reinvested in the overall organization in areas that support clinical quality and operations efficiencies, such as our information and data management systems, general clinical training, community outreach, quality management and compliance program, leadership development, etc. For example, SBHG Wraparound programs spent $100k on specialized Family, Search, and Engagement training and consultation from Seneca trainers to enhance Family connection and natural support finding efforts. Surplus funds are also used for working capital and to manage cash flow for the company to avoid the need for debt. SBHG is organized as an Employee Stock Ownership Program (ESOP) and is a 100% ESOP, meaning our employees own the company and any surpluses we earn. The ESOP operates like a retirement savings program and is therefore an employee benefit. Surpluses therefore are reinvested in our employees by providing this unique benefit. There are no requirements from our county partners to reinvest surplus behavioral healthcare funds in our wraparound or any other specific programs. However, should counties implement such mandates, we would comply. The CalAIM waiver that moved reimbursement from cost reimbursement to fee for service, allowing for surpluses to occur, does not require reinvestment of surpluses.
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
a. SBHG ensures flexible funds are available and included in all High Fidelity Wraparound funding plans, with amounts and approval parameters defined by county contracts. Staff are oriented to both the values and the procedures governing flexible fund use, with clear expectations that requests are driven by Child and Family Team recommendations and tied directly to the individualized Plan of Care. The CFT process includes discussions about what would be needed/helpful for the family to be able to sustain themselves in ways temporarily supported through Flex Funds. PGM 06.08 Flex Fund Request, pgs. 1-3. SEE ALSO SBHG Wraparound Flexible Fund Form, pg. 1.
b. (1)Flexible funds are used to address urgent and individualized needs—such as housing stability, basic necessities, education, wellness, recreation, and community, cultural, or Tribal participation—when these needs cannot be met through other resources. (2)Requests are evaluated using a consistent framework to ensure the use of funds supports the team mission, builds on family strengths, addresses identified youth and family needs, is culturally relevant, strengthens natural and community supports, represents a sound investment, and includes consideration of sustainability beyond the immediate purchase. Processes are designed to ensure timely access for families, including mechanisms to address urgent needs outside of standard business hours. (3)A defined approval process, documented in policy and supported by standardized request forms, governs the justification, use, and tracking of flexible funds, and includes a clear appeal pathway with communication to teams, youth, and families when requests are denied. This structured yet responsive approach ensures fiscal accountability while preserving the flexibility and individualized problem solving central to High Fidelity Wraparound. PGM 06.08 Flex Fund Request, pgs. 1-3. SEE ALSO SBHG Wraparound Flexible Fund Form, pg. 1-2.
8.5 Collaborative Oversight of Flex Funds
a. In our experience and contracts, for collaborative oversight of flex funds, counties typically establish guidelines for the total amount potentially available for a given child/youth/young adult and/or family, while also placing the funds as a pooled line item in budgets for program teams to manage per written policies and procedures. Counties’ guidance is toward using no cost or low cost options to meet needs as much as is possible, yet they also make Flex Funds available. Flex Fund accounting is captured in our accounting systems that have layers of oversight, with information provided to stakeholders in cost reports and budget reconciliation discussions. This is not a contentious topic; rather Flex Funds are overseen in a disciplined and collaborative manner. PGM 06.08 Flex Fund Request, pgs. 2-4.
b. County programs are billed monthly and include accounting for Flex Fund use. The bill submitted is based on fee for services provided or cost reimbursement. Cost reimbursement programs have cost reports which are done annually once the county provides the cost report template to complete. True Fee for service program do not have cost reports. There are some programs that are a hybrid, monthly bill fee for service but true up annually with a cost report. PGM 06.08 Flex Fund Request, pgs. 2-4.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
a. Flex funds are generally provided by counties to each HFW program as an annual pool of funding, allowing for each HFW program to flexibly utilize the funds based on the differing needs of the clients and families served. Braiding resources can occur depending on the distinct funding mix behind each contract.
b. If funding amounts are depleted, requests are made to counties to add or transfer funds from other programs. Braiding resources can occur depending on the distinct funding mix behind each contract. Teams are also adept at locating no cost/low cost resources for families as in-kind contributions from varied sources.
c. As noted in Standard 8.3, SBHG also backstops Flex Funds on occasion to meet the needs of our children/youth/young adults and their families. Service Validations, pg 2.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
a. With regard to comparative client to staff demographics, teams leverage SBHG’s bi-annual Cultural Attunement Plan process to provide information to HR for diversity recruitment and to plan with their staff teams for the resources and supports needed to meet SBHG’s Cultural Attunement Plan reviews, trainings, and QI initiatives for responsive services in light of client demographics. SBHG HFW programs recruit for both monolingual and bilingual treatment teams. While majorities (93%) of child/youth/young adult clients speak/read English as their primary language, 6% prefer Spanish — and many more caregivers (currently estimated at 20%) do as well. Additionally, as much as is possible, treatment teams are structured to ensure that at least one staff member is able to communicate in the family’s preferred or native language. SBHG Cultural Attun Plan Template 25-26 & FY 26-27, pgs. 1-2. SEE ALSO SBHG Example of Cultural Attunement Plan, pgs. 1-5.
b. SBHG agencies apply much effort to recruiting/hiring according to the cultural, racial and linguistic needs of families, in order to meet families’ needs for cultural representation. We note that the behavioral health care field attracts female staffs over males in a roughly 3:1 ratio; thus, a feature across a number of our current Cultural Attunement Plans are staff trainings to better understand and work effectively for Boy’s and Men’s Mental Health. Within a couple of our wraparound programs, the teams have also specifically designed group services and workshops to engage and support Fathers with services and to provide ‘Fathers Matter’ training to their staffs. We will generalize this focus across all of our programs as part of ‘up-tuning’ to HFW standards and we include ‘Fathers Matter’ trainings on the Training Plan. SBHG HFW Training Plan, pg. 6.
c. We have multiple varied ways, which align to Cultural Linguistic Accessible Services (CLAS) standards, to address language needs: a) For positions requiring bilingual capacity in areas where recruitment for such is tough, local hiring managers and HR staffs spell out in their Cultural Attunement Plans the extra efforts they will take to address how they will meet this need. PGM 01.01 Cultural Attunement Program, pg. 4, section 4.
These efforts may include a) Sign-on bonuses, targeted outreach, bilingual salary differentials, and other recruitment incentives designed to attract qualified candidates from relevant communities (SBHG Bilingual Pay Differential, pg. 1); b) HR/QA language proficiency testing protocols to make sure those we hire to provide bilingual services are sufficiently fluent to provide services; c) Translations of consumer facing documents into county threshold languages. Given we provide services in many counties and to California’s most diverse large counties by population (e.g., Alameda, Fresno, Los Angeles, Sacramento, San Bernardino, Santa Clara, Riverside), we have a lot of translated materials in many languages. We maintain an active Language Bank account for this work, while also tapping resources that might be available from the county; and d) Staff training on how to access Language Line Services or use the provider network in the wider community or within our company to provide interpreter services when needed. For clients prescribed psychotropic medications, if the prescribing provider does not speak the client’s preferred language, a bilingual team member is present during the appointment to provide interpretation and ensure accurate communication. In addition, SBHG program teams have access to professional translation and interpretation services through county services and various contracted vendors to further support linguistic access as needed. PGM 01.01 Cultural Attunement Program, pg. 4, section 4(c).
9.2 Tribally Responsive Workforce
a. The HFW principles and practices covered throughout our application apply equally to those served from tribal communities, as with all clients, as we are a Tribally Responsive Workforce. Among SBHG’s HFW relevant programs, typically under 1% (.25 of a percent FY 24-25) of the children/youth/young adults were of an American Indian/Native American/First Peoples background, and thus, the large majority do not have a tribal affiliation. The primary reason for the low prevalence, beyond population numbers, is that counties and tribes typically have preferred provider networks for such select subgroups to which (in this case) American Indian/Native Americans/First Peoples are referred and linked into services. Our staff are trained on how to reach out, engage and coordinate with tribes as natural/community supports – e.g., to participate in the CFT process and/or for resource/linkages in fulfillment of individualized Plan of Care / Safety / Transition Plans. The SBHG HFW Training Plan addresses tribal sovereignty, traditions, and values, as well as how to ensure respectful communication, collaboration, and advocacy. On a larger organization-scale our SBHG RPP Clinical Program Writer recently signed up for U.C. Davis’s training unit ‘Indian Child Welfare Act (ICWA) Overview & Tribal Engagement in Teaming Best Practices’ and is assigned to create an SBHG Practice Guide for our service teams based on the information provided at this training. HFW Training Plan, pgs. 2 & 6.
b. Programs can (and have) included a focus on American Indian/Native Americans/First Peoples in their Biennial Cultural Attunement Plans, such as inviting indigenous speakers to provide in-services and including local tribes in invitations to events and activities that the agency provides or co-sponsors in the community. For example, Star View Teammates organizes and co-sponsors LGTBQ+ Pride festivals in Compton and they include outreach communications with the Gabrielino-Tongva (or Tongva) tribe, among the many communities of this area. Some counties identify “Cultural Brokers” (e.g., Tribal Representatives) that our team members partner with when attempting to optimally link referred children/families with culturally specific providers.
9.3 Flexible and Creative Work Environment
a. By design, SBHG’s business and organizational structure and processes generate a “systemic press” for management to foster a flexible and creative work environment. We are an Employee Stock Ownership Program (ESOP) engaging in continuous quality improvement (CQI) in the context of an overarching Total Quality Management (TQM) program that has evolved over a 30 year period. This means that staff have a vested interest in the success of their agencies/programs’ operational efficiencies, financial viability and the quality of care being provided to those we serve. Our staffs are accustomed to data driven care (use of data to drive practice and programmatic improvements), measurement based care (use of standardized behavioral/functional assessments to monitor individual client/family progress and outcomes), technological and regulatory changes to the work environment (e.g., most recently CalAIMS), and to changes arising from the strategic initiatives and QI projects of company/agency and local program leadership that are systematically informed by staff’s creative ideas and participatory inputs. Expectations for engaging with quality improvement are established from the start – every SBHG job description includes a line like “will participate in and contribute to the agency’s quality improvement program.” Staff become involved in strategic initiatives and QI work in any number of ways: through company-sponsored listening tours , through the many varied methods employed in our TQM program (e.g. Rapid Cycle Improvement Process (RCIP), Joint Commission Tracers, Focus Groups, Surveys, review of Contract KPIs and Probes data, etc.), as described under Standard 10.2; and through structured committee and workgroup processes (e.g., for CQI, Cultural Attunement, HR Voice, Social Justice & Equity, etc.). SBHG’s Cultural Attun Plans – Committee Review and Overview, pg. 2-4. SEE ALSO SBHG CiBHS CYBHI SMART Assessment, pg. 1; SBHG Example Biennial TQM Plan’, pgs. 1-12.
b. Leadership development emphases how to build and maintain strong teams. Senior Leaders and promising next generation managers engage in meetings, workshops and book clubs to learn about and then carry forth with foci such as social/emotional intelligence (in leadership), psychological safety, empathy, teamwork, and being a trauma-informed organization. For example, local leadership teams explore and apply the work of Patrick Lencioni, ‘The Five Dysfunction of Teams: A Leadership Fable’ (Wiley, 2002) which emphases methods for building trust, addressing conflicts, fostering commitment, assuring accountability and producing results. The most recent book club explored the work of Amy Edmonson, ‘The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation and Growth’ (2019, Wiley) and culminated in Dr. Edmonson conducting a workshop at SBHG’s last Senior Leadership Meeting (Dec 2025). Our training programs integrate administrator/managers and HR perspectives into unified training curricula (Management Academy, Leadership University series, Senior Leadership Meetings, All Staff Meetings) which foster shared values, principles, language and the teamwork skills necessary for cohesion (communication, coordination and collaboration). From these foundations, teams may be creative and they are – delivering their own leadership trainings aligned to shared principles yet with new contents folded in, mobilizing staff’s inputs to develop shared workplace professional norms; hosting varied types of employee engagement activities including those focused on staff wellness and related support needs; and setting up ongoing informal and/or formal structures that bring staff together online or in person for information sharing and coaching (Office Hours, Clinical Discussion Groups/Grand Rounds, Internal Team Conferences, varied Coaching practices, etc.). We’ve established norms for online meeting participation, encouraged and financially supported in-person activities and meetings as much as possible, and provided periodic site visits from corporate department leaders/staffs to our facilities and outpatient settings. All such efforts signal and manifest that we are one company and one (big) team on behalf of those we serve. SBHG HFW Training Plan, pgs. 10-12. ALSO SBHG Leadership Training Program, pg. 2
c. Openness of communication is fostered by the processes, canon and ethos embedded in the resources and methods described in the last two sections (9.3 a & b) and also through additional formal company-wide mechanisms such as regular Town Hall Meetings (where company leaders encourage and address hard questions from staffs that are submitted anonymously), Employee Advisory Committees (e.g., VOICE, Social Justice & Equity), and our Incogneato system (an anonymous online portal available to all staffs so they may raise concerns and questions). Our administrators/managers also host their own All Staff Meetings at the agency or program level and they are managed/supervised to embrace, communicate and maintain an “open door” and “no wrong door” ethos with their team members. SBHG TM CQI 2025 (July 2024-June 2025), pg 8-9, SBHG Human Resources Programs pg 1-2.
d. We have nine years running of success with our annual ‘Great Place to Work’ surveys of our staffs, that indicates the organization is being managed to the satisfaction of the majority of our staffs. Additionally, HFW teams train in professional facilitation (Kaner et al, Facilitator’s Guide to Participatory Decision Making, Jossey Bass, 2014), which make them particularly adept at fostering cohesion when trouble-shooting, problem-solving and solution building. Furthermore, leadership at various levels utilize various staff facing meetings such as team meetings, group supervisions, and All Staff Meetings to create a clear sense of mission and compliance. During in-person and online meetings, various hands-on activities are used to develop staff skills and reinforce HFW standards and principles.
9.4 Hiring, Performance Evaluation, and Job Descriptions
a. SBHG has developed HFW job descriptions which are aligned to the roles and functions of a HFW team, including the Youth Partner, Parent Partner, HFW Facilitators, Family Specialist, Fidelity Coach, licensed Clinical Supervisor and the HFW Supervisor. Additional job descriptions are developed to support the HFW program, but all roles are reviewed by SBHG HR and program management to ensure full alignment with HFW requirements. Job Descriptions, pgs. 1-31
b. Once hired, each employee receives and signs a job description outlining the minimum qualifications, licensure requirements, specialized skills, core competencies, and duties and responsibilities of the position. Job Descriptions, pgs. 1-31
c. SBHG agencies are equally committed to hiring and retaining top talent that meets or exceeds the minimum qualifications for each position. In alignment with our commitment to hiring a team that reflects and understands the populations we serve, SBHG agencies prioritize candidates whose lived experience, diversity, and community knowledge strengthen our service delivery.
d. Our Talent Acquisition team screens candidates against the qualifications listed on the respective job description, allowing managers to focus interviews on behavioral based questions that help identify individuals who demonstrate a “whatever it takes” approach—an essential mindset for delivering HFW services. “Hiring for Attitude” is a common frame! In addition to recruiting external candidates, SBHG agencies maintain a strong record of promoting from within whenever possible because doing so enhances organizational continuity, deepens experience and institutional knowledge, and provides meaningful growth pathways for our employees. SBHG Human Resources Programs, pg. 3.
e. Employees are assessed against shared and core competencies at their 90 day evaluation, at six months, and annual each November to ensure they continue to meet position expectations and practice standards. SBHG agencies demonstrate a sustained and comprehensive commitment to the professional growth of its leadership team. Supervisors, managers, and emerging leaders participate in a broad portfolio of development opportunities, including New Manager Training, the Management Academy, Core Practices Supervision Training, and a range of ongoing online and live professional development courses. SBHG HFW Training Plan pg, 10. SEE ALSO SBHG Leadership Training Program, pgs. 1-2
9.5 Workforce Stability
a. To address labor competition, we emphasize being an ESOP (five years to vestment is motivating to many) and having excellent employee benefit programs – e.g., competitive holiday/vacation pay, flexible work schedules, employer sponsored health care, supplemental benefits and insurances, employer contributions to retirement savings, accessible independent financial counselors, continuing education tuition reimbursement; and offering a range of employee wellness, fun and support activities (including funding pools for each agency to use as they see fit for employee support activities). SBHG’s HR Department conduct annual labor market and cost of living analyses for each region/county in which we operate, and they make upward adjustments to salaries to stay just above the middle range for each position type, while also offering additional incentive/bonus programs for select positions that are the most difficult to recruit/retain (e.g., Psychiatric Nurses, Teachers, Bilingual Clinicians/Staffs, Senior Leaders).
b. Staff to client caseloads among direct service staffs are budgeted and monitored to contractual expectations and to EBP practice models to assure such are manageable for staffs and support high quality individualized care to clients/families. Productivity is tracked and supported for those who need to improve their workflows or to gain other efficiencies to meet productivity goals. Open lines of communication with immediate supervisors/managers is important so that any/all staff types can express themselves around their workload, and the ethos of teamwork (e.g., making sure work activities and tasks are covered including back-up for persons on PTO/leave) helps much to address/distribute workloads toward the fulfillment of shared goals in ways that do not add unnecessary stress to the busy productive lives of staffs.
c. Persons with lived experiences/peer staffs have their own Job Descriptions, training/certification trajectories and role contributions (including service on SBHG and/or local agency committees/workgroups) in which they may contribute, learn and grow. Individuals with lived experience may participate in promotional and advancement opportunities. SBHG Job Descriptions, pgs.19-24, 29-31.
d. Without having to change jobs, staff can experience growth opportunities which reflect merit (performance/productivity), service/contribution to quality improvement, and demonstrating leadership from involvement in committees/workgroups. Staff may receive partial tuition reimbursement for external coursework/trainings tied to their work role and thus they may build up their skill sets for their current and/or a future job. HRP 5.06 Educational Assistance- CEU’s, pg.2.
9.6 High Fidelity Training Plan
a. While our initial High Fidelity Training Plan is to have staffs participate in option “1: Statewide Standardized Foundational HFW training through UC Davis”, we aim to build upon our organizational experience to phase in our own comprehensive training program to cover all required contents. This effort is bolstered by SBHG’s Training Department’s leaders/trainers who are certified by the Association for Talent Development (ATD) with expertise in adult learning, use of technology in training environments, and mastery at delivering interactive learning to an organized lesson plan. We note that SBHG’s training units typically achieve CEU status from the APA and other professional associations, which supports our staffs with maintaining their credentials and expectations for professional development. As is gets underway, our internal training program will draw upon the many years of experience and expertise of key leaders from our Los Angeles, Santa Clara and Fresno wraparound programs: units are being built/rebuilt, and in person units will be delivered collaboratively between SBHG Training Department personnel and our wraparound experts. Our teams will continue to rely on U.C. Davis’s Foundations and other training units until such time as the state/U.C. Davis approves our training curricula, and we look forward to information about the pathway(s) for future curricular review and approval. SBHG HFW Training Plan, pgs. 1-4.
b. To achieve skill mastery and practice integration into work roles, we fully recognize that “one and done” trainings provided during new hire orientations are insufficient. We keep training lessons alive, and sharpen skill sets through a variety of methods including: a) making sure supervisors and CFT facilitators are well trained and supported as a ’community of practice’ by meeting periodically with a HFW Practice Champion (an SBHG senior leader with years of wraparound experience and high commitment to successful wraparound practice); b) providing staff with coaching and feedback from their supervisor and/or their fidelity specialist (e.g., those who administer/debrief the WFI and TOMs). Coaching also includes a minimum of 12 hours of shadowing which involves supervisors or their designee (e.g., senior staff of the same type as the new employee) accompanying new staffs into the field or to CFT meetings, to help them understand how to apply wraparound principles and practices in an in vivo context. Permission from the client/family is established before shadowing occurs. SBHG HFW Training Plan, pgs. 10-11.
c. Staff take U.C. Davis Wraparound 101 Foundations of Fidelity as an annual refresher course. Additionally, SBHG is committed to offering monthly boosters as part of regular staff team meetings that are anchored to the principles, phases and discrete job role responsibilities within wraparound. Fidelity data (e.g., TOMS, WFI, DART) are used by supervisors/trainers to select the units most of need among staff at any given time; and e) providing ‘level up’ trainings on wraparound adjacent topics important to client/family success (e.g., trauma-informed care, cultural attunement, community safety interventions, etc.) with staff assigned to such units based on their Learning Pathway. SBHG HFW Training Plan, pgs. 11-12.
d. Program leadership groups (administrators, managers, QA staffs, trainers and at least one peer professional per agency) began taking U.C. Davis trainings last year. Individuals from these leadership groups have participated in U.C. Davis’ on-line units designed to support HFW implementation planning and the foundational trainings (Wraparound 101 Foundations of Fidelity: orientation, principles, phases, roles, functions and teaming); and our Clinical Supervisors and select Research/Fidelity/QA representatives are accessing “Utilizing CANS Throughout the Wraparound Process” and/or other units. SBHG HFW Training Plan, pgs. 1-3.
e. Many service staff from across the company are currently on U.C. Davis’ trainings waitlists, eager to get started, and others are being directed to track and sign up as openings permit. This includes directing select staff to the U.C. Davis unit ‘Indian Child Welfare Act (ICWA) Overview & Tribal Engagement in Teaming Best Practices’. SBHG HFW Training Plan, pgs. 1-3.
9.7 Community-based Training Program
a. We appreciate the opportunity expressed by the standard Community-based Training Program, which compels us to build upon our historical instincts and patterns. We have long included (for 20+ years) clients/families and community partners in our Quality Councils. We have practiced (and published long ago) on how to engage young people in quality improvement process and projects (Dresser, K.L., Zucker, P.Z., Orlando, R.A., Krynski, A.A., White, G., Karpur, A., Deschenes, N. & Unruh, D.K. (2009). To further express and strengthen this set of values and our pattern, our SBHG Training Department HFW Workgroup (the team building out our internal wraparound training program) will identify and engage at least one Peer Staff and one community partner per agency as either a workgroup attendee/participant and/or to review and provide feedback on their work over the next ten months. During this process, this workgroup will discover and discuss opportunities with Peer Staffs and/or community partners to participate further as co-trainers and/or as training participants and this groups recommendations will inform and guide the build-out of SBHG’s HFW Training Program.
b. We regularly invite community partners to attend and/or to present at outreach, advocacy, educative and training events as part of our Cultural Attunement Plans (e.g., one popular topic is gang intervention presented by local specialists). Indeed, we invited county/community partners to our FSE trainings over the last few years, and a few attended; others in the county welcomed hearing about this training series at provider meetings. As mentioned before, our wraparound leaders in LA collaborated with other local provider agencies over many years to build and run the LATC. As one last example, over the last ten years, we embraced, integrated and advanced peer staffs in varied roles across our programs (SBHG currently has 74 parent partner / peer staffs as employees), including supporting such staffs in their pursuit and achievement of state Peer Certifications. SBHG HFW Training Plan, pgs. 11-12.
9.8 Coaching and Supervision
a. In our coaching and supervision approach, much of staff’s development into their work roles occurs once initial New Employee Orientation (NEO) is well along and thereafter. This is because we have found that newly hired staffs can become easily overwhelmed with information intake during NEO, from their first encounters with the complexities of life presented by their clients/families, and from getting adjusted to the activities, rhythms, milestones — and necessity to be flexible — that are inherent features of the wraparound service process. Initially, staff’s first weeks on the job are shaped by their trainers, supervisors and connection to IT and HR representatives. Much attentiveness from such personnel to new hires is essential during onboarding to optimally situate new staffs into their role, equip them properly, answer their questions, address anxieties, and plan/execute introduction onto their Child Family Teams. We encourage and structure deliberate attentiveness to the new hire’s experience through multiple built-in steps required during the NEO process and beyond — i.e., clearly laid out training schedules along and additional 1:1 orientations to technology, EMR documentation, policies and procedures, and to the company’s varied employee support structures. From there, supervisors (or their designee) are to be in the field (in vivo) with a new employee for a minimum of 12 hours during their staff’s first 90 days to observe/gauge the new person’s interaction skills with clients/families, role model engagement and professional comportment, and facilitate the family’s acceptance of the new staff person. Thereafter, coaching also occurs in the context of debriefing CFT meetings, Service Integration Team (SIT) discussions, contact with CFT Facilitators, and in vivo accompaniment of the supervisor with the staff during field work at least once every six months for staff with less than two years’ experience. Additionally, SBHG utilizes feedback from the TOM in debriefs with supervisors, Program Directors (when available) and wraparound team members to provide feedback to enhance targeted service delivery. We use the positive coaching practice promoted in the book: The Coaching Habit: Say Less, Ask More & Change the Way You Lead Forever, M.B. Stanier, 2016, Box of Crayons Press. This framework teaches leaders and supervisors how to ask the right questions to get staff thinking about how they work and motivated to improve as a constructive opportunity. SBHG HFW Training Plan, pgs. 1-12.
b. New staff have daily contact with their supervisor and opportunities to meet and share with other staff. Supervisors provide weekly 1:1 and group/team supervision throughout a person’s term of employment and are available to their staffs 24/7. Personal cell phone numbers are shared with staff. ADM 6.31 TEAMMATES_FSP 24/7 LPS Crisis Coverage 12.30.21, pg. 1.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
a. Our data collection and systems address what we refer to as Measurement Based Care (MBC) including Individual Treat to Target (T2T) Outcomes – to improve practice with youth and families, including giving staff timely feedback from data or reports relevant to their service provision and using data to identify staff training needs. The MBC Treat to Target process specifically includes staff administering standardized behavioral/functional assessment tools (e.g., CANS-IP, PSC-35, MHSA DCR, etc.) and reviewing their BA T2T Dashboard data during individual/group supervision, individual/family service sessions, and/or at CFT meetings. RPP 01.15 Measurement Based Care, pgs. 1-3.
b. SBHG prioritizes the use of collected data to identify and address program needs to better serve youth and families, with the express purpose to improve overall program effectiveness. SBHG mobilizes MBC tools regular MBC Completion Rate Reports are issued — pushed via email — quarterly (for solidly performing teams) or monthly (if rates drop below expectations – 85% matched pairs) and a Completion Rates Dashboard is also available for QA/Supervisors to check at will. Program Clinical Directors/Managers host MBC tool application trainings where they join group supervision to provide in-services focused on case examples, both those with positive and not so good results to explore intervention strategies that work, do not work, or might work (to be tried) to improve outcomes. SBHG is a Joint Commission (JC) accredited behavioral health care service organization, with a recently renewed cycle (FY 25-26 – FY 28-29). A key methodology is called JC Tracers during which Commissioners interview staff about randomly selected cases, tracing service processes from the point of referral through discharge, including reviewing relevant EMR documentation together. Our QA teams also run tracers throughout the year, similarly, monitoring the progression of randomly sampled client enrollments, providing feedback to teams, keeping the program ‘tuned up’ for the JC’s processes. Data is reviewed and applied for quality improvement initiatives and is embedded into the fabric of SBHG culture, with each agency develops and fulfills a Biennial TQM Plan that addresses their CQI Committee/Subcommittee structures and participants, methodologies and maintenance of their TQM system, and priority areas for QI focus (SBHG Example Biennial TQM Plan, pgs.5-12); (SBHG BA Reporting Tool Examples, pgs. 1-7).
c. As SBHG organization operates across several counties in California, each agency within the organization sponsors an Annual Quality Council to which agency partners (e.g., county contract monitors, child welfare and probation representatives, collaborative partners/providers from community and other external stakeholders) are invited to attend — many do, and more so over time – along with representative clients/families, program staffs, and program/company leadership. In this way SBHG’s TQM program centers transparency and varied stakeholder inputs into programming and quality improvement, and structures opportunities for system of care partners to hear from our staffs about what is working (or not) as they interface with the wider system on behalf of clients/families. We are grateful to the helpful feedback that our agency partners bring to the table. Other methods we use to engage stakeholders/collaborators in our work include Agency Partner Surveys (run annually), extending trainings/consultative opportunities to others (e.g., inviting agency representatives to Family Search & Engagement (FSE) sessions with the NIPFC) and having managers/directors attend county provider meetings, provider associations and other forums (MHSA planning meetings, county led program development initiatives, etc.) in the community to unpack and build solutions to system of care issues. We have active ongoing participation of our managers/directors in such county/community forums in every region in which we operate, which are reported on bi-monthly at SBHG Executive Team Meetings.(SBHG TM CQI 2025 (July 2024-June 2025), pgs. 11 & 67).
Fidelity Indicators
1.1 Timely Engagement and Planning
At Inner Circle Foster Family Agency, our commitment to effective engagement is demonstrated through adherence to California’s High-Fidelity Wraparound (HFW) fidelity indicators. These standards guide interactions with families and promote organizational coherence through structured protocols and thorough documentation:
a. The HFW Manager Supervisor closely oversees initial contacts following referrals, as detailed in the Treatment Tracker (page 1), ensuring that support for families begins promptly.
b. The HFW Manager Supervisor systematically tracks completion of the Plan of Care; this document, referenced on page 1 of the Treatment Tracker, guarantees that every family receives a clear, actionable plan.
c. The Plan of Care undergoes regular review during team meetings, with all discussions documented by the HFW Manager Supervisor to maintain alignment and engagement throughout the youth’s care process (Treatment Tracker, page 1).
d. Any updates to the Plan of Care are diligently monitored by the HFW Manager Supervisor, reinforcing our dedication to meeting each family’s evolving needs (Treatment Tracker, page 1).
e. To encourage transparency and collaboration, weekly staff meetings include reviews of the Treatment Tracker, led by the HFW Manager and Supervisor and involving both staff and supervisors (Treatment Tracker, page 1).
f. Staff receive comprehensive training from the Fidelity Coach, focusing on meaningful engagement and team-building activities designed to strengthen interpersonal relationships; these initiatives are outlined in Engagement and Team Building Activities, pages 1-2.
1.2 Led by Youth and Families
Effective implementation of the HFW model relies on fully incorporating families’ perspectives, honoring their values, cultural identities, and unique expertise. Input from families is actively solicited during meetings and visits, with all feedback comprehensively documented in the youth’s case file and via the following processes:
a. The HFW Facilitator gathers input from youth and families using the Strengths-Needs-Culture-Discovery Form (pages 1-2), ensuring that their perspectives remain central to the care process.
b. The HFW Facilitator works to identify each family’s core values and viewpoints, developing a holistic understanding of their strengths and needs (Strengths-Needs-Culture-Discovery Form, pages 2-3).
c. Observations by the HFW Fidelity Coach during meetings are recorded to provide actionable feedback for continuous staff development and best practice compliance (Coaching Observation Form, page 1).
d. The effectiveness of program approaches is continually evaluated through satisfaction surveys completed by youth and families and managed by the HFW Manager Supervisor (Youth and Family Satisfaction Surveys, page 1).
1.3 Strength-Based
Our philosophy centers on recognizing and leveraging individual strengths. The Manager is responsible for developing a strengths inventory form based on data from the IP-CANS assessment:
a. The HFW Facilitator conducts a thorough strengths inventory for each team member, as documented in the Team Strengths Inventory (page 1), fostering a culture of empowerment and appreciation.
b. The HFW Family Specialist integrates insights from the IP-CANS assessment to highlight each family’s strengths (IP-CANS, page 1).
c. All staff participate in targeted training on solution-focused, strength-based methodologies, as described in our Training Curriculum (page 1).
d. Continuous feedback is sought from youth and families through satisfaction surveys overseen by the HFW Manager Supervisor, ensuring our services align with the needs and expectations of those we serve (Youth and Family Satisfaction Surveys, page 1).
1.4 Needs Driven
Drawing from both the Strengths Inventory and the IP-CANS, we collaborate with families to identify and document their expressed needs.
a. The HFW Facilitator utilizes the identified needs to set and prioritize goals, as detailed in the Strengths-Needs-Culture-Discovery Form (page 3), ensuring a targeted approach to support.
b. The HFW Fidelity Coach provides training focused on needs-based planning, thereby enhancing staff expertise (see Training Curriculum, page 1).
c. The HFW Facilitator conducts careful reviews of documented needs from the IP-CANS (page 1) to maintain their centrality in planning activities.
d. Transition plans are systematically developed using feedback gathered from Team meetings, emphasizing collaborative engagement (refer to Wraparound Team Meeting Template, page 1).
1.5 Individualized
Inner Circle Foster Family Agency is deeply committed to developing individualized plans that reflect the distinct circumstances and aspirations of each youth and family.
a. The HFW Facilitator uses the Plan of Care to identify strategies tailored to the specific needs of each youth and family (see Plan of Care, page 2).
b. The HFW Fidelity Coach delivers ongoing training on adaptive and individualized approaches, ensuring responsiveness to family preferences (see Training Curriculum, page 1).
c. Continuous coaching is provided by the HFW Fidelity Coach, highlighting the customization of the HFW process and Plan of Care to foster a supportive environment (see Coaching Observation Form, page 1).
d. Monthly chart audits conducted by the HFW Clinical Supervisor rigorously review Plan of Care elements, upholding standards of care and quality assurance (see HFW Chart Audit, page 1).
e. Feedback from youth and families is regularly collected through satisfaction surveys managed by the HFW Manager Supervisor, reinforcing our dedication to continuous improvement (see Youth and Family Satisfaction Surveys, page 1).
1.6 Use of Natural and Community Based Supports
The HFW Manager Supervisor is responsible for establishing a comprehensive catalog of natural and community resources accessible to families. This resource inventory encompasses supports currently in use or potentially required over time across health, housing, recreation, financial assistance, nutrition, legal services, communication, spiritual needs, education, and additional critical life domains.
a. The HFW Facilitator compiles and updates the support inventory monthly for each family, as documented via the Natural Supports Inventory Form.
b. The HFW Fidelity Coach provides specialized training on engaging and integrating natural supports, as outlined in the Training Curriculum (page 2).
c. To ensure best practices, the HFW Clinical Supervisor conducts monthly chart audits evaluating all relevant aspects of each plan of care (see HFW Chart Audit, page 1).
d. The HFW Manager Supervisor gathers input from youth and families through satisfaction surveys designed to capture their experiences; refer to Youth and Family Satisfaction Surveys, page 1.
1.7 Culturally Respectful and Relevant
When developing the Plan of Care, the HFW Facilitator collaborates closely with youth and families to understand their unique cultural perspectives. This process addresses dimensions such as language, spirituality, religion, rituals, customs, dietary preferences, leisure activities, traditions, beliefs, and values to honor individual identities comprehensively.
a. The HFW Facilitator diligently seeks information reflecting the cultural perspectives of youth and families, guided by the Strengths-Needs-Culture-Discovery Form (page 3).
b. The HFW Fidelity Coach delivers training on eliciting and incorporating family and cultural insights into both planning and service delivery (see Training Curriculum, page 2).
c. Ongoing feedback is solicited by the HFW Manager Supervisor through satisfaction surveys to continuously refine and enhance cultural responsiveness (see Youth and Family Satisfaction Surveys, page 1).
1.8 High-Quality Team Planning and Problem Solving
Team planning is conducted collaboratively, with agreements formulated in partnership with each youth and their family. The HFW Facilitator works directly with the team, integrating contributions from the youth, family, and support network to produce meaningful agreements.
a. As part of the engagement protocol, the HFW Facilitator develops team agreements for each client’s HFW team, as recorded in the Team Agreement form (page 1).
b. The HFW Manager Supervisor collects insights from youth and families via satisfaction surveys (see Youth and Family Satisfaction Surveys, page 1).
c. Monthly feedback updates are communicated to staff by the HFW Manager Supervisor, utilizing the CQI Indicators Form (page 1).
d. The HFW Clinical Supervisor maintains accountability and quality through meticulous monthly chart audits, reviewing Plan of Care components and meeting minutes (see HFW Chart Audit, page 1).
1.9 Outcomes Based Process
To drive measurable progress, the Facilitator develops a comprehensive Plan of Care (POC) incorporating clear, achievable, relevant, and time-bound strategies. Action items are assigned to team members with defined deadlines and tracked during HFW meetings until they are completed.
a. The HFW Facilitator integrates quantifiable objectives, benchmarks, timelines, and strengths within the Plan of Care (pages 2-3).
b. Weekly progress monitoring by the HFW Facilitator enables timely adjustments (see Plan of Care, pages 2-3).
c. The Plan of Care remains adaptable, with the HFW Facilitator empowered to revise as circumstances evolve (see Plan of Care, pages 2-3).
d. The HFW Family Specialist completes the IP-CANS assessment and presents findings at team meetings (see IP-CANS, page 1).
e. Data from IP-CANS is incorporated into the Plan of Care to enhance its precision and relevance (see Plan of Care, pages 2-3).
1.10 Persistence
The HFW team stays committed to working with youth and families, even when they experience setbacks or slow progress. The HFW Manager Supervisor holds weekly staff meetings to review each family’s situation and progress, promoting accountability and mutual support. When challenges arise, HFW staff carefully analyze root causes and develop specific plans to address them.
a. If difficulties arise, the HFW Fidelity Coach observes the team’s interactions and gives helpful feedback, using information recorded in the Coaching Observation Form on page 2.
b. To help connect families with resources, the HFW Manager Supervisor provides guidelines for accessing services, as explained in the Fidelity Indicators policy on page 4.
c. Staff training is essential; the HFW Fidelity Coach trains team members in safety planning, conflict resolution, and brainstorming methods, following the Training Curriculum on pages 2-3.
1.11 Transitions as a part of the Fourth Phase of HFW
Recognizing the importance of smooth transitions, HFW staff proactively work to prevent service interruptions. If a youth or family misses a meeting or activity, the HFW Family Specialist or HFW Parent Partner quickly contacts them to reconnect and reschedule, maintaining ongoing support.
a. The HFW team focuses on ensuring smooth transitions, using warm hand-offs to link families to continuing service providers, as described in the Transition Plan on page 1.
b. With active participation from the youth and family, the HFW team marks achievements by creating thoughtful recognition plans, as detailed in the Commencement and Celebration of Success Plan on page 1.
Expected Outcomes
2.1 Youth and Family Satisfaction
The HFW Family Specialist is responsible for collecting feedback from youth and their families to gauge satisfaction levels. This input should be thoroughly recorded in the Treatment Tracker (tab 2) and referenced in the Expected Outcomes policy on page 1.
2.2 Improved School Functioning
Tracking and evaluating how youth perform in school falls under the duties of the HFW Family Specialist. Relevant information is available in the Treatment Tracker, tab 2, with further guidelines found in the Expected Outcomes policy on page 1.
2.3 Improved Functioning in the Community
With guidance from the HFW Manager Supervisor, both the HFW Facilitator and Family Specialist assess youth involvement and functioning within their communities. Detailed records are kept in the Treatment Tracker, tab 2, along with additional context in the Expected Outcomes policy on page 2.
2.4 Improved Interpersonal Functioning
The HFW Family Specialist gathers comprehensive data on interpersonal abilities through the IP-CANS assessment. All critical details should be documented in the Treatment Tracker, tab 2, and cross-referenced with instructions in the Expected Outcomes policy on page 2.
2.5 Increased Caregiver Confidence
To support youth, the HFW Family Specialist collects information that demonstrates caregivers’ growing confidence. Documentation goes into the Treatment Tracker, tab 2, alongside recommendations from the Expected Outcomes policy on page 2.
2.6 Stable and Least Restrictive Living Environment
Each month, the HFW Manager Supervisor evaluates the youth’s placement to ensure it remains stable and as unrestricted as possible. Any updates about new placements are entered promptly in the Treatment Tracker, tab 2, and referenced in the Expected Outcomes policy on page 3.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
The HFW Manager Supervisor actively tracks monthly admissions to inpatient facilities, striving for improved care. All changes are recorded in the Treatment Tracker (tab 2) and detailed in the Expected Outcomes policy on page 3.
2.8 Reduction in Crisis Visits
By regularly monitoring the youth’s crisis visits, the HFW Manager Supervisor aims to manage crises proactively. Information about these events is available in the Treatment Tracker (tab 2) and in the Expected Outcomes policy on page 3.
2.9 Positive Exit from HFW
The HFW Manager Supervisor supervises the youth’s progress and transition dates, focusing on facilitating a successful exit from the program. Details about the process are tracked in the Treatment Tracker, tab 2, and specified in the Expected Outcomes policy on page 3.
Engagement
3.1 Orientation
Upon admission to the Home and Family Wellness (HFW) program, each youth and their family participate in a comprehensive orientation session. This session provides an essential overview of the program’s guiding principles and outlines the legal and ethical considerations pertinent to family well-being. The orientation further clarifies the roles of all team members, underscores the value of natural supports—including connections to tribal resources when relevant—and addresses critical factors necessary for a successful experience within the HFW program.
a. At the onset of engagement, the HFW Manager Supervisor conducts the orientation, explaining the foundational principles and developmental stages central to HFW. For additional details, refer to the Orientation Format (pages 1–3).
b. During the engagement phase, the HFW Manager Supervisor discusses the legal and ethical standards applicable to the HFW program. Further information is provided in the Orientation Format (pages 1–3).
c. When Indian children are involved, the HFW Manager Supervisor delivers supplemental orientation regarding specific team member roles. Comprehensive details are available in the Orientation Format (pages 1–3).
3.2 Safety and Crisis stabilization
Recognizing that youth entering the HFW program may encounter safety challenges—including tendencies toward runaway behavior, suicidal or homicidal ideation, or other significant risk factors—an initial crisis plan is developed proactively before formalized crisis and safety planning.
a. During engagement, the HFW Facilitator or designated representative initiates open discussions about potential crises and safety concerns. Detailed procedures are available in the Crisis Plan (page 1).
b. The HFW Facilitator or designee is responsible for developing a comprehensive crisis plan that equips youth and families with key resources and strategies for managing challenges during engagement. Reference the Crisis Plan (page 1) for specifics.
c. The HFW Facilitator or designee provides essential information regarding the crisis plan, including access to a 24/7 response service, ensuring support is available as needed. See the Crisis Plan (page 1) for further details.
3.3 Strengths, Needs, Culture and Vision Discovery
Throughout the engagement phase, the HFW Facilitator meets with families to foster a safe environment conducive to discussing strengths, needs, cultural values, and the family’s overall vision.
a. The HFW Facilitator collaborates with each family to develop a Family Vision, reflecting their goals and aspirations. Refer to the Strengths-Needs-Culture-Discovery form (page 3) for more information.
b. Within ninety days of program entry, the HFW Facilitator prepares a comprehensive plan encompassing the family’s strengths, needs, cultural context, and vision. Details are available in the Strengths-Needs-Culture-Discovery form (page 5).
3.4 Engage All Team Members
During engagement, the HFW Facilitator completes the Natural Supports Inventory, working collaboratively with youth, families, and team members to evaluate and identify natural supports within their networks that can actively contribute to the team process.
a. Each youth and family receives a tailored Natural Supports Inventory from the HFW Facilitator, incorporating relevant supports. For specifics, see the Natural Supports Inventory (page 1).
b. In partnership, the HFW Facilitator identifies key stakeholders from the Children’s System of Care to join the HFW team. More information is found in the Natural Supports Inventory (page 1).
c. The HFW Facilitator precisely identifies potential team members and clarifies their respective roles to ensure clarity and purpose. Additional information is available in the Natural Supports Inventory (page 1).
d. The HFW Facilitator documents all team-building activities to promote transparency and cohesion. Records are maintained in the Wraparound Team Minutes (page 1).
3.5 Arrange Meeting Logistics
Meetings are scheduled with consideration for the availability and circumstances of both youth and their families. Inner Circle Foster Family Agency emphasizes flexibility and encourages HFW staff to adjust work schedules—including evenings and weekends—to facilitate participation during these meetings.
a. HFW staff recognize the responsibility to maintain flexible hours and practices. Comprehensive information is found in the Facilitator Job Description (page 1).
b. All HFW staff complete training designed to equip them with effective techniques for interacting flexibly with youth and families, ensuring inclusivity and accessibility. For details, refer to the Training Curriculum (page 1).
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
Before developing the HFW Plan of Care, a series of collaborative activities must be completed, including creating team agreements, a thorough inventory of team strengths, and an articulated mission statement, in partnership with each family. These documents are systematically recorded in the youth’s file, ensuring that the unique strengths of each family member identified during engagement are accurately captured and revised as additional strengths surface.
a.. The HFW Facilitator leads the formulation of team agreements, strengths inventory, and mission statement in collaboration with each youth and their family. Detailed procedures can be found in the Team Strengths Inventory, Team Agreement Form, and Team Mission Statement on page 1.
b. Throughout the HFW process, the HFW Facilitator consistently updates the strengths of the youth and family, as documented in the Team Strengths Inventory on page 1.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
In preparing to construct the HFW Plan of Care, it is essential to identify, define, and prioritize each family’s core needs. These needs are documented in the youth’s file. Measurable goals and outcomes are then established, emphasizing a strength-based methodology.
a. The HFW Facilitator is responsible for clarifying the underlying needs of the youth and family, utilizing the Strengths-Needs-Culture-Discovery Form located on page 3.
b. Goals and outcomes are measurable and rooted in the identified needs of the youth and family, as indicated in the Measurable Goals and Outcomes Form on page 1.
c. Inclusive engagement of the entire HFW team in goal-setting is vital, as reflected in the Measurable Goals and Outcomes Form on page 1.
d. The HFW Facilitator facilitates brainstorming sessions to encourage innovation and collaboration in formulating effective goals and outcomes, documented in the Wraparound Team Minutes on page 1.
e. To foster proficiency in Needs Focused Planning, the HFW Fidelity Coach delivers specialized training, detailed in the Training Curriculum on page 1.
f. Development of the Plan of Care is conducted through a team-based approach, ensuring comprehensive input and collaboration, as recorded in the Wraparound Team Minutes on page 1.
4.3 Develop an Individualized Child or Youth and Family Plan
The Plan of Care serves as a comprehensive document that integrates the goals and objectives developed by team members and is tailored to the specific needs of the youth and family. It is carefully recorded in the youth’s file, distributed to all team members, and designed to meet established effectiveness standards.
a. The HFW Fidelity Coach provides training and guidance on effective team engagement to strengthen collaboration, as noted in the Coach Observation notes on page 2 and the Training Curriculum on page 1.
b. The HFW Facilitator ensures all goals and objectives comply with the standards set forth by the Children’s System of Care, as documented in the Plan of Care on page 1.
c. A complete version of the Plan of Care, encompassing all required elements, is disseminated to team members, referenced in the Plan of Care on page 1 and the Strengths-Needs-Culture-Discovery Form on page 5.
d. To uphold quality standards, the HFW Manager Supervisor conducts monthly audits of the chart for updates to the Plan of Care, detailed in the HFW Chart Audit on page 1.
4.4 Develop a Crisis and Safety Plan
To proactively address potential challenges, Crisis and Safety Plans are individually developed and documented in the youth’s file. These plans effectively target safety concerns, identify high-risk situations, delineate crises, and outline both proactive and reactive strategies collaboratively chosen with family members. Each plan includes clear instructions regarding whom to contact for round-the-clock support.
a. The HFW Facilitator or designee develops the Crisis and Safety Plan based on information from the initial Crisis Plan, as specified in the Crisis and Safety Plan on page 1.
b. Input and insights from the HFW team are integral in shaping this plan, guaranteeing it reflects the collective expertise and perspective of all members, as documented in the Crisis and Safety Plan on page 1.
c. To ensure continued relevance and efficacy, the HFW Facilitator reviews the Crisis and Safety Plan monthly or as needed, confirming its adaptability to the family’s evolving circumstances, as noted in the Crisis and Safety Plan on page 1.
Implementation
5.1 Implement The Plan of Care
The HFW Facilitator is essential to guiding the team as they carry out the Plan of Care, making sure each part is executed efficiently. After a comprehensive review and approval, and once every team member has their own copy, the Facilitator actively tracks assignments and action items derived from the plan.
a. The Facilitator cultivates collaboration by encouraging thoughtful discussions among team members about strategies in the Plan of Care, including adapting action items as needed (see Wraparound Team Minutes, page 1).
b. Training sessions led by the HFW Fidelity Coach help team members gain the necessary knowledge and skills to implement and adjust the Plan of Care, ensuring everyone understands and is prepared for their responsibilities (refer to Training Curriculum, page 1).
5.2 Review and Update The Plan of Care
During structured meetings, the HFW team thoroughly reviews the Plan of Care, examines strategies, monitors progress, and focuses on action items. The Facilitator is central to identifying new needs, adjusting the plan accordingly, and developing fresh strategies and actions.
a. In these meetings, the Facilitator carefully assesses strategies, progress, and action plans to keep all members informed and involved (see Wraparound Team Minutes, page 1).
b. The Facilitator leads updates to address new needs and recognizes when goals have been met (documented in the Wraparound Team Minutes, page 1).
c. The Facilitator keeps detailed records of completed tasks and new responsibilities to ensure transparency and accountability (see Wraparound Team Minutes, page 1).
d. To address evolving situations, the Facilitator updates relevant forms so they match the team’s current requirements (noted in Wraparound Team Minutes, page 1).
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
The HFW Facilitator promotes a strong sense of unity and trust within the team by consistently applying team agreements at all stages of the process. These agreements are regularly reviewed with members, updated as needed, and presented during meetings.
a. Team agreements provide a solid foundation at HFW Team Meetings, reinforcing shared values and expectations (see Team Agreement Form, page 1).
b. The Fidelity Coach delivers impactful training on creating high-performing teams, helping members develop skills for better collaboration and cohesion (Training Curriculum, pages 3 and 4).
c. The Facilitator observes the participation of natural supports, ensuring they are integrated into the team and properly documented (Natural Supports Inventory, page 1).
d. For onboarding new members, the Facilitator uses the Orientation Format to fully inform and integrate newcomers into the HFW process (Orientation Format, page 1).
Transition
6.1 Develop a Transition Plan
The HFW team—comprising youth, family, and support members—assesses whether goals in the Plan of Care have been met against agreed-upon benchmarks.
a. The HFW Facilitator evaluates readiness for transition based on these benchmarks (see Plan of Care, p.2).
b. Insights from families and identified post-program needs guide the creation of a Transition Plan (see Transition Plan, p.1).
c. The Facilitator leads the team meeting to finalize the Transition Plan with input from all members (see Wraparound Team Minutes, p.1).
d. The Facilitator identifies available post-transition supports and services (see Transition Plan, p.1).
6.2 Develop a Post-Transition Safety Plan
The existing Crisis and Safety Plan is updated as needed to fit changing needs during and after transition. New plans may be developed if required.
a. The Facilitator or designee updates the plan to include new requirements or contacts (see Crisis and Safety Plan, p.1).
b. The plan is revised collaboratively in team meetings (see Wraparound Team Minutes, p.1).
c. During meetings, the entire team reviews the plan to ensure understanding and cooperation (see Wraparound Team Minutes, p.1).
6.3 Create a Commencement and Celebrate Success
Transitions are milestones worth recognizing.
a. The Facilitator uses the Commencement and Celebration framework to discuss how the family wants to celebrate achievements (see Commencement Plan, p.1).
b. Staff and team are involved in planning an appropriate celebration (see Commencement Plan, p.1).
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
Inner Circle Foster Family Agency is committed to enhancing service delivery by establishing an advisory board for HFW comprised of volunteer youth and families who have completed or are actively participating in the HFW process.
a. The HFW Manager Supervisor will convene periodic advisory group meetings to obtain input from families; refer to Advisory Group Agenda, page 1.
b. The HFW Manager Supervisor will utilize these meetings to gather feedback regarding decision-making, aiming to strengthen services, workforce, implementation, and policies; see Advisory Group Agenda, page 1.
7.2 Community Leadership Team
The HFW Manager Supervisor or appointed representative will serve as the organization’s liaison on any HFW Community Leadership team.
a. The HFW Manager Supervisor or designee is responsible for attending Community Leadership Meetings; see Manager Job Description, page 2.
7.3 Eligibility and Equal Access
Inner Circle Foster Family Agency recognizes the importance of maintaining a well-resourced HFW team capable of delivering high-quality services to all youth and families transitioning from the STRTP program.
a. The HFW Manager Supervisor evaluates each youth and family based on eligibility criteria and ensures acceptance regardless of the severity or nature of their needs; see Eligibility Criteria, page 2.
b. The HFW Manager Supervisor staffs the organization appropriately to provide the necessary intensity and frequency of services; see Organizational Chart, page 1.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
Contracts ensure the inclusion of high-fidelity direct services and supports to meet the immediate, individualized needs of youth and families; see Fiscal Supports Policy, page 1. They also require workforce development and staffing, including specified roles or functions (see Fiscal Supports Policy, page 1), as well as required data collection and/or data management systems.
a. The HFW Manager Supervisor reviews contracts to ensure that funding is included to provide support for the youth and family’s needs; see Fiscal Supports Policy, page 1.
b. The HFW Manager Supervisor reviews contracts so that sufficient staff can be hired and retained to support HFW activities; see Fiscal Supports Policy, page 1.
c. The HFW Manager Supervisor reviews contracts so that funding allows for data collection and data management systems; see Fiscal Supports Policy, page 1.
8.2 Equitable Funding Across System Partners
8.3 Cost Savings are Reinvested
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
Flex funds earmarked for the HFW youth and families served by Inner Circle Foster Family Agency form a critical component of the program’s budget.
a. The HFW Manager Supervisor allocates funds for flex funds; see Fiscal Supports Policy, pages 1-2.
b. The HFW Manager Supervisor trains the staff on the process for youth and families receiving flex funds and documenting them; see Fiscal Supports Policy, pages 1-2.
8.5 Collaborative Oversight of Flex Funds
The HFW Manager Supervisor maintains overall oversight of the approval process for all flex fund requests.
a. The HFW Manager Supervisor ensures that all flex fund requests are documented; see Fiscal Supports Policy, page 2.
b. The HFW Manager Supervisor keeps the flex funds as an aggregate amount so that they are available to all families; see Fiscal Supports Policy, page 2.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
The Executive Director and HFW Manager Supervisor work collaboratively to ensure flex funds are readily available to each family.
a. The Executive Director and HFW Manager Supervisor review program funding and request additional flex funds if an insufficient amount is allocated; see Fiscal Supports Policy, pages 2-3.
b. If the Executive Director and HFW Manager Supervisor find funding limitations, they contact the Community Leadership Team and their county liaison; see Fiscal Supports Policy, pages 2-3.
c. The Executive Director and HFW Manager Supervisor ensure that flex funds are available for all families; see Fiscal Supports Policy, pages 2-3.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
At Inner Circle Foster Family Agency, the Executive Director compiles thorough statistical profiles on youth residents, laying a foundation for building a workforce that mirrors client diversity.
a. The HFW Manager Supervisor plays an essential role in ensuring staff demographics align with those of the local community; more details can be found in the Workforce Development and Human Resource Management Policy and Procedures, page 1.
b. Where needed, the HFW Manager Supervisor seeks out and utilizes natural community supports to boost cultural representation, reinforcing the standards set by our policies (see page 1).
c. To facilitate clear communication, the HFW Manager Supervisor provides translation services as necessary, which helps overcome language barriers (refer to page 1).
9.2 Tribally Responsive Workforce
HFW staff at Inner Circle Foster Family Agency undertake specialized training on the Indian Child Welfare Act (ICWA), deepening their understanding of relevant laws and Native American cultures.
a. The HFW Manager Supervisor organizes thorough training sessions focused on ICWA, as described in the Policy and Procedures manual, page 2.
b. To ensure culturally inclusive practices, the HFW Facilitator reaches out to tribal partners and representatives, encouraging collaboration that includes traditional ceremonies in the HFW process; further details are provided in the Policy and Procedures manual, page 2.
9.3 Flexible and Creative Work Environment
The HFW program champions a “Whatever It Takes” approach, emphasizing adaptability and creative service delivery tailored to each youth and family.
a. The Fidelity Coach delivers comprehensive training on continuous improvement methods to maintain high-quality programming (see Training Curriculum, pages 4-6).
b. The Fidelity Coach also leads trainings on team cohesion; for more information, refer to pages 4-6.
c. Open Communication is emphasized during these sessions, fostering transparency within teams (see pages 4-6 for details).
d. Additionally, the training covers Mission Alignment and adhering to HFW Philosophy, ensuring all staff are unified around shared goals (pages 4-6).
9.4 Hiring, Performance Evaluation, and Job Descriptions
Every employee is evaluated after their first 90 days to ensure they meet job requirements and evolving expectations, supporting a high standard of care and professionalism.
a. The HFW program has clearly defined roles with detailed responsibilities—reference the HFW Manager Supervisor Job Description, pages 1-2.
b. These descriptions outline each position’s purpose, functions, and desired qualities; see the HFW Facilitator Job Description, pages 1-2.
c. State-compliant job descriptions are specifically crafted for HFW program needs; consult the HFW Family Specialist Job Description, pages 1-2.
d. Staff are given opportunities to highlight their skills, as outlined in the Workforce Development and Human Resource Management Policy and Procedures, pages 3-4.
e. Constructive performance feedback is regularly provided, facilitating ongoing dialogue between the HFW Manager, Supervisor, and their teams (see page 5).
9.5 Workforce Stability
Inner Circle Foster Family Agency’s Human Resources Department is committed to developing a strong and stable workforce by providing resources that enhance effectiveness.
a. Wages are adjusted by the HFW Manager Supervisor to remain competitive with community agency salaries and cost of living, as noted in Policy and Procedures, page 6.
b. Staffing levels are maintained to keep workloads manageable and the work environment supportive, as shown in the Organizational Chart, page 1.
c. Career advancement and promotion opportunities are openly communicated, creating clear paths for professional growth; refer to Policy and Procedures, page 6.
d. Additionally, staff have access to leadership development and pay increases without having to change jobs, promoting lasting engagement and satisfaction (see page 6 for details).
9.6 High Fidelity Training Plan
The HFW Manager Supervisor plays a pivotal role in coordinating a comprehensive staff training calendar, meticulously aligning HFW courses with UC Davis RCFFP offerings. This alignment ensures that all staff receive high-quality, relevant training essential to their roles within the HFW framework. Upon hiring, the HFW Manager Supervisor will carefully assess and identify the required and recommended courses tailored to each position. This ongoing process will include diligent tracking of staff progress to ensure timely completion.
a. HFW staff will enhance their expertise by participating in the Statewide Standardized Foundational HFW training conducted by UC Davis RCFFP, as outlined in the Workforce and Human Resource Management policy on page 1.
b. The HFW Fidelity Coach will facilitate continuous professional development by providing specialized training in courses that delve into Wraparound services and the essential skills associated with them; further information can be found in the Training Curriculum on page 1.
c. To ensure knowledge retention and skill enhancement, the HFW Fidelity Coach will also conduct annual booster training sessions, as detailed in the Training Curriculum on page 1.
d. Both the HFW Manager Supervisor and the Clinical Supervisor are mandated to partake in general training, alongside initial, ongoing, and booster training specific to their responsibilities, as specified in the HFW Manager Supervisor Job Description on page 3.
e. Additionally, the HFW Fidelity Coach will equip staff with essential training on the Indian Child Welfare Act (ICWA), as noted in the Training Curriculum on page 6.
9.7 Community-based Training Program
While training courses are compulsory for HFW employees, those offered by UC Davis RCFFP provide invaluable opportunities for all individuals involved in the HFW process to deepen their understanding and skills.
a. The HFW Fidelity Coach will enrich training sessions by integrating insights from former youth participants, families, and youth or parent partners, fostering a collaborative learning environment; further details are available in the Workforce and Human Resource Management policy, page 6.
b. The HFW Manager Supervisor will proactively inform community partners about available training sessions, whether conducted in-house, online, or within the broader community, ensuring widespread access to these developmental opportunities; refer to the Workforce and Human Resource Management policy on page 6 for more information.
9.8 Coaching and Supervision
The HFW Fidelity Coach, alongside the HFW Manager, Supervisor, and HFW Clinical Supervisor, offers staff numerous opportunities to receive both initial and ongoing coaching and supervision, enhancing their professional growth.
a. The HFW Manager, Supervisor, or their designee will facilitate opportunities for staff to shadow experienced team members during their apprenticeship, covering essential competencies specific to their roles, as indicated in the Competency Checklist, Facilitator Tab.
b. As part of their commitment to professional support, the HFW Fidelity Coach, HFW Manager Supervisor, and HFW Clinical Supervisor are accessible to the team around the clock, reflecting their dedication to the staff’s development and well-being; please refer to the HFW Manager Supervisor Job Description on page 3 for further details.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
The HFW Manager Supervisor oversees data collection and reporting at Inner Circle Foster Family Agency to ensure effective and transparent program practices.
a. The HFW Manager Supervisor uses outcomes data to improve service delivery, as noted in the Treatment Tracker, Outcomes Tracker tab.
b. By reviewing Outcomes Tracker data, the supervisor identifies program gaps and addresses them through training or procedural changes; see the Treatment Tracker, Outcomes Tracker tab for details.
c. The supervisor also reports systemic issues from the Outcomes Tracker to the Community Leadership Team, supporting ongoing improvement and accountability, as referenced in the Treatment Tracker, Outcomes Tracker tab.
Fidelity Indicators
1.1 Timely Engagement and Planning
(a) We receive Wraparound referrals through the Los Angeles County Department of Mental Health (LAC DMH) Services Request Tracking System (SRTS) (Appendix A: SRTS User’s Manual). Our HFW Supervisors are notified via email when we have a new referral. Within 24 hours, the Supervisor notifies the HFW team of the referral. They also notify our Family Engagement Team (FET), who creates the client account in Exym, our electronic health record system (EHRS). Within 24 hours of the notification, the Intensive Care Coordinator (ICC aka Facilitator) contacts the family by phone to schedule a face-to-face Outreach and Engagement (O&E aka Orientation) meeting. The ICC documents all attempted and actual contacts with the family into the client’s record in Exym (Appendix GK: HFW Policy, Page 12, Referral from WTS Section).
Note: We rarely receive self-referrals of Adoption Assistance Program (AAP) eligible children. If we do, they come to us in one of two ways. One, the family completes the Wraparound referral with their Post Adoption Worker, who then sends it to DMH. Two, the family emails the Wraparound referral directly to us, and we then follow-up with DMH to obtain authorization (Appendix GK: HFW Policy, Page 12, Referral from WTS Section, Last Paragraph).
We track and evaluate timely engagement, as well as other HFW data points, through our internal reporting system, Tableau. Our Research and Evaluation Team (RET) ensures that data from our EHRS is securely exported to Tableau and continuously updated for real-time data. For timely engagement, we use the “Intensive Patients Communications” report (Appendix BH). This report displays the average days from referral to first communication at the program level, as well as the “days to engage” at the individual client level. As part of their performance expectations, HFW Supervisors regularly interface with Tableau for fidelity monitoring. In individual and group supervision, as well as clinical program meetings, our Supervisors support staff with adhering to timely engagement and other HFW fidelity indicators (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 145).
(b) Note: In Los Angeles County, the Plan of Care (POC) is referred to as the Child and Family Team Matrix (Appendix D). After the orientation, the family has an intake with our HFW therapist and the Intensive Care Coordinator, and the therapist completes a comprehensive clinical assessment. Once the assessment is concluded, the ICC coordinates with all team members (e.g. client, caregivers, natural supports, formal supports, DCFS, Probation, school, our HFW team) to schedule the initial Child and Family Team Meeting (CFTM). Our policy is that this initial CFT is scheduled within 30 calendar days from the start of services (i.e. intake). During this initial meeting, the Matrix is collaboratively developed, documented in a fillable PDF by the ICC, and uploaded into the youth’s medical record (Appendix GK, HFW policy, Page 19, First CFT Meeting, Bullet Points 1 and 5).
For tracking and evaluation of timely completion of the Plan of Care, we use the “Intensive Patients Communications” report (Tableau Caseload Report: Appendix BI). The report has a “CFT” column to draw attention to families with pending POCs. The yellow triangle indicates that the POC is pending completion but not yet late; the red telephone indicates that the POC is late (i.e. not completed within 30 calendar days from the start of services). As part of their performance expectations, HFW Supervisors regularly interface with Tableau for fidelity monitoring. In individual and group supervision, as well as clinical program meetings, our Supervisors support staff with adhering to timely care planning and other HFW fidelity indicators (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 145).
(c) It is our policy that ongoing Child and Family Team Meetings (CFTMs aka HFW meetings) are held at least every 30-45 calendar days and more often as needed (for example, in response to crisis). The team not only reviews, but also updates, the plan (aka Matrix) at each and every CFT meeting. This process means that our Matrix (Appendix D) serves a dual purpose—as both the Plan of Care and as the meeting minutes. Our Intensive Care Coordinator (ICC) documents the updates in a PDF-fillable version of the Matrix and uploads it into the youth’s record after each meeting (Appendix BZ: Exym External Documents – CFT Matrix Listed, Matrices tagged with yellow squares) (Appendix GK, HFW policy, Page 22, Phase Three: Implementation, Bullet Points 1, 4, and 5). As each Matrix document is dated, this Exym tab allows supervisors and direct service staff to quickly verify, on an individual client basis, if meetings are occurring as per our internal frequency standards (Appendix BZ). The frequency of CFT meetings (i.e. Matrix updates) is also consolidated in our Tableau CFT Details Report (Appendix EC).
(d) Our internal policy is that we update the Plan of Care (aka Matrix) at least every 30-45 calendar days and more often as needed. During each CFT Meeting, our Intensive Care Coordinator (ICC) documents the updates in a PDF-fillable version of the Matrix. The ICC then uploads the updated Matrix, dated according to the CFT meeting date, into the youth’s record after each meeting (Appendix BZ: Exym External Documents – CFT Matrix Listed, Matrices tagged with yellow squares). Our Matrix (Appendix D: CFT Matrix – English) has a signature page (Page 6) that includes a column for email addresses for each team member. After each CFT meeting, our ICC distributes updated Matrices to all team members via secure email (Appendix CD: Child and Family Team Meeting Training, Slide 41). We verify the frequency of CFT meetings (i.e. Plan of Care updates) in our Tableau CFT Details Report (Appendix EC).
(e) Our HFW Continuous Quality Improvement (CQI) Plan lists all reports that track and evaluate timely engagement and planning (Appendix EF: CQI Plan Behavioral Health and Wellness _ HFW, Page 20). These reports are generated through Tableau, a visual analytics platform that centralizes all of our data and helps us view and understand it in a digestible way (Appendix EF, Page 6, Research and Evaluation Section). Upon hire, all staff are trained by our Quality Assurance Department and given access to Tableau (Appendix DY). HFW staff receive additional training on Tableau via our Intensive Tableau Reports Training (Appendix ZZ), which is facilitated by our HFW supervisors and program manager.
As an organization, we want to empower everyone with data in order to problem-solve gaps and provide opportunities in care, as well as support staff in what to do with this information (Appendix ZZ: Intensive Tableau Reports Training, Slide 2). Part of these Tableau trainings include how staff can access data and reports—at their fingertips—on compliance with HFW Fidelity Indicators. For example, staff learn how to access the Case Load report for their cases, so they can identify if CFT meetings are occurring within expected frequencies (Appendix DY: BHW Tableau Reports for Staff – General, Slide 42). Importantly, Tableau allows the user to set up email alerts when key timelines are not being met—for example, when Child and Family Team Meetings are not occurring within expected timelines (Appendix DY: BHW Tableau Reports for Staff – General, Slide 38). Supervisors are expected to use this Caseload Intensive Report twice a month to monitor and track due dates and ensure that all clinical documents are submitted before the expiration date (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 11, Tracking Due Dates section). To support this process, our Individual Supervision Guide and Note Template includes an administrative check-in that prompts for review of this Tableau report (Appendix DK: Bottom of Page 3).
(f) Upon hire, our staff are initially trained in HFW through attending the UC Daivs training: “Wraparound 101: Foundations of Fidelity.” This training fulfills 6 key goals for participants, one of which is to understand what engaging children, youth and families means and why it is so important (Appendix R: Intensive Behavior Health Onboarding Checklist, Page 3, UC Davis section, First Check box). We also recognize the impact of trauma on the HFW engagement process. As such, all HFW staff complete, upon hire, the 4 hour National Childhood Traumatic Stress Network (NCTSN) Core Curriculum for Childhood Traumatic Stress (Appendix R, Page 3, External Webinars, First Check Box). Staff also participate in 28 hours of training through the Department of Mental Health (DMH) Child Welfare Division. Training topics include but are not limited to: Child and Family Engagement and Team Preparation; Engaging Youth in Placement: From Engagement to Aftercare; and Intergenerational Trauma: The Trauma Inheritance (Appendix R, Section DMH Child Welfare Division Training, Pages 4-5). Training continues in individual supervision, which routinely explores barriers to consistent sessions, challenges in building rapport, and “being stuck” in one of the phases of treatment, including engagement (Appendix DK: Individual Supervision Guide and Note Template, Page 2, Ongoing Items). Supervisors encourage alternate strategies when contact with the family is difficult. For example, one strategy is to engage formal supports (e.g. DCFS, teachers, medical doctors, Regional Center, etc.) who may have cultural insight relevant to the family (Appendix VV: Intensive Behavioral Health Supervisor Manual , Page 58). Other strategies—such as educating families about the impact of trauma and loss or the exploration of relationships—are also encouraged as appropriate to the family’s unique needs and experiences (Appendix VV, Page 58, Engagement Column).
1.2 Led by Youth and Families
We believe that families are the central decision-makers. Their values, culture, expertise, capabilities, interests and skills guide the planning and delivery of HFW services. We honor this fidelity standard through the following practices:
(a) The foundational platform for elicitation and use of families’ and Tribes’ perspectives is the Children and Family Team (CFT) meetings and process. As we emphasize in our CFT training, “Client’s role in the Child and Family Team Meeting is to tell their story, share the family’s long-term view, and choose the members of their team. This will be their Child and Family Team Meeting where they will have the opportunity to express their opinions and preferences. Their voice and point of view is very important in this process” (Appendix CD, Slide 5). Prior to the first CFT meeting, members of the HFW team meets with the family to prepare them for the first CFT. This meeting sets the tone and expectation that their voice and choice are paramount in this process (Appendix GK, HFW policy, Page 17, Preparation of Family for CFT, Bullet Point 4). During this meeting, the team elicits and honors the youth’ and family’s perspective—including but not limited to their strengths, needs, and culture, as well as natural and community supports (Appendix GK, HFW policy, Page 18).
During the first CFT meeting, the Family Vision statement is revisited and documented in the “Child/Youth/Family Long-Term View (Future Hopes and Aspirations)” section of the Matrix (Appendix EG: CFT Matrix Guide, Page 1, Column to the Left, 2nd Row from Bottom). The Long-Term View is the vision that all team members can look to as a guide for long lasting change and also represents the Team Mission. We train our staff that the Long-Term View section should be written as stated and articulated by the child/youth and family, using their own words (Appendix CD: CFT Training, Slide 20). Our training also provides a sample of how to document this section (Slide 25).
(b) We elicit family values, culture, expertise, capabilities, interests and skills in a variety of ways and throughout the entire HFW process. For example, the HFW therapist, upon intake and throughout the assessment process, uses the Los Angeles County (LAC) Department of Mental Health (DMH) Immediate / Same Day Services Assessment (Appendix C) elicit and document the following:
• Special Service Needs and Cultural Considerations (Top of Page 1)
• Family strengths (Page 3, VIII. RELEVANT PSYCHOSOCIAL INFORMATION)
• Strengths to assist with achieving treatment goals (Page 4, XI. CLINICAL FORMULATION AND PLAN)
The HFW therapist documents this assessment in the youth’s case file (i.e. Exym). The use of the Integrated Practice: Child and Adolescent Needs and Strengths tool (IP-CANS) also sets the stage for the HFW services being youth and family led. As part of the assessment process, the therapists completes the CANS (if the existing one is not received with the referral) and/or updates the existing one if received (Appendix GK, HFW policy, Page 15, Assessment, Bullet Point 7). The CANS ratings, and the date of the CANS completion, are entered directly into Exym (Appendix FB: Exym CANS Submission Link). Family values, culture, expertise, capabilities, interests and skills are elicited throughout the CANS, but especially in the domains of Cultural Factors, Strengths, and Caregiver Resources and Needs. As part of their job descriptions, our supervisors are expected to conduct a clinical review of the IP-CANS. This review verifies that the CANS ratings are supported by and aligned with the information documented in DMH Same Day Assessment (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 6, Section 4).
(c) Our HFW supervisors utilize the Team Observation Measure (TOM 2.0) to evaluate the effectiveness of HFW services and provide feedback to the team about successes and areas of growth (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 147, Supervisor Section, Bullet Point 5). We are currently licensed to use this tool (Appendix CU). In terms of frequency, our supervisors complete one TOM per month during a Child and Family Team meeting. The supervisor will then schedule a treatment planning meeting with the therapist, Intensive Care Coordinator (ICC), Intensive Home-Based Services (IHBS) Worker, and Parent Partner to provide feedback to the team on their progress utilizing HFW principles during the CFT meeting (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 141, Bullet Point 2).
The TOM questions and scores are incorporated into our Microsoft Forms system, which allows us to generate reports on subscale scores and the total score (Appendix FT: TOM Report). We in turn are able to use aggregate TOM data to improve our program practice as part of our HFW Continuous Quality Improvement Plan (Appendix EF, Bottom of Page 20 – 21). Our CQI BHW HFW Meeting Minutes and Notes Template specifically prompts us to review this data (Appendix EU, Page 3, Section 2: Review Data, Middle Table Column, Second Check Box).
Our HFW supervisors and Quality Assurance (QA) team also assess the quality of rendered clinical services and fidelity to the HFW model through reviewing youth records. We have an internally-developed tool, the Quality Assurance Report (QAR), to support and standardize this process (Appendix M). This Excel document includes a HFW tab—with a category devoted to the review of CFT Meetings and Plans of Care (Row 14). Review items specific to “led by youth and families” include but are not limited to: “Strengths identified as actionable in the Strengths and Caregiver section of the CANS are included in the Plan of Care” (Row 21); “The Plan of Care is worded in a strengths-based fashion and uplifts long-range goals for the entire family (not just the youth)” (Row 23); “Strategies consider culture” (Row 29); and “When a task is completed or there is progress towards a strategy, there is evidence of praise” (Row 30). Our supervisors are required to complete 2 QARs per month (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 107).
Feedback from QAR findings are built into our individual supervision process. For example, our Individual Supervision Guide and Note Template includes the following prompt: “If a QAR was completed, use the HFW tab to support your supervision” (Appendix DK, Page 2, under Clinical Review). We also consolidate QAR scores into a QAR Tracking Log (Appendix DZ), which is reviewed as part of our CQI Plan (Appendix EF, Bottom of Page 20 – 21). Our CQI BHW HFW Meeting Minutes and Notes Template specifically prompts us to review this data (Appendix EU, Page 3, Section 2: Review Data, Middle Table Column, Second Check Box).
(d) We routinely elicit feedback from families through our Family Experience Calls (FEC) (Appendix DD) and the Youth Services Survey for Families. The FEC form is an internally-created survey with questions designed to assess the family’s experience of and satisfaction with Wraparound services, as well as to collect their feedback to inform local HFW implementation. Question 7 on the FEC (Appendix DD, Page 2, identifies if the family is affiliated with a Tribe, so we have a way to evaluate satisfaction for this specific population. We use questions 12-25 (Appendix DD, Pages 4-6) to collect information about our family’s experience of the Wraparound process. HFW Supervisors make two FEC calls per month (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 40, Paragraph 1). Families are selected for FEC calls based on the following factors: staff need, client feedback, or evidence of challenges reported in case reviews (Appendix EF (CQI Plan Behavioral Health and Wellness _ HFW, Page 15, 2. Fidelity Indicators, Last Sentence). All collected data is captured by our Family Experience Call Results Report, which shows the number of responses to each question, as well as aggregate and individual responses (Appendix DO: See example on Page 5, Questions 13 and 14).
We also use the Youth Services Survey for Families (YSSF) Client Response form (Appendix N) and YSSF Caregiver Response form (Appendix WW) to collect information on the family’s experience. The surveys were developed through the collaborative efforts of the federally funded Mental Health Statistics Improvement Program and included the direct assistance and feedback of consumers, their families, and mental health advocates. Our Parent Partner directly asks the YSSF questions to caregivers during an in-person contact, while our Intensive Home-Based Services (IHBS) Worker directly asks the client the YSSF questions, also during an in-person contact. Responses are entered and tracked into Exym, our Electronic Health Record (Appendix WW (EXYM YSSD Client Response Form) and Appendix N (Exym YSSF Caregiver Response Form)). These surveys are administered to all families upon six months of HFW service, and then every six months thereafter. In the event that the caregiver and/or youth prefers to answer these questions more anonymously and independently, the IHBS Worker and/or Parent Partner will then provide a link to the questions via secure email (Appendix EF: CQI Plan Behavioral Health and Wellness _ HFW, Page 18, YSSF Row, Last Sentence).
1.3 Strength-Based
(a) Our Wraparound Statement of Work with the Los Angeles County (LAC) Department of Mental Health (DMH) notes the following, “Contractor shall utilize the CFT Matrix, a documentation template that will be provided by the County” (Appendix AO, Page 5, Section 2.2.3, Item 2.2.3.1). Appendix D is the blank version of the county’s matrix. When we began this certification process, we reach out to the county to see if we could utilize the UC Davis California Wraparound Plan of Care SAMPLE, as it reflects all of the nuances of the aftercare standards. Our Wraparound liaison from the county replied, “We have been advised to inform our providers to continue to utilize the CFT Matrix per policy until the updated policies and forms are provided. Our admin teams are working on updating those policies/forms and hope to provide updates soon.” As such, we created a CFT Matrix Guide (Appendix EG) to help us bridge the current DMH Matrix form with the HFW certification standards. For example, the County’s Matrix only includes a strengths inventory for the youth and caregivers; it does not have a specific section for every member of the team. Our Matrix Guide indicates that in the Strengths section: Family/Caregivers box, staff should “Add a section titled “Additional Team Members Strengths” for any informal and formal supports that identifies their strengths and resources that they can contribute to the team (Appendix EG, Page 2). All HFW staff are trained on the CFT Matrix Guide as part of our internal Child and Family Team Meeting (Appendix CD: Child and Family Team Meeting Training, Slide 17).
When we meet with the family to prepare them for the initial CFT meeting and overall process, we walk them through each section of the Matrix. This walk-through includes a discussion with the family on their strengths, as well as a review of the strengths identified from the IP-CANS, as well as the corresponding rating (Appendix GK: HFW Policy, Page 18, Bullet Point 2). All identified strengths are documented in the Strengths section of the Matrix (Appendix EG, Page 2), and the ICC prints out a copy of this Preliminary Matrix so it can be displayed and updated during the CFT meeting with the entire team (Appendix GK: HFW Policy, Page 19, First CFT Meeting, Bullet Point 4). A copy of the current Matrix is shared at each subsequent meeting (Appendix GK: HFW Policy, Page 22, Third Bullet from the Bottom).
At the first Child and Team Meeting, the strengths inventory is updated and finalized via the Matrix. All members of the CFT are asked to share at least one strength of both the client and the caregiver/family (Appendix EI, Page 1, Checkboxes 9 and 10). This process also includes identifying the strengths of every member of the team, including other resources in the family’s local community (Appendix, All information is documented in the Matrix, which is sent out.
(b) Our identification of individualized strengths includes, but is not limited to, the strengths identified on the CANS. For example, all members of the CFT are initially asked to share at least one strength of both the client and the caregiver/family, and this inventory is updated as new strengths are identified (Appendix EI: Preparing for CFT Meeting, Page 1, Checkboxes 9 and 10). Upon intake, our therapists complete the county’s Immediate / Same Day Services Assessment (SDA) (Appendix C). The SDA supports identification of strengths in two areas: Relevant Psychosocial Information (Top of Page 3) and Clinical Formulation and Plan (Page 4, Strengths Section at top, as well as the last sentence of the Clinical Formulation and Diagnostic Justification section). Additionally, our therapists administer the Pediatric Symptom Checklist (PSC-35) at intake and every six months thereafter. This tool assesses a range of emotional, behavioral and attentional risks in children—including identifying areas that are not clinically significant and thus can be viewed as strengths (Appendix GC: PSC-35 Quick Guide). The same applies to our DMH-required Outcome Measure Application (OMAs) (Appendix GG: Baseline OMA Child)—which help us identify strengths across, for example, Living Arrangements (Pages 2-3), School Attendance and Grades (Page 5), and Physical Health, Substance Abuse, and Emergency Intervention (Page 8). (Appendix GK: HFW Policy, Page 16, Bullet Point 2).
(c) All HFW receive ongoing training and coaching in HFW principles, phases, and standards—with individual supervision serving as a key platform for learning. All direct service staff attend, at minimum, weekly individual supervision that is at least one hour in duration (Appendix VV: Intensive Behavioral Health Supervisor Manual, Bottom of Page 138). During these interactions, our supervisors provide guidance, coaching, support, and feedback—aimed at the enhancement of clinical skills, adherence to ethical and legal practices, reflective practice, relationship building, and creation of a safe and supportive environment (Appendix VV, 137-138). We structure this supervision through an Individual Supervision Guide and Note Template (Appendix DK). Part of the standing agenda includes a Clinical Review, which asks the supervisee to pick 1-3 clients to check in on and consider if Wraparound Principles are being incorporated in treatment (Appendix DK, Bottom of Page 2). Specifically, the principle of strengths-based care is considered through the question: “What are two examples of how client’s strengths are being highlighted in treatment?” (Appendix DK, Top of Page 3, Item 2). This check-in question is aligned with a reflective practice in that it is open-ended, based in curiosity and nonjudgement, and designed to promote self-awareness, critical thinking, and emotional intelligence (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 138, Section 2).
Our Annual Wraparound Booster focuses on strengths-based services (Appendix BK, Slides 12, 15, 19, 21-23)—including the use of a vignette (Appendix BY: Maribel’s Vignette) to reflect on how outcome tools were utilized to identify strengths (Appendix BK, Slide 28). We use a Maribel Story Answer Key (Appendix CF) to highlight how the principles of strengths-based, individualized, community-based care showed up in the vignette (Appendix CF, Bullet Point 2, in red). Supervisors track and monitor completion of this booster training via Relias (Appendix GE: Relias Wraparound Booster Training Tracker).
Additionally, we hold our internal team meetings to prepare for each family’s initial CFT (Appendix GK: HFW Policy, Page 18, Second Bullet Point from the Bottom). We utilize a document to guide this preparation and for couching purposes. The guide prompts the identification of strengths from the IP-CANS, along with the corresponding IP- CANS Rating (Appendix EI, Page 1, Client Strengths) to leverage for action steps (Page 4).
(d) We routinely elicit feedback from families regarding their experience of strengths-based services. Specifically, we use our Family Experience Calls (FEC) form (Appendix DD), which is an internally-created survey with questions designed to assess family’s experience of and satisfaction with Wraparound services. Question 7 on the FEC (Appendix DD, Page 2) identifies if the family is affiliated with a Tribe, so we have a way to evaluate the experience of this specific population. We use question 20 to specifically gather feedback to comply with this standard: “On a scale of 1-5, with 1 being “Strongly Disagree” and 5 being “Strongly Agree,” how would you rate the following statements about your involvement in treatment?: My strengths are highlighted” (Appendix DD, Top of Page 4). HFW Supervisors make two FEC calls per month (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 40, Paragraph 1). Families are selected for FEC calls by Supervisors based on the following factors: staff need, client feedback, or evidence of challenges reported in case reviews (Appendix EF: CQI Plan Behavioral Health and Wellness _ HFW, Page 15, Section 2. Fidelity Indicators). All collected data is captured by our Family Experience Call Results Report, which shows the number of responses to each question, as well as aggregate and individual responses (Appendix DO: Top of Page 7).
We routinely evaluate our effectiveness in achieving expected outcomes through our CQI HFW Subcommittee (Appendix EF: CQI Plan Behavioral Health and Wellness, Pages 13 and 14, Foundations of our HFW CQI Process). This Subcommittee meets on a quarterly basis, at minimum, and follows a structured Agenda (Appendix EA) and Meeting Minutes and Notes Template (Appendix EU) that ensure a comprehensive and strategic program improvement process. Specifically, the Meeting Minutes and Notes template includes a section on data review (Appendix EU, Pages 3-4, Section 2: Review Data). We list all 9 of the expected outcomes in the right-hand column of our data table, so we can check which ones we focus on across our meetings and monitor our progress across all expected outcomes.
1.4 Needs Driven
(a) As part of the assessment process, our HFW therapist initiates the completion of the IP-CANS and enters the scores into the youth’s record (Appendix GK: HFW Policy, Page 15, Second Bullet Point from the Bottom). As per our CFT Meeting Agenda, we identify needs and prioritize them before establishing outcomes and brainstorming strategies (Appendix BR). Our guidelines in Preparing for the CFT Meeting includes supporting all team members in understanding and leveraging the IP-CANS ratings to identify youth and caregiver needs (Appendix EI, Page 1, Checkboxes 13 and 14). These guidelines include listing the CANS needs items scored as a 2 or 3 that require action, as well as items that need monitoring (1s) and items (0s) that can be praised (Appendix EI, Page 4). As per our Child & Family Team Planning Matrix Guide (Appendix EG), needs are prioritized based on the preferences of the family (Page 3, Top Row, Both Columns). We have an Underlying Needs Guide (Appendix BM) to support staff in creating strong needs statements, across a variety of domains, that are specific and recognize the effects of trauma on behavior.
(b) We recognize that staff need ongoing training and coaching in needs-focused planning—and especially in developing needs statements. It takes both skill and care to identify the underlying reasons for situations or behavior and then craft meaningful and trauma-informed needs statements that drive service planning and outcomes. We provide ongoing support through our Underlying Needs Guide (Appendix BM), which serves as a key reference for all HFW staff. The Guide covers Characteristics of Crafted Services and Supports and Strong Needs Assessments (Page 1). It also provides a wide range of examples of underlying needs in the following categories: Safety (Pages 1-2), Trauma-Related (Pages 2-3), Attachment (Pages 3-4), Developmental (Page 4), Physical Health (Page 5), Emotional (Page 5), Educational/Vocational (Bottom of Page 6-8), Self-Efficacy (Page 8), Social (Bottom of Page 8 – 9), and Family/Caregiver (Page 9).
Ongoing training and coaching around a needs-driven approach occurs during individual and group supervisions. For example, in their weekly individual supervision of HFW direct services staff, supervisors bring underlying needs to the forefront—with a particular focus on how these needs play out in emergent situations. Individual supervision begins with a Clinical Check-in around Emergent Needs/Concerns—including crisis events, high-risk behaviors, and safety concerns. As part of this Check-In, supervisors use the Underlying Needs Guide (Appendix BM) to facilitate a reflection on and discussion of “What underlying needs are at play with this situation or behavior?” (Page 1, Emergent Needs/Concerns, Bullet Point 4).
(c) Our identification of individualized needs includes, but is not limited to, the needs identified on the CANS. Upon intake, our therapists complete the county’s Immediate / Same Day Services Assessment (SDA) (Appendix C). The SDA supports identification of needs across multiple domains. For example, Special Service Needs are assessed, including cultural considerations (Page 1, Top). The Columbia Suicide Severity Rating Scale Screener is embedded into the SDA to assess for safety needs (Page 1, Suicidal Thoughts/Attempts), and additional risk and safety concerns are identified in Section 3 (Page 2). The SDA also supports identification of needs related to medical conditions (Page, IV), Substance Use Disorders (Page 2, VII), and Psychosocial domains (Page 3, VIII). All of these needs are summarized through the Problem List, which, similar to the CANS, provides a quick way to see everything in one place (Appendix FU: Problem List Guide + Training Slides, Slides 10-14). An example of the Problem List, documented in our Exym system, is found in Appendix E.
Additionally, our therapists administer the Pediatric Symptom Checklist (PSC-35) at intake and every six months thereafter (Appendix G). This tool assesses a range of emotional, behavioral and attentional risks in children—including identifying areas that are clinically significant (Appendix GC: PSC-35 Quick Guide). The same applies to our DMH-required Outcome Measure Application (OMAs) (Appendix GG: Baseline OMA Child)—which help us identify needs across, for example, Living Arrangements (Pages 1-2), School Attendance and Grades (Page 5), and Physical Health, Substance Abuse, and Emergency Intervention (Page 8). (Appendix GK: HFW Policy, Page 16, Bullet Point 2).
(d) We always plan transitions in advance (Appendix GK: HFW Policy, Page 24, Bottom Bullet Point). We only consider transition when the child/youth and family have made progress towards their goals, and the concerns that brought them into Wraparound are occurring less (Appendix CE: CII Developing a Transition Plan, Top). Our Intensive Care Coordinator (aka Facilitator) leads the HFW team in identifying when the youth and family are ready for transition. This conversation is based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process. This discussion occurs during the context of a CFT Meeting and considers, at minimum, the following indicators:
• Progress towards the Child/Youth/Family Long-Term View (Future Hopes and Aspirations)
• Progress towards meeting underlying needs (i.e. desired outcomes)
• The child’s and family’s accomplishments during Wraparound—including skills learned and positive changes made.
• There are no pressing safety or crisis concerns.
• Client and family’s strengths to aid them during the transition process.
• Natural supports who will continue to support child/youth and family after transition.
• Progress as per outcome measures scores over time (e.g. IP-CANS, PCS-35, and Full Service Partnership Outcome Measurement Application (OMA)
The ICC supports the team in reaching a determination about the family’s readiness to transition from Wraparound, which includes clinical input from the team’s supervisor (Appendix GK: HFW Policy, Page 25, Transition is Initiated).
1.5 Individualized
(a) The Child & Family Team Planning Matrix we use (Appendix D) is designed to allow for sufficient flexibility in creating individualized plans for each child/youth and family. The most salient evidence of this flexibility is that our Matrix is comprised of free-form narrative fields and NOT generic or cookie-cutter checkboxes. Each Matrix is therefore completed from scratch for each family, and does not have any text limitations in the narrative fields. Another example is our Safety and Crisis Plan (Appendix NN). The “Know when to Get Help,” “Known Triggers,” and “What We Can Do” sections are completed by the youth and caregiver (Page 2) in free-form spaces. The only things that are “pre-filled” into this document are the “other important numbers” (Page 3) that list local crisis intervention resources.
(b) All HFW staff receive ongoing training and coaching in HFW principles, phases, and standards— with individual supervision serving as a key platform for learning. All direct service staff attend, at minimum, weekly individual supervision that is at least one hour in duration (Appendix VV: Intensive Behavioral Health Supervisor Manual, Bottom of Page 138). During these interactions, our supervisors provide guidance, coaching, support, and feedback—aimed at the enhancement of clinical skills, adherence to ethical and legal practices, reflective practice, relationship building, and creation of a safe and supportive environment (Appendix VV, 137-138). We structure this supervision through an Individual Supervision Guide and Note Template (Appendix DK). Part of the standing agenda includes a Clinical Review, which asks the supervisee to pick 1-3 clients to check in on and consider if Wraparound Principles are being incorporated in treatment (Appendix DK, Bottom of Page 2). Specifically, the principle of Individualized care is considered through the question: “Are services occurring at a time/location that match client’s needs” (Appendix DK, Top of Page 3, Question 3). This question includes a prompt to review our Appendix CN (Tableau BHW YSS Report – YSS Child Subscales) and Appendix CO (Tableau BHW YSS Report – YSSF Caregiver-Family Subscales) to review aggregate data on this principle. This check-in question is aligned with a reflective practice in that it is open-ended, based in curiosity and nonjudgement, and designed to promote self-awareness, critical thinking, and emotional intelligence (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 138, Section 2).
(c) Our Intensive Care Coordinators (ICCs) (aka Facilitators) receive ongoing training and coaching in HFW principles, phases, and standards—with group supervision serving as a key platform for learning. Our ICCs must attend group supervision on a monthly basis for one hour in duration (Appendix VV: Intensive Behavioral Health Supervisor Manual, Bottom of Page 139). During these interactions, our supervisors provide guidance, coaching, support, and feedback—aimed at the enhancement of clinical skills, adherence to ethical and legal practices, reflective practice, relationship building, and creation of a safe and supportive environment (Appendix VV, Top of Page 138). Group supervision for our ICC staff is structured with a role-specific guide and standing agenda (Appendix FW: ICC Group Supervision Guide). As part of this agenda, ICCs are asked to pick 1-3 clients to check in on (Appendix FW, Bottom of Page 1). This check-in includes a consideration of their unique role on the HFW team and if specific principles and practices are being incorporated in treatment for the selected families. This check-in includes the ICC’s role and experience in leading the HFW team around the principle of individualized services (Appendix FW, Bottom of Page 1, Item 1). Specifically, ICCs are asked these questions: “How are you leading the team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences?;” What support and/or additional training do you need around this principle to improve the quality and effectiveness of services that you provide to HFW families?.” These check-in questions are aligned with a reflective practice in that they are open-ended, based in curiosity and nonjudgement, and designed to promote self-awareness, critical thinking, and emotional intelligence (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 138, Section 2).
(d) Our HFW supervisors and Quality Assurance (QA) team routinely review our HFW plans of care (i.e. matrix) for individualized strengths, needs, outcomes and strategies. We use our internally-developed tool, the Quality Assurance Report (QAR), to support and standardize this process (Appendix M). This Excel document includes a HFW tab—with a category devoted to the review of CFT Meetings and Plans of Care (Row 14). Specific review areas within this category include strengths (Rows 21-23), Needs (Rows 24-25), Outcomes (Rows 24-25), and Strategies (Row 29). The QAR also includes a review of strategies that capitalize on the assets of the family’s community (Row 27) and informal networks (Row 28). Our supervisors complete 2 QARs per month (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 109). QA also completes QARs on a quarterly basis—with the goal that at the end of the year, they will have conducted reviews for 5% of our total HFW cases. QA and Supervisors select cases for QARs based on recent incident reports, recent client crisis, new cases (first 30 days of services), cases with HFW staffing changes, extended service length, and a high volume of services (Appendix EF: CQI Plan Behavioral Health and Wellness _ HFW, Page 15, Section 2. Fidelity Indicators).
(e) We routinely elicit feedback from families regarding their experience of customized services using the Youth Services Survey for Families (YSSF) Client Response form (Appendix N) and YSSF Caregiver Response form (Appendix WW). Our Parent Partner directly asks the YSSF questions to caregivers during an in-person contact, while our Intensive Home-Based Services (IHBS) worker directly asks the client the YSSF questions, also during an in-person contact. Responses will be entered and tracked in Exym, our Electronic Health Record (Appendix WW: EXYM YSFF Client Response Form and Appendix N: Exym YSSF Caregiver Response Form). These surveys are administered to all families upon six months of HFW service, and then every six months thereafter. In the event that the caregiver and/or youth prefers to answer these questions more anonymously and independently, the IHBS Worker and/or Parent Partner will then provide a link to the questions via secure email (reference CQI Plan). Specifically, we use question seven on both surveys “I received services that were right for me” (Appendix WW ); “The services my child and / or family received were right for us” (Appendix N) to evaluate the family’s experience of this fidelity indicator. All collected data is captured by our Tableau BHW YSSF – Youth Aggregate Report (Appendix AT) and our Tableau BHW YSSF – Caregiver Aggregate Report (Appendix FM). These reports provide a percentage of improvement in the total score across matched pairs (upper left). They also show “positive feedback” and “areas of concern” across the survey items (bottom of report).
We routinely evaluate our effectiveness in achieving expected outcomes through our CQI HFW Subcommittee (Appendix EF: CQI Plan Behavioral Health and Wellness, Pages 13 and 14, Foundations of our HFW CQI Process). This Subcommittee meets on a quarterly basis, at minimum, and follows a structured Agenda (Appendix EB, Page 1, Section 2: Data Review) and Meeting Minutes and Notes Template (Appendix EU) that ensures a comprehensive and strategic program improvement process. Specifically, the Meeting Minutes and Notes template includes a section on data review We list fidelity indicators in the middle column of our data table, so we can check which ones we focus on across our meetings and monitor our progress over time across all indicators (Appendix EU: CQI BHW HFW Meeting Minutes and Notes Template, Pages 3-4, Section 2: Review Data).
1.6 Use of Natural and Community Based Supports
(a) During the Engagement Phase, and before the first CFT meeting, the ICC schedules two separate meetings to prepare the family for the CFT process. The ICC and/or Parent Partner meets with the caregiver(s) to prepare them for the CFT. In a separate meeting, the Therapist and/or Intensive Home-Based Services Worker (IHBS) meets with the client to prepare them for the CFT. During this meeting, a Natural and Community Supports inventory is developed. This inventory helps to identify potential CFT members (including Tribes, in the case of an Indian child), as well as their specific role (Appendix EI: Preparing for CFT Meeting). We train our staff in the value of natural supports and the questions to ask to help families identify them (Appendix CD: Child and Family Team Meeting Training, Slide 6). HFW also staff use Lorraine Mezanko-Alexander’s document: Powerful Open Ended Questions, to explore the family’s goals (Appendix CG, Section: Exploring Natural Supports). This inventory is documented in an IHBS progress note in the youth’s record (Appendix GK: HFW Policy, Page 18, Bullet Point 9). Updates to this inventory are noted in subsequent CFT meeting notes, and natural supports who are added to the CFT team are noted on the last page of the Matrix (Appendix EG: CFT Matrix Guide, Page 6, Signatures).
(b) Upon hire, all staff are trained in Child and Family Team Meetings (Appendix CD). This training includes the definition of natural supports, as well as specific questions to consider when identifying informal supports. For example, “Who listens to you when you need someone to talk to?” and “Who do you share good or bad news with?” (Appendix CD, Slide 6). Natural supports are revisited in our annual Wraparound Booster Training (Appendix BK, Slide 26). This booster also includes a review and discussion of the vignette of “Maribel” (Appendix BK – Slide 28). Attendees are provided with an “Maribel Story Answer Key” (Appendix CF, Page 3, Paragraph One) that provides a concrete example of the use of natural supports during the transition phase.
All HFW receive ongoing training and coaching in HFW principles, phases, and standards—with individual supervision serving as a key platform for learning. All direct service staff attend, at minimum, weekly individual supervision that is at least one hour in duration (Appendix VV: Intensive Behavioral Health Supervisor Manual, Bottom of Page 136). During these interactions, our supervisors provide guidance, coaching, support, and feedback—aimed at the enhancement of clinical skills, adherence to ethical and legal practices, reflective practice, relationship building, and creation of a safe and supportive environment (Appendix VV, 137-138). We structure individual supervision through a Supervision Guide and Note Template (Appendix DK). Part of the standing agenda includes a Clinical Review, which asks the supervisee to pick 1-3 clients to check in on and consider if Wraparound Principles are being incorporated in treatment (Appendix VV, Bottom of Page 2). Specifically, the principle of natural supports is considered through the question: Have any natural supports participated in either of the last two CFT meetings? (Appendix DK, Top of Page 3, Item 4). This check-in questions is aligned with a reflective practice in that it is open-ended, based in curiosity and nonjudgement, and designed to promote self-awareness, critical thinking, and emotional intelligence (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 137, Section 2).
(c) Our HFW supervisors and Quality Assurance (QA) team routinely review our HFW plans of care (i.e. matrix) for the inclusion of natural supports in the plan and in action items. We use our internally-developed tool, the Quality Assurance Report (QAR), to support and standardize this process (Appendix M). This Excel document includes a HFW tab—with a category devoted to the review of CFT Meetings and Plans of Care (Row 14). Specific review areas within this category include: “At least one natural support …who youth/family identified as integral attended most CFT meetings or were invited to all CFT meetings” (Row 20) and “The strategies include many informal supports…The number of formal supports should be less than the number of informal. (Row 28). Our supervisors complete 2 QARs per month (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 107). QA also completes QARs on a quarterly basis—with the goal that at the end of the year, they will have conducted reviews for 5% of our total HFW cases. QA and Supervisors select cases for QARs based on recent incident reports, recent client crisis, new cases (first 30 days of services), cases with HFW staffing changes, extended service length, and a high volume of services (Appendix EF: CQI Plan Behavioral Health and Wellness _ HFW, Page 15, Section 2. Fidelity Indicators).
(d) We routinely elicit feedback from families regarding their experience of strengths-based services. Specifically, we use our Family Experience Calls (FEC) form (Appendix DD), which is an internally-created survey with questions designed to assess family’s experience of and satisfaction with Wraparound services. Question 6 on the FEC (Appendix DD, Page 2, Question 7) identifies if the family is affiliated with a Tribe, so we have a way to evaluate experience of strengths-based services for this specific population. We use question 25 to specifically gather feedback on this fidelity indicator: “Are natural supports being included in CFT meetings? Can you provide some examples? What is your experience of having natural supports engaged on your team?.” HFW Supervisors make two FEC calls per month (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 40, Paragraph 1). Families are selected for FEC calls based on the following factors: high acuity (clients with recent or frequent crisis), extensive duration of service, nearing transition, team request, and randomly selected. All collected data is captured by our Family Experience Call Results Report, which shows the number of responses to each question, as well as aggregate and individual responses (Appendix DO: Page 8, Question 25).
We routinely evaluate our effectiveness in the use of natural supports through our CQI HFW Subcommittee (Appendix EF: CQI Plan Behavioral Health and Wellness, Pages 13 and 14, Foundations of our HFW CQI Process). This Subcommittee meets on a quarterly basis, at minimum, and follows a structured Agenda (Appendix EB, Page 1, Section 2: Data Review) and Meeting Minutes and Notes Template (Appendix EU) that ensures a comprehensive and strategic program improvement process. Specifically, the Meeting Minutes and Notes template includes a section on data review. We list fidelity indicators in the middle column of our data table, so we can check which ones we focus on across our meetings and monitor our progress across all indicators (Pages 3-4, Section 2: Review Data).
1.7 Culturally Respectful and Relevant
(a) We initiate a Strengths, Needs, and Culture discovery during the Engagement Phase. Before the first CFT meeting, the ICC schedules two separate meetings to prepare the family for the CFT process. The ICC and/or Parent Partner meets with the caregiver(s) to prepare them for the CFT. In a separate meeting, the Therapist and/or Intensive Home-Based Services Worker (IHBS) meets with the client to prepare them for the CFT. During these meetings, a preliminary Matrix (aka Plan of Care) is developed, in collaboration with the youth and caregiver(s) that includes a Strengths and Needs Discovery. This discovery includes review of the youth’s IP-CANS, including an explanation of the ratings, which are updated as needed to reflect the family’s input (Appendix GK, HFW Policy, Page 18). The Strengths Discovery is documented in the Strengths section of the Matrix (Appendix EG: CFT Matrix Guide, Page 2). The Needs Discovery is documented in the Underlying Needs section of the Matrix (Appendix EG: CFT Matrix Guide, Page 3). The Family Vision is documented in the “Child/Youth/Family Long-Term View: Future Hopes and Aspirations” on the CFT Matrix (Appendix EG: CFT Matrix Guide, Page 1, Second Row from the bottom, on the left). This Preliminary Matrix is reviewed by the HFW supervisor and once approved, the ICC uploads it into the youth’s record (Appendix GK: HFW Policy, Page 18, Bullet Point above HFW Team Prepares for First CFT). We have a Culture Discovery Worksheet (Appendix BV) that asks about the family’s cultural identity across domains such as Traditions & Celebrations; Food & Culture; Music, Art & Expression; and Values & Beliefs (Appendix BV). This information is entered directly into a progress note in the youth’s record (Appendix EQ). It is also entered in the “Cultural Considerations: I.E., Faith, SOGIE, Ethnicity, Language, Pronouns, etc.” section of the Preliminary Matrix (Appendix EG (CFT Matrix Guide, Page 1, Row 3).
(b) All HFW receive ongoing training and coaching in HFW principles, phases, and standards—with individual supervision serving as a key platform for learning. All direct service staff attend, at minimum, weekly individual supervision that is at least one hour in duration (Appendix VV: Intensive Behavioral Health Supervisor Manual, Bottom of Page 138). During these interactions, our supervisors provide guidance, coaching, support, and feedback—aimed at the enhancement of clinical skills, adherence to ethical and legal practices, reflective practice, relationship building, and creation of a safe and supportive environment (Appendix VV, 137-138). We structure individual supervision through a Supervision Guide and Note Template (Appendix DK). Part of the standing agenda includes a Clinical Review, which asks the supervisee to pick 1-3 clients to check in on and consider if Wraparound Principles are being incorporated in treatment (Appendix DK, Bottom of Page 2). Specifically, the principle culturally respectful and relevant is considered through the question: “Are referrals, natural supports, and interventions relevant to and respectful of the youth and family’s culture?” (Appendix DK, Top of Page 3, Item 6). This check-in questions is aligned with a reflective practice in that it is open-ended, based in curiosity and nonjudgement, and designed to promote self-awareness, critical thinking, and emotional intelligence (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 138, Section 2).
(c) We routinely elicit feedback from families regarding their experience of culturally relevant services and strategies using the Youth Services Survey for Families (YSSF) Client Response form (Appendix N) and YSSF Caregiver Response form (Appendix WW). Our Parent Partner directly asks the YSSF questions to caregivers during an in-person contact, while our Intensive Home-Based Services (IHBS) worker directly asks the client the YSSF questions, also during an in-person contact. Responses will be entered and tracked in Exym, our Electronic Health Record (Appendix WW: Exym YSSF Resonse Form and Appendix N: Exym YSSF Caregiver Response Form). These surveys are administered to all families upon six months of HFW service, and then every six months thereafter. Specifically, we use these questions to evaluate our efforts: 12. Staff treated me with respect; 13. Staff respected my religious / spiritual beliefs; and 15. Staff were sensitive to my cultural / ethnic background. All collected data is captured by our Tableau BHW YSSF – Youth Aggregate Report (Appendix AT) and our Tableau BHW YSSF – Caregiver Aggregate Report (Appendix FM). These reports provide a percentage of improvement in the total score across matched pairs (upper left). They also show “positive feedback” and “areas of concern” across the survey items (bottom of report).
We routinely evaluate our effectiveness in achieving culturally relevant care through our CQI HFW Subcommittee (Appendix EF: CQI Plan Behavioral Health and Wellness, Pages 13 and 14, Foundations of our HFW CQI Process). This Subcommittee meets on a quarterly basis, at minimum, and follows a structured Agenda (Appendix EB, Page 1, Section 2: Data Review) and Meeting Minutes and Notes Template (Appendix EU) that ensures a comprehensive and strategic program improvement process. Specifically, the Meeting Minutes and Notes template includes a section on data review (Pages 3-4, Section 2: Review Data). We list fidelity indicators in the middle column of our data table, so we can check which ones we focus on across our meetings and monitor our progress over time across all indicators.
1.8 High-Quality Team Planning and Problem Solving
(a) During the initial CFT meeting, right after introductions and a review of the meeting agenda (Appendix BR), we create team agreements. Based on the county’s Matrix, we refer to team agreements as “ground rules,” and operationalize them as a list of things the team agrees will help them be productive (Appendix D, Page One, Lower left-hand corner). Our CFT Matrix Guide provides the following prompts for this section: “Collaborate and co-create team agreements; Potential question to ask: How can we work together for a positive and productive process?” Our CFT Meeting training provides more specifics creating these agreements (Appendix CD, Slide 20, Bullet Point 4), and it also includes a specific example of team agreements/ground rules (Slide 24). Our ICC documents these agreements in the Matrix, which is uploaded to the youth’s file after the CFT meeting and upon supervisor review and approval (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 17).
(b) We routinely elicit feedback from families regarding their experience of team engagement and collaboration. Specifically, we use our Family Experience Calls (FEC) form (Appendix DD), which is an internally-created survey with questions designed to assess family’s experience of and satisfaction with Wraparound services. Question 6 on the FEC (Appendix DD, Page 2, Question 7) identifies if the family is affiliated with a Tribe, so we have a way to evaluate experience of strengths-based services for this specific population. We use question 20 to gather feedback on this specific fidelity indicator: On a scale of 1-5, with 1 being “Strongly Disagree” and 5 being “Strongly Agree,” how would you rate the following statements about your involvement in treatment: My voice is heard; My strengths are highlighted; My opinion matters (Appendix DD, Top of Page 5). HFW Supervisors make two FEC calls per month (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 40, Paragraph 1). Families are selected for FEC calls based on the following factors: high acuity (clients with recent or frequent crisis), extensive duration of service, nearing transition, team request, and randomly selected. All collected data is captured by our Family Experience Call Results Report, which shows the number of responses to each question, as well as aggregate and individual responses (Appendix DO: Family Experience Call Results, Top of Page 7).
We also use the Team Observation Measure 2.0 (TOM 2.0) to gather observational data about HFW team members’ experience of engagement and collaboration. We are currently licensed to use this tool (Appendix CU). Specifically, we focus on Subscale 2: Effective Teamwork to collect information about this fidelity indicator. In terms of frequency, our supervisors complete one TOM per month during a Child and Family Team meeting. The supervisor then schedules a Treatment Planning Meeting with the therapist, Intensive Care Coordinator (ICC), Intensive Home-Based Services (IHBS) Worker, and Parent Partner to provide feedback on findings related to effective teamwork (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 141, Bullet Point 2). The TOM questions and scores are incorporated into our Microsoft Forms system, which allows us to generate reports on subscale scores and the total score (Appendix FT: TOM Report).
(c) We utilize feedback from families and HFW team members regarding their experience of team engagement and collaboration through our CQI HFW Subcommittee (Appendix EF: CQI Plan Behavioral Health and Wellness, Pages 13 and 14, Foundations of our HFW CQI Process). This Subcommittee meets on a quarterly basis, at minimum, and follows a structured Agenda (Appendix EB, Page 1, Section 2: Data Review) and Meeting Minutes and Notes Template (Appendix EU) that ensures a comprehensive and strategic program improvement process. Specifically, the Meeting Minutes and Notes template includes a section on data review (Appendix EU, Pages 3-4, Section 2: Review Data). We list fidelity indicators in the middle column of our data table, so we can check which ones we focus on across our meetings and monitor our progress across all indicators. In our CQI HFW Plan, we also includes the specific reports we use to monitor our fidelity indicators (Appendix EF, Page 23, Row 1.8 Quality Team Planning and Problem-Solving). As per our CQI BHW HFW Agenda (Appendix EB), key functions of this Subcommittee is to identify interventions and create and implement a plan for interventions to improve our practices (Appendix EB, Steps 4 and 5).
(d) Our HFW supervisors and Quality Assurance (QA) team routinely review our HFW plans of care (aka Matrices) and meeting minutes for shared ownership and follow-through on strategies and action items. It is important to highlight that we update the Matrix at each and every CFT meeting. This means that each CFT meeting matrix also serves as the minutes for the meeting (Appendix GK: HFW Policy, Page 22, Bottom Two Bullet Points). We use our internally-15, developed tool, the Quality Assurance Report (QAR), to assess shared ownership and follow-through (Appendix M). This Excel document includes a HFW tab—with a category devoted to the review of CFT Meetings and Plans of Care (Row 14). We review for this indicator using this prompt: “CFT meetings discuss progress with goals and strategies/action items at each meeting. If progress towards goals have not been made, it is described in a trauma informed way and problem solved in a way that contributes to resilience development/maintenance” (Appendix M, Line 31). Our supervisors complete 2 QARs per month (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 109). QA also completes QARs on a quarterly basis—with the goal that at the end of the year, they will have conducted reviews for 5% of our total HFW cases. QA and Supervisors select cases for QARs based on recent incident reports, recent client crisis, new cases (first 30 days of services), cases with HFW staffing changes, extended service length, and a high volume of services (Appendix EF (CQI Plan Behavioral Health and Wellness _ HFW, Page 15, Section 2. Fidelity Indicators).
1.9 Outcomes Based Process
(a) Our Matrix (aka Plan of Care) includes specific, measurable strategies and action items with timeframes. Our CFT Meeting Agenda provides an overview of this process. For example, one agenda item is to “Brainstorm Strategies: The team generates a list of strategies to meet each prioritized need/outcome statement.” The next agenda items is to take “Action Steps: The specific list of action items assigned to team member(s) in order to support the strategy/intervention and achieve the desired outcomes. Track completion of previous action items in every CFT Meeting” (Appendix BR: CII Team Meeting Agenda). In our Matrix, the brainstorming of strategies are documented under the “Planning For Needs” section: “Brainstorm Ideas/Update on Action Items” subsection. The action items with timeframes are documented in the subsection: “Action Steps/New Action Steps: Who (name), What, When (date) (Appendix D: CFT Matrix, Page 3, second half). As part of our CFT Meeting training, we also provide a sample Matrix that provides documentation examples of specific, measurable strategies and action items and timeframes (Appendix CD, Slides 29-34). In our team’s preparation for the initial CFT meeting, we ensure that the Matrix entries also include a section titled “Applicable Strengths” that will identify strengths from client, caregiver/family, and treatment team that can be applicable to addressing needs (Appendix EI, Page 2: Planning for Needs, Bullet Point 1). Our Intensive Care Coordinator is responsible for ensuring that all sections of the Matrix are completed thoroughly (Appendix GK: HFW Policy, Page 20, Secind Main Bullet Point from the Bottom).
(b) It is important to highlight that we update our Matrix (i.e. Plan of Care) at each and every CFT meeting. This means that each CFT meeting matrix also serves as the minutes for the meeting (Appendix GK: HFW Policy, Page 22, Last Two Bullet Points). Our Intensive Care Coordinator (ICC aka Facilitator) follows up on the action plan in every Child and Family Team Meeting (Appendix CD: CFT Meeting Training, Slide 20, Last Bullet Point: Action Steps). The ICC documents if an action item was competed or not in the “Brainstorm Ideas/Update on Action Steps section of the Matrix (Appendix BL: Completed CFT Matrix Example, Page 3, Box on Bottom Left: Follow-up on Past Action Steps). For the items that were not completed, the ICC will ensure that they continue to be listed in the “Action Steps/New Action Steps” section of the Matrix (Appendix BL: Page 3, Box on Bottom Right: Next Action Steps.
(c) We view each Plan of Care as a living, breathing document that will evolve over time—just as the family’s needs and strengths evolve over time. As such, our forms and processes are flexible and allow strategies and action items to be adjusted or changed as needed. The fact that we hold Child and Family Teams Meetings every 30-45 days, AND that we update the Plan at each of these meetings, means that we can make real-time adjustments to the Plan as needed to support the family. Changes are promptly communicated to all team members, as our ICC securely emails the Matrix to each HFW team member after each meeting. The Planning for Needs section of our Matrix (Appendix D: CFT Matrix – English, Pages 3-4) is comprised of free-form textboxes that allow us to develop and update individualized strategies and action steps for each family. Additionally, we can hold CFT meetings more frequently than the 30-45 days if this is what the family needs (Appendix GK: HFW Policy, Page 22, Phase Three: Implementation, Bullet Point 1).
(d) The IP-CANS is completed by our HFW therapist who must maintain active IP-CANS certification as per current Department of Health Care Services (DHCS) policy. If an existing CANS was received with the HFW referral, the therapist will use the copy to inform and update the current ratings, as appropriate. Given that the CANS is designed to foster a shared understanding of the family’s needs and inform the action plan, the CANS is finalized in collaboration with and consensus of the entire CFT during the first meeting ((Appendix GK: HFW Policy, Bottom of Page 15). The therapist enters the CANS scores into the client record via Exym and makes updates to the record as needed (Appendix FB: Exym CANS Submission Link). Our ICC brings copies of the IP-CANS to the first CFT Meeting so all team members can discuss and agree upon the ratings (Appendix GK: HFW Policy, Page 19, First CFT Meeting, Bullet Point 4).
(e) We use the Los Angeles County (LAC) Mental Health Plan (MHP) Matrix to track needs, goal completion, and action item completion to plan for transition. As per our HFW policy, our Intensive Care Coordinator (ICC) updates the Matrix at each and every CFT meeting (Appendix GK: HFW Policy, Page 23). Tracking of needs is documented in the “Underlying Needs (From all team members and CANS)” section of the Matrix. For each underlying needs section (i.e. Child/Youth and Family/Caregivers), it is noted that all team members contribute to identifying needs during the CFT meeting. In addition, the team also considers the needs identified from the IP-CANS and their corresponding rating (Appendix EG: CFT Matrix Guide, Bottom of Page 3-4, Last Row: Right Column).
Our Intensive Care Coordinator (ICC aka Facilitator) also follows up on the action plan in every Child and Family Team Meeting (Appendix CD: CFT Meeting Training, Slide 20, Last Bullet Point: Action Steps). The ICC documents if an action item was competed or not in the “Brainstorm Ideas/Update on Action Steps section of the Matrix (Appendix BL: Completed CFT Matrix Example, Page 3, Box on Bottom Left: Follow-up on Past Action Steps). For the items that were not completed, the ICC will ensure that they continue to be listed in the “Action Steps/New Action Steps” section of the Matrix (Appendix BL: Page 3, Box on Bottom Right: Next Action Steps). New action steps, as determined by the HFW team, will also be added to this section. Goal completion is documented in the “Child/Youth/Family Long Term View” section (Appendix GK: HFW Policy, Page 25, Transition is Initiated, Page 25, Bullet Point 4).
1.10 Persistence
(a) As per the HFW model, persistence is a critical component of the service we provide to families. Persistence is essential to building trust, sustaining engagement, and achieving long-term outcomes aligned with the family’s vision. As such, we approach setbacks and challenges not as evidence of a youth, or parent failure, but as an indicator of our need to revise the Plan. Staff are expected to use creative, strengths-based strategies that honor the family’s strengths, cultural, and values—maintaining consistent connection even when engagement becomes difficult (Appendix GA: Clinical Program Meetings Agenda, Page 1, HFW Principles, 10 Persistence). We primarily provide this support through individual and group supervision, as well as our Clinical Program Meetings. Our have standing agendas for each of these learning platforms includes a reference to all 10 HFW principles, including persistence, so that we always take these into consideration (as an example, Appendix DK: Individual Supervision Guide and Note Template, Bottom of Page 2-3). As another example, our Senior Clinical Supervisor or Clinical Supervisor facilitate a clinical program meeting one time monthly for two hours (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 139-140). This Meeting Agenda prompts HFW staff to select cases for presentation “where there are challenges, setbacks, and/or limited progress” (Appendix GA, Page 2).
(b) First and foremost, we take special care to ensure that our HFW leaders create safe and supportive relationships so that staff and teams feel comfortable reaching out for help. Upon hire, all supervisors receive 8 hours of training via our Intensive Behavioral Health Supervisor Manual (Appendix VV). This includes training specific to Supervision of Direct Service Staff—with a focus on establishing a positive supervisory relationship “founded in trust, safety, rapport, empathy, and mutual respect” (Appendix VV, Page 137, Facilitation of Clinical Supervision, 1. Establish a positive supervisory relationship, Bullet Point 1). Our approach to supervision acknowledges that staff will face challenges—including team conflict and complex client scenarios—and that during such times, a supervisor’s role is to provide both positive and constructive feedback, in collaboration with their supervisees (Appendix VV, Page 138, 3. Address Challenges). This approach and foundation is carried out throughout the course of ongoing individual and group supervision. Supervisors are “expected to have an open door policy for their supervisees where the supervisees can go to their supervisor for questions, help, and support outside of their scheduled individual supervision” (Appendix VV, Page 139, Bullet Point 4). Managers utilize our HFW Training Tracking Log (Appendix DF) to track completion of this 8-hour training.
In terms of accessing flexible funding, all HFW staff receive a 2-hour training on Flex Funds (Appendix T: Case Rate for Wraparound) within their first 30 days of employment. Supervisors tracking completion of this training through our Intensive Behavior Health Onboarding Checklist (Appendix R, Page 1, Clinical Trainings, Check Box 2). This comprehensive and detailed training (Appendix T) covers the various elements of Requesting Case Rate, including but not limited to: documentation in the Matrix (i.e. Plan of Care) and Progress Notes (Appendix T: Slides 12-13), examples of purchases (Appendix T: Slide 16), and completion of our County’s Case Rate Services and Supports (CRSS) Supplemental Information Form (Appendix T: Slides 39-43).
(c) Our Intensive Care Coordinators (ICCs) (aka Facilitators) receive ongoing training and coaching in HFW principles, phases, and standards—with group supervision serving as a key platform for learning. Our ICCs must attend group supervision on a monthly basis for one hour in duration (Appendix VV: Intensive Behavioral Health Supervisor Manual, Bottom of Page 139). During these interactions, our supervisors provide guidance, coaching, support, and feedback—aimed at the enhancement of clinical skills, adherence to ethical and legal practices, reflective practice, relationship building, and creation of a safe and supportive environment (Appendix VV, 137-138). Group supervision for our ICC staff is structured with a role-specific guide and standing agenda (Appendix FW: ICC Group Supervision Guide). As part of this agenda, ICCs are asked to pick 1-3 clients to check in on (Appendix FW, Bottom of Page 1). This check-in includes a consideration of their unique role on the HFW team and if specific principles and practices are being incorporated in treatment for the selected families. This check-in includes the ICC’s role and experience in leading the HFW team around the principle of persistence (Appendix FW, Top of Page 2, Item 2). Specifically, ICCs are asked these questions: How are you leading the team in post-crisis safety planning, conflict resolution, and effective brainstorming and ongoing plan revision? What support and/or additional training do you need around this principle to improve the quality and effectiveness of services that you provide to HFW families? These check-in questions are aligned with a reflective practice in that they are open-ended, based in curiosity and nonjudgement, and designed to promote self-awareness, critical thinking, and emotional intelligence (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 138, Section 2).
1.11 Transitions as a part of the Fourth Phase of HFW
(a) A key tenet of transition is that it only happens when the youth and family have had their needs met, not due to an adverse event or an administrative requirement (Appendix GK, HFW Policy, Page 24, Second Bullet Point from the Bottom). Instead, our ICC leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process. This discussion occurs during the context of a CFT Meeting and considers the following:
• The family’s progress towards their vision and goal.
• The child’s and family’s accomplishments during Wraparound.
• Skills learned and positive changes made.
• Client and family’s strengths to aid them during the transition process.
• Natural supports who will continue to support child/youth and family after transition.
• Progress as per outcome measures scores over time (e.g. IP-CANS, PSC-35, and FSP OMA)
Assuming the determination is made, the ICC leads the team to create an individualized transition plan that considers the following types of services and needs:
• Mental health or wellness supports (e.g. non-intensive behavioral health or specialized services)
• Medication support needs
• Case management supports (e.g. Enhanced Care Management, Community Supports (including housing support, food access, etc.)
• Youth development activities (e.g., afterschool programs, tutoring, sports, art classes, etc.)
The process includes identifying the team member who will be responsible for following up on the need, supporting the linkage, and the timeframe for follow up. The Transition Plan, along with a Safety and Crisis plan, are documented, distributed, signed, and uploaded into the client record (Appendix GK: HFW Policy, Page 25, Transition is Initiated).
(b) We celebrate transitions out of HFW according to the child or youth and family’s culture, values, and preferences. Our HFW staff receive initial and ongoing training that reinforces this practice. For example, our Wraparound Booster Training frames the transition phase as a time celebrate successes and the conclusion of services with the client and family. This celebration includes the use of flex funds to provide a gift such as a book, toy, etc. (Appendix BK – Slide 24). It also includes presenting the family with a formal Wraparound Certificate of Completion (Appendix CA). Our booster training also includes a review and discussion of the vignette of “Maribel” (Appendix BK – Slide 28). Attendees are provided with an “Maribel Story Answer Key” (Appendix CF, Page 3, Last Paragraph) that provides a concrete example of the use of flex funds to purchase something that matches “Maribel’s” unique interests and preferences.
During a CFT meeting, team collaborates with the family to ensure that the celebration reflects their culture, values, and preferences. Additionally, the family’s “Culture Discovery” document (Appendix BV) is revisited to inform the celebration, especially in terms of food, music, and the family’s other traditions and practices. Celebrations are supported by the use of flex funds. Approval of flex funds for celebrations include the same considerations as with other uses. Meaning, the flex fund:
1. Adds value to the team mission and supports the individualized care plan,
2. builds on family strengths,
3. meets identified youth and family needs,
4. are culturally relevant,
5. builds on natural support and/or community capacity,
6. represents a good deal for the investment.
7. includes a plan for sustainability.
Flex funds can be used to purchase an item (e.g. book, toy, food, etc.) that is meaningful to the family and/or reflection of the work between family and team. All members of the HFW team are able to coordinate and participate in celebrations as part of their Direct Service Expectation, thus ensuring staff are available to attend celebrations. In preparation for the celebration process, HFW staff are also allocated both time and support for the community resourcing and community partnerships, which are critical for the “warm hand-off” process. During the celebration, a Certificate of Completion is provided to the family (Appendix GK: HFW Policy, Page 28).
Expected Outcomes
2.1 Youth and Family Satisfaction
As a general overview, we use multiple standardized tools to routinely evaluate our effectiveness in providing High Fidelity Wraparound. A summary of these tools and processes are captured in our HFW Outcomes Matrix (Appendix EZ). This matrix is also embedded into our HFW CQI Plan (Appendix EF, Pages 20-26). This matrix includes: the expected HFW outcomes, corresponding data collection tools and associated questions and/or items, who administers the tool, how, how often, sampling methods, and the corresponding reports. We routinely evaluate our effectiveness in achieving expected outcomes through our CQI HFW Subcommittee (Appendix EF: CQI Plan Behavioral Health and Wellness, Pages 13 and 14, Foundations of our HFW CQI Process). This Subcommittee meets on a quarterly basis, at minimum, and follows a structured Agenda (Appendix EB, Page 1, Section 2: Data Review) and Meeting Minutes and Notes Template (Appendix EU) that ensures a comprehensive and strategic program improvement process. Specifically, the Meeting Minutes and Notes template includes a section on data review (Pages 3-4, Section 2: Review Data). We list all 9 of the expected outcomes in the right hand column of our data table, so we can check which ones we focus on across our meetings and monitor our progress across all expected outcomes.
In order to evaluate youth and family satisfaction, we use three tools: Family Experience Calls (FECs); the Youth Services Survey for Families (YSSF); and Requests for Change of Providers. The FEC form (Appendix DD) is an internally-created survey with questions designed to assess family’s experience of and satisfaction with Wraparound services, as well as to collect their feedback to inform local HFW implementation. Question 7 on the FEC (Appendix DD, Page 2, Top) identifies if the family is affiliated with a Tribe, so we have a way to evaluate satisfaction for this specific population. We use questions 14-26 (Appendix DD, Pages 4-6) as primary benchmarks to evaluate this expected outcome. HFW Supervisors make two FEC calls per month (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 40, Paragraph 1). Families are selected for FEC calls based on the following factors: high acuity (clients with recent or frequent crisis), extensive duration of service, nearing transition, team request, and randomly selected. All collected data is captured by our Family Experience Call Results Report, which shows the number of responses to each question, as well as aggregate and individual responses (Appendix DO: See example on Page 5, Questions 14 and 15).
We also use the Youth Services Survey for Families (YSSF) Caregiver Response form (Appendix N) and YSSF Client Response Form (Appendix WW) to evaluate satisfaction with services. The surveys were developed through the collaborative efforts of the federally funded Mental Health Statistics Improvement Program and included the direct assistance and feedback of consumers, their families, and mental health advocates. Our Intensive Care Coordinator (ICC) or Parent Partner directly asks the YSSF questions to caregivers during an in-person contact, while our Therapist or Intensive Home-Based Services (IHBS) worker directly asks the client the YSSF questions, also during an in-person contact. Responses will be entered and tracked into Exym, our Electronic Health Record (Appendix N: Exym YSSF Caregiver Response Form & Appendix WW: Exym Client Response form). These surveys will be administered to all families upon six months of HFW service, and then every six months thereafter. All collected data is captured by our Tableau BHW YSSF – Youth Aggregate Report (Appendix AT) and our Tableau BHW YSSF – Caregiver Aggregate Report (Appendix FM). These reports provide a percentage of improvement in the total score across matched pairs (upper left). They also show “positive feedback” and “areas of concern” across the survey items (bottom of report).
And, finally, we collect data on satisfaction when a family requests a change in provider (Appendix DW). These requests provide us with a direct pathway to better understanding a family’s potential dissatisfaction with our service. In our evaluation efforts, we focus on Question 2: “Please select the reason(s) for requesting the change” (Appendix DW, Page 1). We track all requests using our Request for Change in Provider Log (Appendix EN).
2.2 Improved School Functioning
In order to evaluate improved school functioning, we use the Integrated Practice: Child and Adolescent Needs and Strengths (IP-CANS). We record and evaluate school functioning using items 15, 16, and 17 from the Life Functioning Domain, and item 34 from the Strengths domain (Appendix FF). Our HFW therapists initiate completion of the IP-CANS for all families at intake, every six months thereafter, as ratings change throughout HFW service delivery, and at case closing. It is very important to stress that ultimately, the IP-CANS is completed collaboratively through the Child and Family Team (CFT) process. The therapist is responsible for entering scores into Exym, our Electronic Health Record, and ensuring ratings are updated as per the consensus of the CFT (Appendix FB: Exym CANS Submission Link). We track staff compliance with required CANS completion using our Tableau Caseload Log (Appendix BI, CANS Column). The report identifies past due CANS with the word “missing” (Appendix VV: Intensive Behavioral Health Supervisor Manual, Pages 17-18, How to Track CFT Meetings). The collected data is captured by our Tableau CANS – HFW – School Functioning report (Appendix FP). The middle of the report, under “High-Fidelity WRAP Items,” lists the number of matched pairs CANS for individual clients across the four ratings, and the improvement noted through pre-/update-/post- comparison.
2.3 Improved Functioning in the Community
In order to evaluate improved community functioning, we use the Integrated Practice: Child and Adolescent Needs and Strengths (IP-CANS). We record and evaluate community functioning using item 38 from the Strengths domain (Appendix FF). Our HFW therapists initiate completion of the IP-CANS for all families at intake, every six months thereafter, as ratings change throughout HFW service delivery, and at case closing. It is very important to stress that ultimately, the IP-CANS is completed collaboratively through the Child and Family Team (CFT) process. The therapist is responsible for entering scores into Exym, our Electronic Health Record, and ensuring ratings are updated as per the consensus of the CFT (Appendix FB: Exym CANS Submission Link). We track staff compliance with required CANS completion using our Tableau Caseload Log (Appendix BI, CANS Column). The report identifies past due CANS with the word “missing” (Appendix VV: Intensive Behavioral Health Supervisor Manual, Pages 17-18, How to Track CFT Meetings). Collected data is captured by our Tableau CANS – HFW – Community Functioning Report (Appendix EM). The middle of the report, under “High-Fidelity WRAP,” lists the number of matched pairs CANS for individual clients and the improvement noted through pre-/update-/post- comparison.
In order to evaluate the level of justice involvement for our HFW youth, we use the
Los Angeles County (LAC) Department of Mental Health (DMH) Full Service Partnership (FSP) Outcome Measures Application (OMA) forms. Specifically, we use the Child Baseline (Appendix GG); Transitional Age Youth (TAY) Baseline (Appendix KK); Child Key Event Change (KEC) (Appendix II); and TAY KEC (Appendix HH). The Baseline form completed upon HFW case opening by our Intensive Care Coordinator (i.e. Facilitator), collects data on the child/youth’s Residential Type – with a category for Justice Placement, and subcategories of Division of Juvenile Justice; Jail; Juvenile Hall; Juvenile Probation Camp/Ranch; and Prison (Appendix KK: Baseline OMA TAY, Page 3). The Key Event Change (KEC) form is completed by the Intensive Care Coordinator at any point during services to indicate a new residential status and the date of the change (Appendix II: KEC, Pages 3-4). If, for example, a youth is placed in Juvenile Hall, the ICC submits one KEC form for the date of admission, and another KEC for the date of release. The ICC also administers the KEC form to collect data on the child/youth’s living arrangement upon disenrollment from HFW. We have checklists to prompt completion of the OMAs upon intake, every six months, and at discharge (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 91). Our Administrative Assistants also use an OMA Tracking Log to oversee completion of these documents and their required entry into the Los Angeles County Mental Health Department OMA system (Appendix FC). The data collected is captured through our Tableau BHW Clients with Placement Changes report (Appendix BF). This report tracks placement changes for all clients, including the type of Living Arrangement and the length of stay.
2.4 Improved Interpersonal Functioning
In order to evaluate improved interpersonal functioning, we use the Integrated Practice: Child and Adolescent Needs and Strengths (IP-CANS). We record and evaluate community functioning using items 10 and 12 from the Life Functioning domain (Appendix FF). Our HFW therapists initiate completion of the IP-CANS for all families at intake, every six months thereafter, as ratings change throughout HFW service delivery, and at case closing. It is very important to stress that ultimately, the IP-CANS is completed collaboratively through the Child and Family Team (CFT) process. The therapist is responsible for entering scores into Exym, our Electronic Health Record, and ensuring ratings are updated as per the consensus of the CFT (Appendix FB: Exym CANS Submission Link). We track staff compliance with required CANS completion using our Tableau Caseload Log (Appendix BI, CANS Column). The report identifies past due CANS with the word “missing” (Appendix VV: Intensive Behavioral Health Supervisor Manual, Pages 17-18, How to Track CFT Meetings). Collected data is captured by our Tableau CANS – HFW – Interpersonal Functioning (Appendix FN). The middle of the report, under “High-Fidelity WRAP,” lists the number of matched pairs CANS for individual clients and the improvement noted through pre-/update-/post- comparison.
2.5 Increased Caregiver Confidence
In order to evaluate increased caregiver confidence, we use the Integrated Practice: Child and Adolescent Needs and Strengths (IP-CANS). We record and evaluate caregiver confidence using items 41, 42, and 43 from the Caregiver Resources and Needs section (Appendix FF). Our HFW therapists initiate completion of the IP-CANS for all families at intake and at least every six months thereafter. It is very important to stress that ultimately, the IP-CANS is completed collaboratively through the Child and Family Team (CFT) process. The therapist is responsible for entering scores into Exym, our Electronic Health Record, and ensuring ratings are updated as per the consensus of the CFT (Appendix FB: Exym CANS Submission Link). We track staff compliance with CANS completion every six months using our Tableau Caseload Log (Appendix BI, CANS Column). The report identifies past due CANS with the word “missing” (Appendix VV: Intensive Behavioral Health Supervisor Manual, Pages 17-18, How to Track CFT Meetings). Data collected through the CANS on caregiver confidence is reported on through our Tableau CANS – HFW – Caregiver Confidence Report (Appendix FO). The middle of the report, under “High-Fidelity WRAP,” lists the number of matched pairs CANS for individual clients, across each rating item, and the percentage of improvement noted through pre-/update-/post- comparison.
2.6 Stable and Least Restrictive Living Environment
In order to evaluate stable and least restrictive living environment, CII uses Los Angeles Department of Mental Health (DMH) Full Service Partnership (FSP) Outcome Measures Applications (OMA): Child or TAY Baseline and Key Event Change (KEC) forms. The Baseline form, completed upon HFW case opening by the Intensive Care Coordinator (i.e. Facilitator), collects data on the child/youth’s Residential Type across these categories: General Living Arrangement, Shelter/Homeless, Hospital, Residential Program, Justice Placement, and Other (Appendix GG: Child Baseline OMA, Pages 2-3). The KEC form is completed by the Intensive Care Coordinator at any point during services to indicate a new residential status and the date of the change (Appendix II: KEC, Pages 3-4). If, for example, a youth is hospitalized, the ICC submits one KEC form for the date of admission, and another KEC for the date of discharge. The ICC also administers the KEC form upon the youth and family’s disenrollment from HFW. We have checklists to prompt completion of the required OMAs (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 91). Our Administrative Assistants also use an OMA Tracking Log to oversee completion of these documents and their required entry into the Los Angeles County Mental Health Department OMA system (Appendix FC). Collected data is captured by two reports. Our Tableau BHW – Stable and Least Restrictive Living Environment report (Appendix BF, Page 1, Halfway down) highlights specific clients with placement changes, type of placement changes, and duration in each new placement. Our Tableau BHW Hospitalizations and Changes in Placements report (Appendix BD) provides the overall percentage of clients without hospitalizations (top left) and without any placement changes (middle left).
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
To evaluate reduction in psychiatric hospital visits, we use the Los Angeles Department of Mental Health (DMH) Full Service Partnership (FSP) Outcome Measures Applications (OMA): Child or TAY Baseline and Key Event Change (KEC) forms. The Baseline form, completed upon HFW case opening by the Intensive Care Coordinator (ICC), collects data on the child/youth’s living arrangements during the last twelve months. This includes information related to a Hospital setting—specifically Acute Psychiatric Hospital/Psychiatric Health Facility (PHF) or State Psychiatric Hospital (Appendix HH: (Key Event Change OMA TAY, Page 3, Half-Way Down)
The Key Event Change (KEC) form is completed by the ICC at any point during services to indicate a change in residential type and the date of the change. In alignment with the Baseline OMA, the KEC includes information related to a Hospital setting (Appendix II: Child KEC OMA, Page 3). If, for example, a youth is hospitalized, the ICC submits one KEC form for the date of admission, and another KEC for the date of discharge. We have checklists to prompt completion of the required OMAs (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 91). Our Administrative Assistants also use an OMA Tracking Log to oversee completion of these documents and their required entry into the Los Angeles County Mental Health Department OMA system (Appendix FC). Collected data is captured through our Tableau BHW Hospitalizations and Changes in Placement report (Appendix BD). This report provides the percentage of HFW clients with no new hospitalizations (Upper Left, under Hospitalizations). We also use our Stable and Least Restrictive Living Environment report (Appendix BF) to monitor hospitalizations, as well as their duration.
2.8 Reduction in Crisis Visits
To evaluate reduction in crisis visits, CII uses Los Angeles Department of Mental Health (DMH) Full Service Partnership (FSP) Outcome Measures Applications (OMA): Child or TAY Baseline and Key Event Change (KEC) forms. The Baseline form, completed upon HFW case opening by the Intensive Care Coordinator (i.e. Facilitator), collects data on the child/youth’s Emergency Interventions during the last twelve months. This includes information related to 1. The number of times the client received services in an emergency room for psychiatric reasons; 2. The number of times the client received services in a crisis stabilization/urgent care center for psychiatric reasons; and 3. Whether or not the client was seen by PMRT or a 24/7 Crisis Response Team with the past 12 months (Appendix GG: Child Baseline OMA, Page 8). The Key Event Change (KEC) form is completed by the Intensive Care Coordinator at any point during services to indicate the occurrence of Emergency Interventions. In alignment with the Baseline OMA, the KEC includes the same information about Emergency Intervention (Appendix II: Child KEC OMA, Page 7) as the Baseline form. We have checklists to prompt completion of the required OMAs (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 91). Our Administrative Assistants also use an OMA Tracking Log to oversee completion of these documents and their required entry into the Los Angeles County Mental Health Department OMA system (Appendix FC). Collected data is captured by our Tableau BHW Intensive OMA Living Arrangements – Emergency Interventions (Appendix BE). This report lists clients who have ER/Crisis Stabilization Visits and PMRT/Crisis Response Team Interactions, as well as if the PMRT interaction resulted in hospitalization.
2.9 Positive Exit from HFW
In order to evaluate a positive exit from HFW, we use the discharge reason on our discharge progress note (Appendix FD: Exym Discharge Summary Progress Note). Our HFW therapists complete this note in the client’s record as part of our routine case closing process. Completion of this note is tracked and monitored through our Discharge Checklist (Appendix FH, Page 1, Checkbox: “Discharge has been approved by Clinical Supervisor/Program Manager”). The reasons for HFW discharge, across all cases, are consolidated and analyzed through our Tableau BHW Discharge Summary Report (Appendix BG). This report aggregates discharge reason responses across all closed cases, and then breaks down disposition status into three categories: Other Disposition; Unsuccessful; Successful.
Engagement
3.1 Orientation
(a) We recognize that informed consent is the foundation of high-quality care. As such, our orientation to HFW entails clear communication and transparency – ensuring that families and Tribes fully understand the HFW process prior to agreeing to participate. We live out this standard through the following practices:
(a) Our Intensive Care Coordinator (ICC), aka Facilitator, reaches out to the family to schedule the Outreach and Engagement Session (aka “orientation”). The ICC and Parent Partner meet with the family, in-person, to fully explain the HFW process (Appendix GK: HFW Policy, Page 13, Bullet Point 4). This explanation includes an overview of Wraparound—such as its purpose, philosophy, principles, and phases of service delivery—with an emphasis on the family and youth as drivers of the process. To support this explanation, the team uses the Wraparound Process User’s Guide: A Handbook for Families (Appendix AC, pp. 8-9 and 13-17). The family is also offered a copy of this Handbook (Appendix GK: HFW Policy, Page 13, Bullet Points 10 and 11). We utilize a Behavioral Health and Wellness (BHW) Intake Checklist to verify that “Outreach and Engagement is documented, including explanation of offered HFW materials” (Appendix CJ, Page 2, Checkbox 4).
(b) During this orientation, the team communicates with the families about legal and ethical considerations related to HFW (Appendix GK: HFW Policy, Page 13, Bullet Points 6-9). These include but are not limited to:
1. Confidentiality. These discussions include protections of and limits to confidentiality (e.g. mandated reporting requirements) as our CII’s Notice of Privacy Practices (NPP) (Appendix AD: Intake Packet: Pages 9-19). The child’s personal representative is asked to sign an Acknowledgement of Receipt form (Appendix AD: Page 19). Family’s choices, as allowed by HIPAA and other laws, regarding the use and disclosure of Protected Health Information are also discussed and the Release of Information Form(s) is signed as appropriate (Appendix AF).
2. Patient Rights. Our Consent for Services form (Appendix AD: Intake Packet, Pages 1-6) is reviewed with the family. The consent process emphasizes that HFW services are voluntary, and the family has the right to request a change in service provider (agency or staff) or withdraw this consent at any time. The orientation also emphasizes, for example, the family’s right to be treated with respect and dignity, the right to file a grievance at any time without fear of retaliation, and the right to receive culturally and linguistically respectful and responsive services. These ethical standards are solidified in writing through the following documents, which are shared during the orientation: Protection of Rights for CII Clients (Appendix AD: Intake Packet, p. 23) and the Grievance Policy and Procedure for both CII and the Los Angeles County (LAC) Department of Mental Health (DMH) (Appendix AD: Intake Packet, Pages 25-35).
3. Responsibilities of the Family and HFW Team. CII’s orientation process ensures that families have a clear understanding of their role in HFW (including concrete expectations around participation, communication, and reasons why services are discontinued). These responsibilities are solidified through CII’s Mutual Service Agreement (Appendix AD: Intake Packet, Pages 38-40), which is presented to the family during the orientation.
4. Informed Consent. During the orientation, the HFW Team makes very intentional space for the family to ask questions and provide feedback. The Team encourages questions from the family to ensure understanding and comfort with the Wraparound process – recognizing that families may come to services experiencing various forms of vulnerability and trauma. HFW staff are supported in this trauma-informed approach by, for example, completion of the Core Curriculum on Childhood Trauma upon hire (Appendix BJ). Orientation concludes only after the family agrees to participate in Wraparound services (or declines the program, which is their right to do). (Appendix GK: HFW Policy, Page 14, Second Bullet Point from the Top).
(c) During our orientation (aka Outreach and Engagement), the ICC and Parent Partner explain the role of each team member including the family, natural supports, and Tribes in the case of an Indian child (Appendix GK, HFW Policy, Page 13, Bullet Point 9). This communication is facilitated using the Los Angeles County Department of Mental Health Wraparound Brochure (Appendix EW: Wraparound Program Brochure, Page 2, Who Works with My Family?). The team also introduces the Child and Family Team (CFT) Meetings and the Integrated Practice: Child and Adolescent Needs and Strengths Tool (IP-CANS). We use the CA Department of Social Services CFT Parent Brochure (Appendix EX) and the CFT Youth Brochure (Appendix EY) to support this information sharing. Both brochures include the role the family, natural supports, and Tribes in the case on an Indian child (Appendix EX: Page 2, Sections “Who attends the meetings” and “What is my role as a team member;” and Appendix EY: Page 2, “Who attends the meetings.”). (Appendix GK, HFW Policy, Page 13, Bullet Points 10-13). We utilize a Behavioral Health and Wellness (BHW) Intake Checklist to verify that “Outreach and Engagement is documented, including explanation of offered HFW materials” (Appendix CJ, Page 2, Checkbox 4).
3.2 Safety and Crisis stabilization
(a) Within 24 hours of the conclusion of the orientation (aka Outreach and Engagement) process, our Intensive Care Coordinator (ICC) schedules an appointment for the intake. The intake occurs within 10 calendar days from the date of the referral. Both the HFW Therapist and the ICC are present for the intake, and initial crisis and safety concerns are discussed. We create a written Safety Plan during the intake for all HFW cases (Appendix GK: HFW Policy, Page 14, Bullet Point 8). Our Family Safety and Crisis Plan (FSCP) template (Appendix NN) is created in collaboration with the youth and caregiver(s). The FSCP template includes very specific instructions and questions to ask to guide the safety planning process (Appendix NN, Page 1). Upon the conclusion of the intake, the ICC uploads the FSCP into the youth’s Exym record and securely emails a copy to the family (Appendix GK, HFW Policy, Page 15, Bullet Point 3). We monitor this process using our Intake Checklist (Appendix CJ, Page 2, Checkbox 5: Family Safety and Crisis Plan completed and shared). Note: As clinically indicated, the therapist may use the Risk Evaluation Tool (Appendix AE) to better assess the youth’s danger to self and/or danger to others (Appendix GK, HFW Policy, Pages 15, Assessment: Bullet Point 5). In the event that imminent risk is present, the Therapist and Intensive Care Coordinator follow our On-Call Rotation Policy—starting with reaching out to the On-Call Supervisor. A determination is then made as to whether 911, PMRT, or field deployment of additional staff is required to de-escalate the crisis (Appendix AH, Page 4, Section 4.0).
(b) It is our policy that an HFW Safety Plan is created at intake for all HFW families. We use the same template during the engagement phase—i.e. the Family Safety and Crisis Plan (Appendix NN)—as the one we use during the Plan Development phase. The crisis plan developed at intake is used to inform, but not replace, the plan that is developed during the Phase 2. At the first CFT meeting, the crisis plan is reviewed and enhanced, with input from all team members (Appendix GK: HFW Policy, Page 21, Second Bullet Point from the Bottom). Any updates are documented on the plan itself, as well as the “Worries, Safety Considerations, and Health and Education Concerns” section of the Matrix (Appendix EG: CFT Matrix Guide, Page 2-3).
(c) We provide all HFW families with information regarding how to access 24/7 crisis response during the intake session (Appendix GK, HFW Policy, Page 14, Intake: Bullet Point 8). The therapist or Intensive Care Coordinator provides a copy of our CII After-Hours Crisis Support Flyer, which is available in both English and Spanish (Appendix DN). We ensure this flyer is shared using our Intake Checklist (Appendix CJ, Page 2, Checkbox 6).
3.3 Strengths, Needs, Culture and Vision Discovery
(a) During the Engagement Phase, and before the first CFT meeting, the ICC schedules two separate meetings to prepare the family for the CFT process. The ICC and/or Parent Partner meets with the caregiver(s) to prepare them for the CFT. In a separate meeting, the Therapist and/or Intensive Home-Based Services Worker (IHBS) meets with the client to prepare them for the CFT. During these meetings, a preliminary Matrix (aka Plan of Care) is developed, in collaboration with the youth and caregiver(s) that includes a Family Vision (Appendix GK, HFW Policy, Page 18, Bullet Point One). We define Family Vision with the question: “What does a better life look like for the family?” (Appendix BR: CFT Meeting Agenda, Family Vision section). HFW staff also use Lorraine Mezanko-Alexander’s document: Powerful Open Ended Questions, to explore the family’s goals (Appendix CG, Section: Empowering Families by Exploring their Goals). Whenever possible, direct quotes from each family member are used to elevate their unique voice (Appendix GK, HFW Policy, Page 17, Preparation of Family for CFT: Bullet Point 6). The Family Vision is documented in the “Child/Youth/Family Long-Term View: Future Hopes and Aspirations” on the CFT Matrix (Appendix EG: CFT Matrix Guide, Page 1, First Row from the bottom, on the left). This preliminary Matrix is reviewed by the HFW supervisor and once approved, the ICC uploads it into the youth’s record (Appendix GK, HFW Policy, Page 18, Bullet Point 11).
(b) We initiate a Strengths, Needs, and Culture discovery during the Engagement Phase. Before the first CFT meeting, the ICC schedules two separate meetings to prepare the family for the CFT process. The ICC and/or Parent Partner meets with the caregiver(s) to prepare them for the CFT. In a separate meeting, the Therapist and/or Intensive Home-Based Services Worker (IHBS) meets with the client to prepare them for the CFT. During these meetings, a Preliminary Matrix (aka Plan of Care) is developed, in collaboration with the youth and caregiver(s) that includes a Strengths and Needs Discovery. This discovery includes review of the youth’s IP-CANS, including an explanation of the ratings, which are updated as needed to reflect the family’s input (Appendix GK, HFW Policy, Page 19, Bullet Points 1 and 2). The Strengths Discovery is documented in the Strengths section of the Matrix (Appendix EG: CFT Matrix Guide, Page 2, Second Row from the Top). The Needs Discovery is documented in the Underlying Needs section of the Matrix (Appendix EG: CFT Matrix Guide, Page 3, Second Row from the Top). The Family Vision is documented in the “Child/Youth/Family Long-Term View: Future Hopes and Aspirations” on the CFT Matrix (Appendix EG: CFT Matrix Guide, Page 1, First Row from the Bottom, on the Left). This preliminary Matrix is reviewed by the HFW supervisor and once approved, the ICC uploads it into the youth’s record (Appendix GK, HFW Policy, Page 18, Bullet Point 12). We have a Culture Discovery Worksheet (Appendix BV) that asks about the family’s cultural identity across domains such as Traditions & Celebrations; Food & Culture; Music, Art & Expression; and Values & Beliefs (Appendix BV). This information is entered directly into a progress note in the youth’s record (Appendix EQ). It is also entered in the “Cultural Considerations: I.E., Faith, SOGIE, Ethnicity, Language, Pronouns, etc.” section of the Matrix (Appendix EG (CFT Matrix Guide, Page 1, Row 3). We hold Child and Family Team meetings at least every 30-45 calendar days and more often as needed. The Matrix – including the Strengths, Underlying Needs, and Cultural Consideration section, is reviewed and updated at each and every CFT meeting. A copy of the most recent Matrix is provided to new team members as they are identified (Appendix GK: HFW Policy, Page 22, Second Bullet from the Bottom; Page 24, Bullet Point 5).
3.4 Engage All Team Members
(a) During the Engagement Phase, and before the first CFT meeting, the ICC schedules two separate meetings to prepare the family for the CFT process. The ICC and/or Parent Partner meets with the caregiver(s) to prepare them for the CFT. In a separate meeting, the Therapist and/or Intensive Home-Based Services Worker (IHBS) meets with the client to prepare them for the CFT. During this meeting, a Natural and Community Supports inventory is developed. This inventory helps to identify potential CFT members (including Tribes, in the case of an Indian child), as well as their specific role (Appendix GK, HFW Policy, Page 18, Bullet Points 3-5). We train our staff in the value of natural supports and the questions to ask to help families identify them (Appendix CD: Child and Family Team Meeting Training, Slide 6). HFW staff also use Lorraine Mezanko-Alexander’s document: Powerful Open Ended Questions, to explore the family’s goals (Appendix CG, Section: Exploring Natural Supports). This inventory is documented in an IHBS progress note in the youth’s record (Appendix GK, HFW Policy, Page 18, Bullet Point 6).
(b) Throughout all steps of the Engagement Phase (orientation, intake, assessment, and CFT meeting preparation), the HFW team works with the family to identify their formal supports. We also utilize the Wraparound referral information to identify Children’s System of Care partners who should be included on the HFW team. Our team engages with these partners during a System of Care staffing meeting. These meetings are when all professionals working with the family (i.e. the mental health treatment team, Children’s Social Worker, Probation Officer, DMH liaisons, etc.) come together to discuss and collaborate on the client’s case. The Intensive Care Coordinator (ICC), or other designated member of the HFW team, coordinates this staffing meeting, which occurs within 30 days of the referral. During this meeting, the team elicits goals and objectives for the family (especially “non-negotiables” aka court mandates) from all SOC partners for inclusion on the HFW Plan of Care. The team also discusses, for example, client and family strengths, possible or known current trauma and/or history of trauma, and underlying needs. During these discussions, the HFW team ensures that sharing information about the family is done in a respectful, curious, and trauma-informed way—as if the family was actually present at the meeting (Appendix GK, HFW Policy, Page 16: Children’s System of Care Meeting – Page 17).
(c) During the Engagement Phase, and before the first CFT meeting, the ICC schedules two separate meetings to prepare the family for the CFT process. The ICC and/or Parent Partner meets with the caregiver(s) to prepare them for the CFT. In a separate meeting, the Therapist and/or Intensive Home-Based Services Worker (IHBS) meets with the client to prepare them for the CFT. During these meetings, HFW staff work with the youth and family to identify potential team members (including formal, natural supports and Tribes, in the case of an Indian child) (Appendix GK, HFW Policy, Page 18, Bullet Points 4-8). Our staff receive training in how to identify potential team members. For example, we emphasize that the family has the choice of selecting the members of the Child and Family Team. For example, they may invite family members, friends, neighbors, church leaders, or anyone else who they believe will help and support their family to reach their long-term Family View (Appendix CD: Child and Family Team Meeting Training, Slide 5). Our HFW staff also receive training in how to specifically identify natural supports, as well as formal supports (Appendix CD: Slides 6-7). As part of these CFT Preparation Meetings, HFW staff explores and clarifies the role of each identified team member with the family (Appendix GK, HFW Policy, Page 18, Bullet Point 5).
(d) Upon referral, our Engagement Phase begins. It is broken down into the following steps: Outreach and Engagement (aka Orientation), Intake, Assessment, Systems of Care (SOC) Staffing Meeting, HFW Staff Prepare Family for CFT, and the HFW Team Prepares for CFT. HFW staff participating in these engagement and team building activities are responsible for documenting their specific contributions for each and every contact. Depending of the type of service provided and their role, each HFW staff will select the corresponding progress note in our Electronic Health Record, Exym, and complete the note. These practices are embedded into our overarching documentation expectations. For example, we believe that documentation is the backbone of effective, ethical, and legal practices. In terms of progress notes, they are the detailed record of all treatment activities, client response, and clinical interventions that were provided to the client and family throughout treatment (Appendix AQ: Professional Development Training, Slide 25). We expect staff to document ALL their work related to their client—including short consultations, phone calls, and check-ins (Appendix AQ: Slide 23: TIPS #1). Our policy is that services are documented within 24 hours, when staff have the best recall of the session and can write progress notes that accurately details the services rendered. This accuracy applies to start time, session duration, type of activity, and what occurred in the session (Appendix AQ: Slide 25).
3.5 Arrange Meeting Logistics
(a) Our staff are flexible in working hours and scheduling meeting times and locations to accommodate family and Wraparound Team needs. Meetings may be conducted in person, virtually, or in hybrid formats based on team needs and preferences. Meetings can take place in the office, at school, at home, or in community settings such as parks or libraries (Appendix GK, HFW Policy, Page 22, Phase 3: Implementation, Bullet Points 2-4). This flexibility is noted on all of our HFW staff job descriptions, so staff are informed of this expectation prior to being hired. For example, the “ability to work varied hours, including nights and weekend” is listed as a job qualification on all HFW staff job descriptions (Example: Appendix U: Intensive Care Coordinator Job Description, Page 2, Other Qualifications, Bullet Point 3). All HFW job descriptions also include the statement “Required to service clients in the community in Los Angeles County (> 75% of the time)” (Example: Appendix U, Page 2, Other Qualifications, Bullet Point 3). And finally, all HFW job descriptions include the characteristic of “Flexible and resilient, adapting plans based on client and family needs” (Example: Appendix U, Page 2, Other Qualifications, Last Bullet Point).
All HFW staff are required to attend the Intensive Behavioral Health: Professional Development Training upon hire. The training reminds staff that “Intensive Behavioral Health takes a “whatever it takes” approach to caring for the clients and families so we also may see clients outside of business hours in order to accommodate the families’ schedule” (Appendix AQ, Slide 9). We verify completion of this training through our Intensive Behavior Health Onboarding Checklist (Appendix R, Page 1, Program Overview, Checkbox 3).
(b) Our internal CFT Meeting training includes guidance around scheduling CFT meetings (Appendix CD). This training emphasizes that meeting dates, times, and locations are not about our own convenience. Instead, the team is expected to use a “whatever it takes approach” to scheduling meetings that are in alignment with family needs and preferences. The more we work with the family to schedule meetings for their convenience, the more motivated and engaged they will be in their participation. In terms of scheduling specifics, the Intensive Care Coordinator (ICC) collaborates with the family to ensure that meeting times fit with their routines and responsibilities, such as after-work and/or after-school hours. The method of meeting (which may be conducted in person, virtually, or in hybrid formats) is considered, along with the specific location. Meetings can take place in the office, at school, at home, or in community settings such as parks or libraries. Additionally, the ICC supports the family in planning for their own transportation, childcare, and other accommodations necessary to ensure their active involvement. Meeting reminders are sent to all participants at least 24–48 hours prior to the scheduled meeting. The ICC records attendance, notes any barriers to participation, and follows up with appropriate actions to support ongoing engagement (Appendix CD: CFT Meeting Training, Slide 15). We verify staff completion of this training through our Intensive Behavior Health Onboarding Checklist (Appendix R, Page 1, Clinical Trainings, Checkbox One).
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
(a) Prior to the initial CFT meeting, HFW staff meet with the family to review the Matrix (aka Plan of Care) and begin completing each section. The Intensive Care Coordinator (ICC) then shares this Preliminary Matrix during initial CFT meeting, and it is further discussed and enhanced with the input from the entire team (Appendix GK: HFW Policy, Page 19, First CFT Meeting, Bullet Point 4). We use a CFT Meeting Agenda to clearly lay out the steps of our Plan Development process. During the initial CFT meeting, right after introductions and a review of the meeting agenda, we create team agreements (Appendix BR). Based on the county’s Matrix, we refer to team agreements as “ground rules,” and operationalize them as a list of things the team agrees will help them be productive (Appendix BR, Page One, Lower left-hand corner). Our CFT Matrix Guide provides the following prompt for this section: “How can we work together for a positive and productive process?” Our CFT Meeting training provides more specifics creating these agreements (Appendix CD, Slide 19, Bullet Point 4), and it also includes a specific example of team agreements/ground rules (Slide 20).
After team agreements, we complete a Team Mission Statement. This statement is captured in the “Child/Youth/Family Long Term Goal” of the Matrix. As part of our internal HFW team preparation meeting, we check that there is a long-term goal for client, family, and team. If there is not a team goal, we use this meeting to come up with one (Appendix EI: Preparing for CFT Meeting, Page 1, Checkbox 8). This statement is then reviewed and enhanced during the initial CFT meeting (Appendix GK: HFW Policy, Page 20, Second Bullet Point from the Bottom).
After the mission, we move to completing a team strengths inventory. All members of the CFT are asked to share at least one strength of both the client and the caregiver/family (Appendix EI, Page 1, Checkboxes 9 and 10). Using the county’s Matrix, we document these responses in the Strengths domain, which is separated into a Child/Youth section and a Family/Caregivers section. We identify the youth’s strengths from the CANS along with the corresponding CANS Rating, as well as the caregiver strengths from the CANS along with the corresponding CANS Rating. The Family/Caregivers section also includes strengths for all team members, such as formal supports and natural supports, and the resources that they can contribute to the team (Appendix EG: CFT Matrix Guide, Page 2).
At the conclusion of the initial CFT meeting, the ICC documents all HFW meeting activities and decisions on the Matrix. After the meeting, the ICC submits the completed Matrix (with purpose of meeting marked as “initial”) to the Supervisor for review and approval. Once approved, the Matrix is uploaded to the External Client Documents tab in Exym. The name of the PDF includes the CFT meeting date, for tracking the frequency of meetings over time (Appendix BZ: Exym External Documents – CFT Matrix Listed). The ICC securely emails the completed Matrix to each member of the team. Note: The Matrix signature page includes email addresses for each of the team members (Appendix GK: HFW Policy, Page 20, Bullet Points 2, 4, and 5).
(b) Prior to the initial CFT meeting and during the engagement phase, HFW staff meet with the family to go over the meeting agenda and create a Preliminary Matrix. 3). The Intensive Care Coordinator (ICC) then shares this Preliminary Matrix during the initial CFT meeting, and it is updated to reflect any additionally discovered strengths (Appendix GK: HFW Policy, Page 19, First CFT Meeting, Bullet Point). As an example, all members of the CFT are asked to share at least one strength of both the client and the caregiver/family (Appendix EI, Page 1, Checkboxes 9 and 10). These strengths are then added to the “Strengths” section of the Matrix (Appendix EG: CFT Matrix Guide, Page 2, Middle). At the conclusion of the initial CFT meeting, the ICC submits the completed Matrix to the Supervisor for review and approval. Once approved, the Matrix is uploaded to the External Client Documents tab in Exym. The name of the PDF includes the CFT meeting date, for tracking the frequency of meetings over time (Appendix GK: HFW Policy, Page 20, Bullet Point 7).
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
(a) As per our CFT Meeting Agenda, we identify and prioritize underlying needs before developing the Plan of Care. We first compile a list of needs from team members and outcomes (e.g. IP-CANs), and then we prioritize them in the following order: legal mandates, family voice and choice, then outcomes. (Appendix BR). Our guidelines in Preparing for the CFT Meeting include supporting all team members in understanding and leveraging the IP-CANS ratings to identify youth and caregiver needs (Appendix EI, Page 1, Checkboxes 13 and 14). These guidelines include listing the CANS needs items scored as a 2 or 3 that require action, as well as items that need monitoring (1s) and items (0s) that can be praised (Appendix EI, Page 4). We also have an Underlying Needs Guide to support staff in creating strong needs statements, across a variety of domains, that are specific and recognize the effects of trauma on behavior (Appendix BM). The Intensive Care Coordinator (ICC) documents underlying needs in the corresponding section of the Matrix. Additionally, the ICC lists the underlying needs based on priority—for example, Need #1 will be the client, caregiver, and family’s first priority and Need #2 will be their second priority (Appendix EG: CFT Matrix Guide, Page 3, Top). Needs across all domains, including legal mandates, are then prioritized in the “Planning for Needs” section of the Matrix (Appendix EG: CFT Matrix Guide, Page 3, Middle). At the conclusion of the initial CFT meeting, the ICC submits the completed Matrix to the Supervisor for review and approval. Once approved, the Matrix is uploaded to the External Client Documents tab in Exym. The name of the PDF includes the CFT meeting date, for tracking the frequency of meetings over time (Appendix GK: HFW Policy, Page 20, Bullets 2, 6, and 7).
(b) During the initial CFT meeting, we develop measurable goals and outcomes from these identified needs. This process is noted in the Outcomes section of our CFT Meeting Agenda. We define “outcomes” as statements that provide measurable indicators of progress for each prioritized need—using the “SMART” formula (Specific, Measurable, Achievable, Realistic, Time Limited). In other words, what the end result looks like when the need is met (Appendix BR). Our CFT Matrix Guide includes an example of this process. For example, the client and caregiver identifies a need statement of “I feel unsafe at home because my neighbors have threatened us.” The outcome statement may be “Find new housing for client and caregiver” (Appendix EG, Page 3, Last Sentence in “Need #1” box). Our training of staff emphasizes that underlying needs often revolve around Safety, Wellbeing, and Permanency (Appendix CD: Child and Family Team Meeting Training, Slides 39-38). This training emphasizes that needs are not behaviors and need are not services—with some corresponding examples (Appendix CD: Slide 37). We also utilize an Underlying Needs Guide (Appendix BM) to support staff in creating strong needs statements, across a variety of domains, that are sensitive to the effects of trauma on behavior.
(c) Goals and outcomes are developed collaboratively with the youth, family, and the rest of the team. We use a person-centered approach—focusing on the specific and unique needs, preferences, strengths, and goals of each individual and the family at large. During the first CFT meeting, the entire team will discuss goals to address the underlying needs (Appendix GK: HFW Policy, Page 20, Develop an Individualized Plan of Care, Bullet Point 1). Ratings and scores from the Integrated Practice Child and Adolescent Needs and Strengths (IP-CANS), Pediatric Symptom Checklist (PSC-35) and the Full Service Partnership Outcome Measure Application (FSP OMA) are used to inform this process. Our overall approach to identifying underlying needs and developing goals and outcomes is that of genuine curiosity. We ask skillful questions and listen with openness, and we explore hunches to reach a shared view. This approach includes recognizing that we don’t have to have all of the answers (Appendix CD: Child and Family Team Meeting Training, Slide 37). Thus, goals and objectives reflect the blending of the family and team members’ perspectives, as well as mandates and resources (Appendix GK: HFW Plan, Page 10, HFW Principles: Collaboration).
(d) A critical component of the initial CFT meeting process is the brainstorming of strategies. As part of this step, the team generates a list of strategies to meet each prioritized need/outcome statement (Appendix BR: CII Team Meeting Agenda). Our guidelines around brainstorming are as follows:
• List all possible solutions or ideas that will help the child/youth and family reach this need.
• Make sure to utilize Strengths when brainstorming ideas.
• Aim to develop creative, unique and individualized interventions (Appendix CD: Child and Family Team Meeting Training, Slide 20: Brainstorming).
The Intensive Care Coordinator (ICC) documents these strategies under the “Planning For Needs” section: “Brainstorm Ideas/Update on Action Items” subsection (Appendix EG: CFT Matrix Guide, Page 3, Last Row – Top of Page 4). As part of our CFT Meeting training, we provide a sample Matrix that provides examples of how to document the strategies (Appendix CD, Slides 31-32). At the conclusion of the initial CFT meeting, the ICC submits the completed Matrix to the Supervisor for review and approval. Once approved, the Matrix, named with the initial meeting date, is uploaded to the External Client Documents tab in Exym (Appendix GK: HFW Policy, Page 20, Bullet Points 2, 6, and 7). This system allows for easy access and referencing to the Matrices and their development over time (Appendix BZ: Exym External Documents – CFT Matrix Listed).
(e) Upon hire, our Intensive Care Coordinators (ICCs) (aka Facilitators) take the UC Davis training Wraparound 101: Foundations of Fidelity (Appendix R: Intensive Behavior Health Onboarding Checklist, Page 3, UC Davis Trainings section). As part of this training, our ICC staff learn to value the Wraparound Child and Family Team including why specific individuals are part of the team and their various roles throughout the Four Phases. They also come to understand how Wraparound works with families by using individualized plans of care from the initial through the transitional plans. They also attend the Los Angeles County Department of Mental Health (DMH) Child Welfare Division Child and Family Team (CFT) Facilitator Webinar Series—which includes training on child and family engagement, team preparation, and initial and ongoing CFT meetings (Appendix R, Page 4, DMH Child Welfare Division Trainings section, Checkbox 6).
As part of their group supervision, our Intensive Care Coordinators (ICCs) also receive ongoing training and coaching in selecting strategies and developing action items. Our ICCs must attend group supervision on a monthly basis for one hour in duration (Appendix VV: Intensive Behavioral Health Supervisor Manual, Bottom of Page 137). During these interactions, our supervisors provide guidance, coaching, support, and feedback—aimed at the enhancement of clinical skills, adherence to ethical and legal practices, reflective practice, relationship building, and creation of a safe and supportive environment (Appendix VV, Top of Page 137-138). Group supervision for our ICC staff is structured with a role-specific guide and standing agenda (Appendix FW:ICC Group Supervision Guide). As part of this agenda, ICCs are asked to pick 1-3 clients to check in on (Appendix FW, Bottom of Page 1). This check-in includes a consideration of their unique role on the HFW team and if specific principles and practices are being incorporated in treatment for the selected families. This check-in also includes the ICC’s role and experience in leading the HFW team in selecting strategies and developing action items (Appendix FW, Top of Page 2, Item 3). Specifically, ICCs are asked these questions: – How are you leading the team in identifying, prioritizing, and selecting strategies and developing action items? How are you leading the team in post-crisis safety planning, conflict resolution, and effective brainstorming and ongoing plan revision? What support and/or additional training do you need around this principle to improve the quality and effectiveness of services that you provide to HFW families? These check-in questions are aligned with a reflective practice in that they are open-ended, based in curiosity and nonjudgement, and designed to promote self-awareness, critical thinking, and emotional intelligence (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 138, Section 2).
(f) We develop a Preliminary HFW Plan of Care (aka Matrix) when we meet with the family to prepare them for the CFT process. their unique voice (Appendix GK, HFW Policy, Page 17, Preparation of Family for CFT, Bullet Points 5 and 6). This Preliminary Plan is revisited and finalized during our first CFT Meeting (Appendix GK: HFW Plan, Page 19, First CFT Meeting, Bullet Points 4 and 5). During this meeting, our Intensive Care Coordinator (aka the Facilitator) guides the team through a collaborative planning process to establish individualized goals, strategies, and action items that constitute a singular, unified plan (Appendix GK: HFW Plan, Page 19, Phase Two: Plan of Care Development, Sentence 2). We utilize the Team Observation Measure (TOM 2.0) to evaluate our effectiveness in creating a team-based, collaborative environment We are currently licensed to use this tool (Appendix CU). Specifically, we focus on Subscale 2: Effective Teamwork to evaluate this practice standard (Appendix EF: CQI Plan Behavioral Health and Wellness _ HFW, Page 23, Row 1.8, Column 2, Report 3). In terms of frequency, our supervisors complete one TOM per month during a Child and Family Team meeting. The supervisor then schedules a Treatment Planning Meeting with the therapist, Intensive Care Coordinator (ICC), Intensive Home-Based Services (IHBS) Worker, and Parent Partner to provide feedback on findings related to effective teamwork (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 141, Bullet Point 4). The TOM questions and scores are incorporated into our Microsoft Forms system, which allows us to generate reports on subscale scores and the total score (Appendix FT: TOM Report).
4.3 Develop an Individualized Child or Youth and Family Plan
(a) Our Intensive Care Coordinators (ICCs) (aka Facilitators) receive ongoing training and coaching in HFW principles, phases, and standards—with group supervision serving as a key platform for learning. Our ICCs must attend group supervision on a monthly basis for one hour in duration (Appendix VV: Intensive Behavioral Health Supervisor Manual, Bottom of Page 139). During these interactions, our supervisors provide guidance, coaching, support, and feedback—aimed at the enhancement of clinical skills, adherence to ethical and legal practices, reflective practice, relationship building, and creation of a safe and supportive environment (Appendix VV, Top of Page 137). Group supervision for our ICC staff is structured with a role-specific guide and standing agenda (Appendix FW:ICC Group Supervision Guide). As part of this agenda, ICCs are asked to pick 1-3 clients to check in on (Appendix FW, Bottom of Page 1). This check-in includes a consideration of their unique role on the HFW team and if specific principles and practices are being incorporated in treatment for the selected families. This check-in specifically addresses the ICC’s role and experience in developing an Individualized Child or Youth and Family Plan (Appendix FW, Page 2, Item 4). ICCs are asked these questions: How are you engaging the team in a planning process that elicits multiple perspectives, builds trust and shared vision, and demonstrates the HFW principles? What support and/or additional training do you need around this principle to improve the quality and effectiveness of services that you provide to HFW families? These check-in questions are aligned with a reflective practice in that they are open-ended, based in curiosity and nonjudgement, and designed to promote self-awareness, critical thinking, and emotional intelligence (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 138, Section 2).
(b) Prior to the initial CFT meeting, our HFW team engages with identified Children’s System of Care (SOC) partners during a SOC staffing meeting. These meetings are when all professionals working with the family come together to discuss and collaborate on the client’s case. Our HFW policy has an inclusive list of all Children’s System of Care partners, as defined by California’s Department of Health and Human Services (Appendix GK: HFW Policy, Page 4, Second Definition from Top). The Intensive Care Coordinator (ICC), or other designated member of the HFW team, coordinates this staffing meeting, which occurs within 30 days of the referral. During this meeting, the team elicits goals and objectives for the family from all SOC partners for inclusion on the HFW Plan of Care. This discussion includes “non-negotiables”—e.g. legal mandates issued for the youth and/or caregiver as per the Department of Children and Family Services (DCFS) and/or Department of Probation. The goals and objectives identified in this meeting are documented by each participating HFW staff in a Treatment Planning Progress Note, which is referenced during the initial CFT meeting (Appendix GK: HFW Policy, Page 17, Top Half of Page).
In our internal meeting to prepare for the initial CFT meeting, we check that all team members, including formal supports, confirmed attendance for the upcoming meeting (Appendix EI: Preparing for CFT Meeting, Page 1, Checkbox 3). During the initial CFT meeting, non-negotiables, legal, and court considerations are discussed. The ICC documents these items in the corresponding section of the Matrix (Appendix EG: CFT Matrix Guide, Page 2, Top Right Corner). Goals and objectives not tied to legal mandates are documented in the Planning for Needs section (Appendix EG, Page 3).
(c) At the conclusion of the meeting, the ICC submits the completed Matrix to the Supervisor for review and approval. The Supervisor reviews the Matrix using the six criteria (UC Davis HFW Standard 4.3) for the development of an Individualized Child or Youth and Family Plan (Appendix GK: HFW Policy, Page 20, Bullet Point 3). These criteria are outlined in our Intensive Behavioral Health Supervisor Manual (Appendix VV, Page 17, Supervisor CFT Matrix Review Guidelines). Once approved, the Matrix is uploaded to the External Client Documents tab in Exym. The name of the PDF includes the CFT meeting date, for tracking the frequency of meetings over time Appendix BZ). The ICC securely emails the completed Matrix to each member of the team. (Appendix GK: HFW Policy, Page 20, Top Half of Page). Note: The Matrix signature page includes email addresses for each of the team members.
(d) Our HFW supervisors and Quality Assurance (QA) team routinely review our HFW Plans of Care for continuous quality improvement. We use our internally-developed tool, the Quality Assurance Report (QAR), to support and standardize this process (Appendix M). This Excel document includes a HFW tab—with a category devoted to the review of CFT Meetings and Plans of Care (Row 14). Specific review areas within this category include, for example, Strengths (Rows 21-23), Needs (Rows 24-25), Outcomes (Rows 24-25), and Strategies (Row 29). Our supervisors complete 2 QARs per month (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 109). QA also completes QARs on a quarterly basis—with the goal that at the end of the year, they will have conducted reviews for 5% of our total HFW cases. QA and Supervisors select cases for QARs based on recent incident reports, recent client crisis, new cases (first 30 days of services), cases with HFW staffing changes, extended service length, and a high volume of services (Appendix EF: CQI Plan Behavioral Health and Wellness _ HFW, Page 15, 2. Fidelity Indicators).
Feedback from QAR findings are built into our supervision and coaching process. For example, our Individual Supervision Guide and Note Template includes the following prompt: “If a QAR was completed, use the HFW tab to support your supervision” (Appendix DK, Page 2, under Clinical Review). We also consolidate QAR scores into a QAR Tracking Log (Appendix DZ), which is reviewed as part of our CQI Plan (Appendix EF, Page 22). Our CQI BHW HFW Meeting Minutes and Notes Template specifically prompts us to review this data (Appendix EU, Page 3, Section 2: Review Data, Middle Table Column, Second Check Box).
4.4 Develop a Crisis and Safety Plan
(a) We create a written Safety Plan during the intake for all HFW cases (Appendix GK: HFW Policy, Page 14, Intake: Bullet Point 6). The HFW Safety Plan, developed during the intake session, is reviewed with the team during the first CFT meeting. It is enhanced as needed from input from the team—especially to support or reinforce the role of natural supports (Appendix GK: HFW Policy, Page 19, First CFT Meeting, Bullet Point 4). The Plan is organized into seven steps—including Known Triggers and What We Can Do (Appendix NN: Safety and Crisis Plan, Page 1: Brief Instructions). The youth/child is asked “Can you tell me about things that make you extremely upset or cause you to hurt yourself?,” whereas the caregiver is asked “Do you know what hurts or triggers your child or youth?” (Appendix NN, Page 1, Step 2). These answers are then documented on in the “Known Triggers” section of the plan (Appendix NN, Page 2). The plan also addresses proactive crisis management strategies. For example, the child/youth is asked “What are some things I can do to get a handle on my behaviors, thoughts, and feelings,?” whereas the caregiver is asked “What can I do to make sure my child/youth is safe and feels safe?” These answers are then documented in the “What Can We Do” section of the Plan (Appendix NN, Page 3). The plan allows an opportunity to identify reactive strategies. For example, the family is guided to consider, “If doubt about using coping strategies is expressed, asked “What might stand in the way of you thinking of these activities or doing them if you think of them?” The staff is then guided to use a collaborative problem-solving approach to ensure that potential roadblocks are addressed and/or that alternative coping strategies are identified (Appendix NN, Page 1, Step 3: Last two sentences).
This plan is also designed to maximize the use of natural supports that are chosen by the family. For example, the child/youth is asked, “Among your family or friends, who do you think you could contact for help during a crisis?” (Appendix NN, Page 1, Step 5). The responses are then documented in the “People We Trust that We Can Call” section. This section also includes a list of Professionals, as well as our After-Hours Number (Appendix NN, Page 3). Upon the conclusion of the initial CFT, the ICC submits the Safety and Crisis plan to their supervisor. The supervisor reviews the plan to ensure it is comprehensive, culturally aligned, includes natural supports, and provides the family with clear direction on when and how to get help. Upon supervisor approval, the ICC securely emails a copy of the plan to the family and team and uploads it into the client’s chart (Appendix GK: HFW Policy, Page 20, Bullet Points 4-7).
(b) Upon hire, our ICC staff (aka Facilitators) receive training around developing a Crisis and Safety Plan (Appendix CD: Child and Family Team Meeting Training, Slides 39 and 40). This CFT Meeting Training also emphasizes the critical role of the ICC in the following areas: ensuring a positive and strengths-based process, including setting the tone for an open and safe environment for communication (Appendix CD, Slide 18). Our Intensive Care Coordinators (ICCs) (aka Facilitators) receive ongoing training and coaching in Crisis and Safety Planning through their group supervisions. Our ICCs must attend group supervision on a monthly basis for one hour in duration (Appendix VV: Intensive Behavioral Health Supervisor Manual, Bottom of Page 139). During these interactions, our supervisors provide guidance, coaching, support, and feedback—aimed at the enhancement of clinical skills, adherence to ethical and legal practices, reflective practice, relationship building, and creation of a safe and supportive environment (Appendix VV, Bottom of Page 137). Group supervision for our ICC staff is structured with a role-specific guide and standing agenda (Appendix FW:ICC Group Supervision Guide). As part of this agenda, ICCs are asked to pick 1-3 clients to check in on (Appendix FW, Bottom of Page 1). This check-in includes a consideration of their unique role on the HFW team and if specific principles and practices are being incorporated in treatment for the selected families. This check-in specifically addresses the ICC’s role and experience in developing a Family Crisis and Safety Plan (Appendix FW, Page 2, Item 5). ICCs are asked these questions: How are you ensuring that the crisis and safety plan occurs in a team based, collaborative environment? What support and/or additional training do you need around this principle to improve the quality and effectiveness of services that you provide to HFW families? These check-in questions are aligned with a reflective practice in that they are open-ended, based in curiosity and nonjudgement, and designed to promote self-awareness, critical thinking, and emotional intelligence (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 138, Section 2).
(c) Our HFW supervisors and Quality Assurance (QA) team assess the quality of Crisis and Safety Plans through our internally-developed tool: the Quality Assurance Report (QAR) (Appendix M). This Excel document includes a HFW tab—with a category devoted to the review of Safety Planning (Row 35). Row 40 addresses this standard: “The Safety Plan(s) are individualized, culturally relevant, use natural supports, and contain a proactive & reactive progression of strategies.” Our supervisors are required to complete 2 QARs per month (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 109). Each quarter, our QA Department also reviews a percentage of HFW charts so that at the end of the year, 5% of all HFW charts are reviewed. QA and Supervisors will audit client charts based on recent incidents, recent client crisis, first 30 days of services, cases with HFW staffing changes, extended service length, and a high volume of services (Appendix EF: CQI Plan Behavioral Health and Wellness _ HFW, Page 15, 2. Fidelity Indicators).
Feedback from QAR findings are built into our supervision and coaching process. For example, our Individual Supervision Guide and Note Template includes the following prompt: “If a QAR was completed, use the HFW tab to support your supervision” (Appendix DK, Page 2, under Clinical Review). We also consolidate QAR scores into a QAR Tracking Log (Appendix DZ), which is reviewed as part of our CQI Plan (Appendix EF, Bottom of Page 20 – 21). Our CQI BHW HFW Meeting Minutes and Notes Template specifically prompts us to review this data (Appendix EU, Page 3, Section 2: Review Data, Middle Table Column, Second Check Box).
Implementation
5.1 Implement The Plan of Care
(a) At each CFT meeting, our Intensive Care Coordinator (ICC aka Facilitator) leads the team in monitoring the implementation of the Plan of Care (aka Matrix). The Plan of Care is completed during the initial Child and Family Team Meeting (CFTM) and is reviewed and updated at each subsequent CFT meeting. Our Matrix thus serves a dual purpose: as both the Plan of Care and the meeting minutes (Appendix GK: HFW Policy, Page 22, Last 3 Bullet Points). This process ensures that the Plan remains current, actionable, and responsive to the family’s evolving needs.
For each meeting, the ICC prints out the previous meeting’s Matrix and guides the team in reviewing, tracking, and evaluating all areas of the plan. This review includes, for example, the effectiveness of strategies and collective and individual action items—including timeliness of completion (Appendix GK: HFW Policy, Page 23, Bullet Points 12 and 13). We view the Plan of Care as a living, breathing document that will evolve over time. As such, we adjust or change goals, strategies, and action items as needed to better serve the family. This flexibility includes adapting to the family’s emerging needs, leveraging newly-identified strengths, and engaging new potential natural supports (Appendix GK: HFW Policy, Page 23, Bullet Points 1 and 2).
The ICC documents changes and/or enhancements to strategies in the “Brainstorm Ideas/Update on Action Steps” section of the Matrix (Appendix EG: CFT Matrix Guide, Page 4, Right Side)The ICC documents if an action item was competed or not in the “Brainstorm Ideas/Update on Action Steps” section of the Matrix (Appendix BL: Completed CFT Matrix Example, Page 4, Left Side: Follow-up on Past Action Steps). For the items that were not completed, the ICC ensures that they continue to be listed in the “Action Steps/New Action Steps” section of the Matrix (Appendix BL: Page 4, Right Side: Next Action Steps). New action steps, as determined by the HFW team, will also be added to this section.
(b) Upon hire, our staff are initially trained in HFW through attending the UC Davis training: “Wraparound 101: Foundations of Fidelity.” This training fulfills 6 key goals for participants, one of which is to understand how Wraparound works with families by using individualized plans of care from the initial through the transitional plans (Appendix R: Intensive Behavior Health Onboarding Checklist, Page 3, UC Davis section, First Check box). Our staff also receive at least one annual training on implementation of the Plan of Care. For example, we have an internally created Wraparound Booster Training (Appendix BK). This one-hour training is facilitated by our CII Supervisors and Managers and includes a review of Phase 3: Implementation phase, which highlights the need to “celebrate successes with meeting needs and improvements with outcomes” (Slide 23). This booster also discusses the vignette of “Maribel” (Appendix BK – Slide 28), which includes examples of how a plan of care was adjusted over time to meet the changing needs of the family. (Appendix CF, Maribel Story Answer Key, Page 3, Paragraph Two).
Individual supervision is a key platform for training and coaching on the implementation phase. All HFW direct service staff attend, at minimum, weekly individual supervision that is at least one hour in duration (Appendix VV: Intensive Behavioral Health Supervisor Manual, Bottom of Page 138). During these interactions, our supervisors provide guidance, coaching, support, and feedback—aimed at the enhancement of clinical skills, adherence to ethical and legal practices, reflective practice, relationship building, and creation of a safe and supportive environment (Appendix VV, Top of Page 137). We structure this supervision through an Individual Supervision Guide and Note Template (Appendix DK). Part of the standing agenda include the questions: “Are we struck in one of the phases of treatment,” and “Success stories? How are these successes being celebrated as they occur?” (Appendix DK, Page 2, Ongoing Items, Bullet Points 3 and 4). These check-in questions are aligned with a reflective practice in that it is open-ended, based in curiosity and nonjudgement, and designed to promote self-awareness, critical thinking, and emotional intelligence (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 138, Section 2, Reflective Practice).
5.2 Review and Update The Plan of Care
(a) We review strategies, progress, and action items in a HFW team meeting setting. For example, our CFT Meeting Agenda includes a section on “Action Steps”—which includes tracking the completion of previous action items in every CFT Meeting (Appendix BR, Action Steps). The frequency of our HFW meetings (at least every 30-45 calendar days and more often as needed) ensures that the family benefits from consistent and timely support from the entire team. During each HFW team meeting, our Intensive Care Coordinator (ICC) leads the team to assess the effectiveness of strategies, track individual action assignments and problem-solve barriers to their timely completion, and evaluate overall progress towards specific outcomes (Appendix GK: HFW Policy, Page 23, Bullet Points 12, 13, and 15).
(b) At each CFT meeting, our Intensive Care Coordinator (ICC aka Facilitator) leads the team in monitoring the implementation of the Plan of Care (aka Matrix). For each meeting, the ICC prints out the previous meeting’s Matrix and guides the team in reviewing, tracking, and evaluating all areas of this plan (Appendix GK: HFW Policy, Page 22, Phase Three: Implementation Section, Bullet Point 5). We view the Plan of Care as a living, breathing document that will evolve over time. As such, we adjust or change goals, strategies, and action items as needed to better serve the family. This flexibility includes adapting to the family’s emerging needs, leveraging newly-identified strengths, and engaging new potential natural supports (Appendix GK: HFW Policy, Page 23, Top of Page). After each CFT meeting, the ICC submits the completed Matrix (with purpose of meeting marked as “follow-up”) to the Supervisor for review and approval. The Supervisor reviews the Matrix using the six criteria (UC Davis HFW Standard 4.3) for the development of an Individualized Child or Youth and Family Plan. Once approved by the supervisor, the ICC uploads the Matrix into the youth’s record (i.e. External Client Documents tab in Exym) (Appendix GK: HFW Policy, Page 24, Bullet Points 7, 8, and 9).
(c) A new Matrix, updated to reflect changes, learnings, and progress from the last meeting, is completed at each CFT meeting. The Matrix thus serves a dual purpose as both the Plan of Care and the Meeting Minutes. In each CFT meeting, the Intensive Care Coordinator (ICC) leads discussions and explorations around, for example, team attendance; collective and individual action items, including timeliness of completion; new action items that may be needed; use of formal and natural supports; and use of flex funds (Appendix GK: HFW Policy, Page 23, Bullet Point 3). The ICC documents each of these areas in the following sections of the Matrix:
• Completion of Tasks: “Brainstorm Ideas/Update on Action Steps” (Appendix BL: Completed CFT Matrix Example, Page 3, Box on Bottom Left).
• New assignments: “Action Steps/New Action Steps” (Appendix BL: Page 3, Box on Bottom Right)
• Team Attendance: “Signatures” (Appendix BL: Completed CFT Matrix Example, Page 6.
• Use of formal and natural supports: Team Attendance: “Signatures” (Appendix BL: Completed CFT Matrix Example, Page 6, Relationship to Child/Youth Column)
• Use of Flex Funds (Appendix BL: Completed CFT Matrix Example, Page 3, “Action Steps/New Action Steps” box, Item #4).
After each CFT meeting, the ICC submits the completed Matrix (with purpose of meeting marked as “follow-up”) to the Supervisor for review and approval. The Supervisor reviews the Matrix using the six criteria (UC Davis HFW Standard 4.3) for the development of an Individualized Child or Youth and Family Plan. Once approved by the supervisor, the ICC uploads the Matrix into the youth’s record (i.e. External Client Documents tab in Exym) (Appendix GK: HFW Policy, Page 24, Bullet Points 7, 8, and 9).
(d) We view each Plan of Care as a living, breathing document that will evolve over time—just as the family’s needs and strengths evolve over time. As such, our forms and processes are flexible and allow strategies and action items to be adjusted or changed as needed. The fact that we hold Child and Family Teams Meetings every 30-45 days, AND that we update the Plan at each of these meetings, means that we can make real-time adjustments to the Plan as needed to support the family (Appendix GK: HFW policy, Page 22, Phase 3: Implementation, Bullet Points 1 and 6). The Planning for Needs section of our Matrix (Appendix D: CFT Matrix – English, Pages 3-4) is comprised of free-form textboxes that allow us to develop and update individualized strategies and action steps for each family. Additionally, these textboxes do not have any space limitations.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
(a) At each CFT meeting, our Intensive Care Coordinator (ICC) prints out the previous meeting’s Matrix and guides the team in reviewing each and every section—including Team Agreements (Appendix GK: HFW Policy, Page 23, Bullet Point 6). We view the Plan of Care as a living, breathing document that will evolve over time. As such, updates to Team Agreements are made, as needed, to reflect the team’s learning around how the family can best be supported in reaching their goals (Appendix GK: HFW Policy, Page 23, Bullet Points 1 and 2). Team Agreements are reviewed every 30-45 days, as is our standard frequency of team meetings (Appendix GK: HFW Policy, Page 22, Phase 3: Implementation, Bullet Point 1). At each CFT meeting, the youth, family, natural supports, and formal supports provide feedback on the team agreements and whether they should be enhanced or modified. If additional natural supports or formal supports join the team, agreements are revisited again and updated with their feedback (Appendix GK: HFW Policy, Page 24, Bullet Point 5). Ultimately team agreements are collaboratively created, reviewed, and changed as needed at each and every CFT Meeting.
(b) Our Intensive Care Coordinators (ICCs) (aka Facilitators) receive ongoing training and coaching in HFW principles, phases, and standards—with group supervision serving as a key platform for learning. Our ICCs must attend group supervision on a monthly basis for one hour in duration (Appendix VV: Intensive Behavioral Health Supervisor Manual, Bottom of Page 139). During these interactions, our supervisors provide guidance, coaching, support, and feedback—aimed at the enhancement of clinical skills, adherence to ethical and legal practices, reflective practice, relationship building, and creation of a safe and supportive environment (Appendix VV, Top of Page 137). Group supervision for our ICC staff is structured with a role-specific guide and standing agenda (Appendix FW: ICC Group Supervision Guide). As part of this agenda, ICCs are asked to pick 1-3 clients to check in on (Appendix FW, Bottom of Page 1). This check-in includes a consideration of their unique role on the HFW team and if specific principles and practices are being incorporated in treatment for the selected families. This check-in specifically addresses the ICC’s role and experience in building supports while maintaining team cohesiveness and trust (Appendix FW, Page 2, Item 6). ICCs are asked these questions: How are you building, engaging, and maintaining effective teams? What support and/or additional training do you need around this principle to improve the quality and effectiveness of services that you provide to HFW families? These check-in questions are aligned with a reflective practice in that they are open-ended, based in curiosity and nonjudgement, and designed to promote self-awareness, critical thinking, and emotional intelligence (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 138, Section 2).
Our Intensive Care Coordinators also attend, at minimum, weekly individual supervision that is at least one hour in duration (Appendix VV: Intensive Behavioral Health Supervisor Manual, Bottom of Page 138). During these interactions, our supervisors provide guidance, coaching, support, and feedback—aimed at the enhancement of clinical skills, adherence to ethical and legal practices, reflective practice, relationship building, and creation of a safe and supportive environment (Appendix VV, Top of Page 137). We structure this supervision through an Individual Supervision Guide and Note Template (Appendix DK). Part of the standing agenda include these questions related to effective teams: “Who are we missing that should be a part of the team?,” “Has there been communication amongst all providers and team members?; and ”Are there any challenges that the team could use support on?” (Appendix DK, Page 3, Questions 7, 8, and 10). These questions are aligned with a reflective practice in that it is open-ended, based in curiosity and nonjudgement, and designed to promote self-awareness, critical thinking, and emotional intelligence (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 138, Section 2).
(c) We utilize the Team Observation Measure (TOM 2.0) to monitor the use of natural supports over time (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 147, Supervisor Section, Bullet Point 5). We are currently licensed to use this tool (Appendix CU). Specifically, we focus on Subscale 5: Use of Natural and Community Supports to evaluate this fidelity measure. In terms of frequency, our supervisors complete one TOM per month during a Child and Family Team meeting. The supervisor then schedules a Treatment Planning Meeting with the therapist, Intensive Care Coordinator (ICC), Intensive Home-Based Services (IHBS) Worker, and Parent Partner to provide feedback on findings related to effective teamwork (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 141, Bullet Point 2). The TOM questions and scores are incorporated into our Microsoft Forms system, which allows us to generate reports on subscale scores and the total score (Appendix FT: TOM Report).
We routinely elicit feedback from families regarding their experience of the use and effectiveness of natural supports. Specifically, we use our Family Experience Calls (FEC) form (Appendix DD), which is an internally-created survey with questions designed to assess family’s experience of and satisfaction with Wraparound services. Question 6 on the FEC (Appendix DD, Page 2, Top) identifies if the family is affiliated with a Tribe, so we have a way to evaluate the experience of this specific population. We use question 25 to specifically gather feedback to comply with this standard: “Are natural supports being included in CFT meetings? What is your experience of having natural supports engaged on your team? Note: for clients with Tribal affiliation, please ask if a Tribal representative has been included in the CFT process” (Appendix DD, Page 6, Question 25). HFW Supervisors make two FEC calls per month (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 40, Paragraph 1). Families are selected for FEC calls based on the following factors: staff need, client feedback, or evidence of challenges reported in case reviews (Appendix EF: CQI Plan Behavioral Health and Wellness _ HFW, Page 15, Section 2. Fidelity Indicators). All collected data is captured by our Family Experience Call Results Report, which shows the number of responses to each question, as well as aggregate and individual responses (Appendix DO). Supervisor will send an email to the family’s treatment team about praise and positive feedback the supervisor received about the team. If there are issues or concerns that the caregiver expressed, Supervisor will follow up with an email or hold a team meeting, whichever is more appropriate (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 141, Bullet Point One).
(d) Whenever a new member joins the team, the ICC explains the HFW process and principles during the new member’s first CFT meeting. This explanation includes an overview of Wraparound—such as its purpose, philosophy, principles, and phases of service delivery—with an emphasis on the family and youth as drivers of the process. Each member of the team discusses their unique role and relationship with the family. To support this explanation, the ICC shares the Wraparound Process User’s Guide: A Handbook for Families (Appendix AC); the Los Angeles County Department of Mental Health Wraparound Brochure (Appendix EW); and the CA Department of Social Services CFT Parent and Youth Brochure (Appendix EX and EY). The ICC also shares and explains the most recent Matrix, which includes current individualized plans and strategies. Before starting the official CFT agenda, team building exercises occur to integrate the new member(s). They may include, for example, the entire team playing a board game, cooking a meal together, or drawing together (Appendix GK, HFW Policy, Page 24, Bullet Points 1-6).
Transition
6.1 Develop a Transition Plan
(a) Our Intensive Care Coordinator (ICC aka Facilitator) leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process. This discussion occurs during the context of a CFT Meeting or Meetings and considers the following:
• Progress toward the vision and goals identified in the CFT Matrix and Problem List.
• The child’s and family’s accomplishments during Wraparound.
• Skills learned and positive changes made.
• There are no pressing safety or crisis concerns.
• Client and family’s strengths to aid them during the transition process.
• Natural supports who will continue to support child/youth and family after transition.
• Youth and family progress towards HFW Expected Outcomes (Appendix FA: HFW Outcomes)
• Progress as per outcome measures scores over time (e.g. IP-CANS, PSC-35, and FSP OMA)
The ICC supports the team in reaching a determination about the family’s readiness to transition from Wraparound. This determination also includes clinical input from the team’s supervisor (Appendix GK: HFW Policy, Page 25, Transition is Initiated).
(b) Once the determination for transition has been made, our ICC leads the team in creating an individualized transition plan. This plan is created collaboratively during a CFT meeting and considers the following types of services and needs:
• Mental health or wellness supports (e.g. non-intensive behavioral health or specialized services)
• Medication support needs
• Case management supports (e.g. Enhanced Care Management, Community Support, food access, housing supports, etc.)
• Youth development activities (e.g., after school programs, tutoring, sports, art classes, etc.).
The process includes identifying the team member who will be responsible for following up on the need, supporting the linkage, and the timeframe for follow up. The ICC will document the Transition Plan on the Matrix (Appendix D), marking the “purpose of the meeting” as “Transition” (Appendix GK: HFW Policy, Bottom of Page 25 -26). Ongoing needs are documented in the Planning for Needs section of the Matrix (Appendix EG: CFT Matrix Guide). Services and supports are noted in a Resource Letter (Appendix GN).
After the meeting, the ICC submits the completed Transition Matrix to the Supervisor for review and approval. The Supervisor reviews the Matrix using the six criteria (UC Davis HFW Standard 4.3) for the development of an Individualized Child or Youth and Family Plan. Once approved, the Matrix is uploaded to the External Client Documents tab in Exym. The ICC securely emails the completed Matrix, as well as the Resource Letter, to each member of the team (Appendix GK: HFW Policy, Bottom of Page 26-27).
(c) Upon hire, our Intensive Care Coordinators (ICCs) (aka Facilitators) take the UC Davis training Wraparound 101: Foundations of Fidelity (Appendix R: Intensive Behavior Health Onboarding Checklist, Page 3, UC Davis Trainings section). As part of this training, our ICCs learn how Wraparound works with families by using individualized plans of care from the initial through the transitional plans. In order to structure the process and ensure it meets HFW standards, we developed a one-page document on Developing a Transition Plan (Appendix CE). This document, used in conjunction with group supervision, ensures continued training and coaching for our ICCs in developing individualized transition plans. Our ICCs must attend group supervision on a monthly basis for one hour in duration (Appendix VV: Intensive Behavioral Health Supervisor Manual, Middle of Page 139). During these interactions, our supervisors provide guidance, coaching, support, and feedback—aimed at the enhancement of clinical skills, adherence to ethical and legal practices, reflective practice, relationship building, and creation of a safe and supportive environment (Appendix VV, Top of Page 138). Group supervision for our ICC staff is structured with a role-specific guide and standing agenda (Appendix FW: ICC Group Supervision Guide). As part of this agenda, ICCs are asked to pick 1-3 clients to check in on (Appendix FW, Bottom of Page 1). This check-in includes a consideration of their unique role on the HFW team and if specific This check-in specifically addresses the ICC’s role and experience in building supports while maintaining team cohesiveness and trust (Appendix FW, Page 2, Item 7). This check-in specifically addresses the ICC’s role and experience in building a team based, collaborative environment (Appendix FW, Page 2, Item 6). ICCs are asked these questions: How are you ensuring that the individualized transition plan occurs in a team based, collaborative environment? What support and/or additional training do you need around this principle to improve the quality and effectiveness of services that you provide to HFW families? These check-in questions are aligned with a reflective practice in that they are open-ended, based in curiosity and nonjudgement, and designed to promote self-awareness, critical thinking, and emotional intelligence (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 138, Section 2).
Our Intensive Care Coordinators also attend, at minimum, weekly individual supervision that is at least one hour in duration (Appendix VV: Intensive Behavioral Health Supervisor Manual, Bottom of Page 138-139). During these interactions, our supervisors provide guidance, coaching, support, and feedback—aimed at the enhancement of clinical skills, adherence to ethical and legal practices, reflective practice, relationship building, and creation of a safe and supportive environment (Appendix VV, bottom of Page 137-138). We structure this supervision through an Individual Supervision Guide and Note Template (Appendix DK). Part of the standing agenda include these questions related to the creation of a team based, collaborative environment: “Who are we missing that should be a part of the team?,” “Has there been communication amongst all providers and team members?; and ”Are there any challenges that the team could use support on?” (Appendix DK, Page 3, Questions 7, 8, and 10). These questions are aligned with a reflective practice in that it is open-ended, based in curiosity and nonjudgement, and designed to promote self-awareness, critical thinking, and emotional intelligence (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 138, Section 2).
(d) Our HFW team verifies that services and supports identified in the transition plan will persist past formal HFW and that the family is able to access them, including post adoption services if applicable. Supervisors support the HFW team in community resourcing and developing community partnerships in order to promote warm hands-offs. Specifically, the designated team member contacts the resource to confirm that services can continue for the family after discharge. The team continues services with the family until linkage occurs (Appendix GK: HFW Policy, Page 26). In accordance with the Integrated Care Practice Model, supervisors ensure that referrals are working effectively as part of the Transition Phase (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 58, Transition Column, Third Box Down). Individual supervision also allows HFW staff to ensure continuity of care during the transition process. For example, the standing agenda for supervision includes a review of upcoming discharges, and a reflection around if the team is stuck in one of the phases of treatment, including transition (Appendix DK: Individual Supervision Guide and Note Template, Page 2, Ongoing Items).
6.2 Develop a Post-Transition Safety Plan
(a) Our Intensive Care Coordinator (ICC) leads the team in creating a Family Safety and Crisis Plan that identifies potential crisis situations that may occur after transitioning from formal HFW (Appendix CE: CII Developing a Transition Plan, Second Checkbox from Bottom). This process occurs during a Child and Family Team meeting and in a team-based, collaborative environment. We use our Safety and Crisis Plan template (Appendix NN) for this post-transition plan. The plan helps the family to identify potential crisis situation that may occur after transition. For example, the youth/child is asked “Can you tell me about things that make you extremely upset or cause you to hurt yourself?,” whereas the caregiver is asked “Do you know what hurts or triggers your child or youth?” (Appendix NN, Page 1, Step 2). These answers are then documented on in the “Known Triggers” section of the plan (Appendix NN, Page 2). The plan also addresses proactive crisis management strategies. For example, the child/youth is asked “What are some things I can do to get a handle on my behaviors, thoughts, and feelings,?” whereas the caregiver is asked “What can I do to make sure my child/youth is safe and feels safe?” These answers are then documented in the “What Can We Do” section of the Plan (Appendix NN, Page 3). The plan allows an opportunity to identify reactive strategies. For example, the family is guided to consider, “If doubt about using coping strategies is expressed, asked “What might stand in the way of you thinking of these activities or doing them if you think of them?” The staff is then guided to use a collaborative problem-solving approach to ensure that potential roadblocks are addressed and/or that alternative coping strategies are identified (Appendix NN, Page 1, Step 3: Last two sentences).
This Transition Safety Plan is designed to maximize the use of natural supports that are chosen by the family. For example, the child/youth is asked, “Among your family or friends, who do you think you could contact for help during a crisis?” (Appendix NN, Page 1, Step 5). The responses are then documented in the “People We Trust that We Can Call” section (Appendix NN, Page 3). The ICC submits the documented plan to their supervisor, who reviews it to ensure cultural alignment, safety, and mitigation of risks. Once approved by the supervisor, this Post-Transition Safety and Crisis Plan is uploaded into the youth’s electronic record. The ICC distributes copies to family and identified supports via secure email (Appendix GK: HFW Policy, Page 27, Development of a Post-Transition Safety Plan).
(b) Upon hire, our Intensive Care Coordinators (ICCs) (aka Facilitators) take the UC Davis training Wraparound 101: Foundations of Fidelity (Appendix R: Intensive Behavior Health Onboarding Checklist, Page 3, UC Davis Trainings section). As part of this training, our ICCs learn how Wraparound works with families by using individualized plans of care from the initial through the transitional plans. Our ICC receive continued training and coaching on developing crisis and safety transition plans during group supervision. Our ICCs must attend group supervision on a monthly basis for one hour in duration (Appendix VV: Intensive Behavioral Health Supervisor Manual, Bottom of Page 139). During these interactions, our supervisors provide guidance, coaching, support, and feedback—aimed at the enhancement of clinical skills, adherence to ethical and legal practices, reflective practice, relationship building, and creation of a safe and supportive environment (Appendix VV, Page 137-138). Group supervision for our ICC staff is structured with a role-specific guide and standing agenda (Appendix FW: ICC Group Supervision Guide). As part of this agenda, ICCs are asked to pick 1-3 clients to check in on (Appendix FW, Bottom of Page 1). This check-in includes a consideration of their unique role on the HFW team and if specific principles and practices are being incorporated in treatment for the selected families. This check-in specifically addresses the ICC’s role and experience in building supports while maintaining team cohesiveness and trust (Appendix FW, Page 2, Item 6). ICCs are asked these questions: How are you ensuring that the post-transition safety plan occurs in a team based, collaborative environment? What support and/or additional training do you need around this principle to improve the quality and effectiveness of services that you provide to HFW families? These check-in questions are aligned with a reflective practice in that they are open-ended, based in curiosity and nonjudgement, and designed to promote self-awareness, critical thinking, and emotional intelligence (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 138, Section 2).
(c) Our Continuous Quality Improvement (CQI) process includes the review of crisis and safety plans for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports. We have an internally-developed tool, the Quality Assurance Report (QAR), to support and standardize this process (Appendix M). This Excel document includes a HFW tab—with a review section devoted to “If in the transition phase of treatment” (Appendix M, Line 48). Specifically, reviewers are prompted to consider if the Post-Transition Safety Plan was developed to support sustainability or progress, address potential crisis once HFW team is no longer in place, and is inclusive of culture, community and natural supports (Appendix M, Line 51).
Our supervisors are required to complete 2 QARs per month (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 109). Each quarter, our QA Department also reviews a percentage of HFW charts so that at the end of the year, 5% of all HFW charts are reviewed. Client charts are selected for review based on recent incident reports, recent client crisis, first 30 days of services, staff leaving the agency, clients who will transition therapists, extended service length, and clients with high volume of services (Appendix EF: CQI Plan Behavioral Health and Wellness _ HFW, Page 15, Section 2. Fidelity Indicators).
Feedback from QAR findings are built into our individual supervision process. For example, our Supervision Guide and Note Template includes the following prompt: “If a QAR was completed, use the HFW tab to support your supervision” (Appendix DK, Page 2, under Clinical Review). We also consolidate QAR scores into a QAR Tracking Log (Appendix DZ), which is reviewed as part of our CQI Plan (Appendix EF, Bottom of Page 20 – 21). Our CQI BHW HFW Meeting Minutes and Notes Template specifically prompts us to review this data (Appendix EU, Page 3, Section 2: Review Data, Left-Hand Column, Last Check Box).
6.3 Create a Commencement and Celebrate Success
(a) We celebrate transitions out of HFW according to the family’s culture, values, and preferences. Our HFW staff receive initial and ongoing training that reinforces this practice. For example, our Wraparound Booster Training frames the transition phase as a time to celebrate successes and the conclusion of services with the client and family (Appendix BK: Wraparound Booster Training, Slide 24). This booster training also includes a review and discussion of the vignette of “Maribel” (Appendix BK – Slide 28). Attendees are provided with an “Maribel Story Answer Key” (Appendix CF, Page 3, Last Paragraph) that emphasizes the importance of celebration.
During a CFT Meeting, the team collaborates with the family to ensure that the celebration reflects their culture, values, and preferences. When planning the celebration, we revisit the Culture Discovery Document (Appendix EQ) that was completed during the CFT preparation meeting with the family. This document helps to inform the specifics of the celebration, especially in terms of food, music, and the family’s other traditions and practices (Appendix GK: HFW Policy, Page 27: Celebration, Bullet Point 1, and Page 28: Bullet Points 1 and 2). We also revisit the “Cultural Considerations” of the most recent Matrix for additional ideas (Appendix EG: CFT Matrix Guide, Page 1, Third Row to the Right). We monitor the practice of culturally aligned celebrations through our Quality Assurance Reports—specifically the review item of: “A closing celebration, rite of passage, or therapeutic acknowledgement was held that is respectful to their culture and traditions (Appendix M: HFW Tab, Line 52).
(b) Celebrations are supported by the use of flex funds. Approval of flex funds for celebrations include the same considerations as with other uses. Meaning, the flex fund:
1. Adds value to the team mission and supports the individualized care plan,
2. builds on family strengths,
3. meets identified youth and family needs,
4. are culturally relevant,
5. builds on natural support and/or community capacity,
6. represents a good deal for the investment.
7. includes a plan for sustainability.
Flex funds can be used to purchase an item (e.g. book, toy, food, etc.) that is meaningful to the family and/or reflection of the work between family and team. All members of the HFW team are able to coordinate and participate in celebrations as part of their Direct Service Expectation, thus ensuring staff are available to attend celebrations. In preparation for the celebration process, HFW staff are also allocated both time and support for the community resourcing and community partnerships, which are critical for the “warm hand-off” process (Appendix GK: HFW Policy, Page 28, Bullet Points 3-7). During the celebration, a Certificate of Completion is provided to the family (Appendix CA).
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
(a) Our Family Experience Calls (Appendix DD) provide a mechanism for families to participate in decisions regarding local HFW implementation. Each HFW supervisor makes two calls a month to two families actively receiving HFW from Children’s Institute. Each family is asked a total of 13 questions (Appendix DD, Items 14-29 found on pages 4-7). These questions were internally developed to better understand our families’ experience of and satisfaction with HFW, as well as if our service delivery is meeting fidelity and other service expectations. Because these surveys are conducted in “real time” and some questions are open ended, it allows our supervisors to ask follow-up questions, clarify statements made, and dialogue with the family about their perspective.
Question 26 specifically asks, “How could CFT meetings be improved? For example, if you could change one thing about these meetings, what would it be?” (Appendix DD: FEC, Last question on page 6). The composition and process of the Child and Family Team, and its emphasis on youth and family as key decision-makers, is essential to HFW expected outcomes. In addition, CFTs are intended to bring together professionals and agencies across the Children’s System of Care to support each family’s Plan of Care. This question helps us know, at the local level, if families are experiencing these meetings as intended. We will collect, organize, and communicate this feedback as part of our participation in the county’s Community Leadership Team – allowing families’ voices and preferences to be lifted up in our local decision making.
(b) The collection and use of family feedback is a critical component of our Behavioral Health and Wellness Continuous Quality Improvement Plan (Appendix EF). In fact, similar to how family voice and choice leads the way in the Child and Family Team meeting process, family feedback is given priority and extra consideration in our CQI process (Appendix EU: CQI BHW HFW Meeting Note Template Page 3, Section 2: Review Data).
We collect feedback from families through the following tools: our Family Experience Calls (Appendix DD) and the Youth Services Survey for Families (Appendix N: Exym – YSSF and Appendix WW: YSS). Additionally, we use feedback provided by the family when they request a change in provider (Appendix DW: Request for Change in Provider). Our CQI efforts are led by our Director of Excellence, who plays a critical role in creating a flexible and creative work environment that engages and motivates all staff in program quality and improvement. We operationalize our CQI process through a High Fidelity Wraparound subcommittee, which meets quarterly and includes participation from a diverse group of both internal and external stakeholders (Appendix EF, Page 7).
The platform for our HFW CQI process is a very structured meeting agenda (Appendix EB). The agenda includes data review, identification of noticeable trends and issues, as well as setting targets for improvement and identifying interventions. The domains of interventions include but are not limited to service planning and intervention, policy and procedure development, and workforce development (Appendix EF, Page 9). Reports specific to family feedback that are used in CQI decision-making include: Appendix DO (Family Experience Call Results); Appendix AT (Tableau BHW YSS – Youth Aggregate); Appendix CO (Tableau BHW YSS Report – YSSF Caregiver-Family Subscales); Appendix EL (Tableau BHW YSS+YSSF Subscales; Appendix EN (Request for Change of Provider Log)
Similar to the CFT process, our CQI meetings include a collective brainstorming around how to use family feedback to improve our HFW program. Our standardized meeting minutes template includes the section: Create and Implement Plan for Interventions, including Action Item; Person Responsible; Deadline; and Notes. Our Director of Excellence—in collaboration with the Director of Intensive Behavioral Health Services and Senior Vice President of Behavioral Health and Community Services—is responsible for motivating and supporting staff in completing action items, which are reviewed at the start of each quarterly meeting (Appendix EU: Section 1, page 2).
7.2 Community Leadership Team
(a) Our HFW Clinical Program Managers will actively participate in the Community Leadership Team.
While not a requirement for this certification process, we would like to highlight that we launched a bi-monthly LA County BHSA FSP Provider Collaborative in October of 2025. This collaborative is specifically designed for organizations currently providing Children’s FSP/Intensive services or interested in becoming FSP providers under BHSA. We notified the county and invited county representatives to attend at any time. The collaborative is a space to: align on state and county-level expectations; share tools, resources, and implementation strategies; raise systemwide questions and flag emerging challenges; and strengthen our collective advocacy and readiness for certification.
The first meeting was on 10/22 (Appendix CZ: BHSA Children’s HFW Provider Collaborative – 10.22.25 Agenda) and the second one was on 12/4 (Appendix DB: BHSA HFW Collaborative Meeting – 12.4.25 Agenda). The first meeting covered The Top 10 Things We Know about HFW (Appendix DA), and we had 42 participants across 18 organizations. The second meeting focused in on certification, training, and staffing (Appendix DC: High Fidelity Wraparound – Collaborative Presentation – 12.4.25), and we again had 42 participants across 17 organizations. Our January 30th meeting expanded to include not just our partner providers but also representatives from CA Behavioral Health Association, UC Davis, and ACHSA. It supported individualized questions around HFW certification and summarizing what we’ve learned so far. We had 69 participants across 34 organizations (Appendix GP: BHSA Children’s FSP Provider Collaborative 1.30.26).
7.3 Eligibility and Equal Access
(a) One of our core commitments here at CII is “to center equity, diversity, and inclusion in decision-making, governance, and day-to-day interactions” (Appendix Q: 2025 Employee Handbook, p. 4). As such, youth that meet established eligibility criteria for HFW are able to receive services and are not excluded based on the severity or nature of their needs. We operationalize this standard in the following ways:
• Upon hire, all HFW staff participate in a 4-hour training on entitled Core Curriculum of Childhood Traumatic Stress and sponsored by the National Child Traumatic Stress Network (Appendix BJ). This training highlights the role that trauma plays in children’s development, and how trauma may manifest itself through behavioral dysregulation, which can be severe. This trauma-focused lens supports us in adhering to our value of equity and treating everyone with compassion and respect (Appendix Q: 2025 Employee Handbook, p. 5). Completion of this training is verified through the use of our Intensive Behavior Health Onboarding Checklist (Appendix R, Page 3, listed under External Webinars).
• Additionally, all HFW staff attend our one-hour Crisis Assessment and Intervention Training upon hire (Appendix AJ). This training provides staff with de-escalation techniques, the stages of crisis intervention, and strategies for effective safety planning. Completion of this training is also verified through the use of our Onboarding Checklist (Appendix R, page 1).
• All HFW staff, upon hire, also complete four LAC DMH Child Welfare webinars that are trauma-informed, address high-risk behaviors, and support safety planning. They are Intergenerational Trauma: The Trauma Inheritance (42 minutes); Prevent the Eruption: Trauma Informed Es-Escalation Strategies (1.52 hours); Addressing High-Risk Behaviors (50 minutes); and Addressing Safety throughout the Child and Family Team (CFT) Process (41 minutes). Our Onboarding Checklist (Appendix R) lists each of these trainings (Pages 4-5).
• Importantly, all of our HFW leaders are Lanterman-Petris-Short (LPS) certified (Appendix CY: Intensive Staff List, Column “LPS expiration”). These certifications allow us to effectively respond when a HFW child needs inpatient care for their own safety and/or that of others.
(b) It is built into our contract with the County that we maintain appropriate case load assignments to support the intensity and frequency of HFW service delivery. Under our Statement of Work with LAC DMH, we are required to “assign Wraparound team members to each child or youth and family enrolled in the Wraparound Program at an average ratio of one full time Wraparound team not to exceed ten (10) children or youth at any one time. In situations where staff are on unplanned temporary leave, the ratio of the Wraparound team to children or youth may be adjusted for no longer than three months” (Appendix AO: DMH Wraparound SOW, Page 13, 5.4).
Additionally, CII implements average caseload expectations for each HFW role. These expectations take into account the intensive level of service we are expected to provide to our HFW families, as it is carried out across each member of the team. It is the responsibility of both the supervisors and Clinical Program Managers (CPMs) to ensure that staff have enough assigned clients to meet average caseloads, which are 10 clients for therapists; 10 clients for IHBS; 15 clients for ICCs; and 12 clients for Parent Partners (Appendix VV: IBH Supervisor Manual, p. 119). Supervisors utilize the Tableau Caseload Log (Appendix BI, Roster function) to monitor and oversee staff caseload assignments.
As per our On-Call Rotation policy (Appendix AH), CII provides 24/7 support to families in crisis—including assessing urgent clinical situations, providing crisis interventions, and facilitating immediate resource support for clients and families after business hours (Appendix AH: Policy section, Page 1). Full-time staff employed in our HFW programs are required to participate in the On-Call Rotation. Staff rotate to answer calls made to the Crisis Telephone Numbers after business hours from Tuesday at 5:01 p.m. to the following Tuesday at 8:59 a.m. (Appendix AH, Section 2.0, Page 3). Schedule is done at least 4 weeks in advance by the Administrative Assistance (Appendix AH, Section 2.3, Page 3). We have two crisis phone numbers for each Service Planning Area—one for English-speaking families and one for Spanish-speaking families (Appendix AH, Top of Page 2). The schedule ensures coverage of both lines. Staff must be reachable and able to respond to calls from the Crisis Telephone Numbers within 15 minutes (Section 1.2, Page 3). We also have one supervisor and one manager on call alongside these staff for consultation and LPS support (Section 2.0, Page 3). We also have special protocols in place to ensure timely, responsive clinical support for clients and families experiencing urgent mental health needs during the holiday periods (Appendix AG: Holiday On-Call Rotation Policy). Families are informed of this crisis support upon intake – generally by the Intensive Care Coordinator but other members of the team may also provide this information. This communication is solidified through our After-Hours Crisis Support Flyer: English and Spanish (Appendix DN).
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
(a) Each year, we continue to operate under our existing Maximum Contract Amount (MCA) with the Los Angeles County Department of Mental Health (LAC DMH) to provide Full-Service Partnership (FSP) and Wraparound services. Our budget allocates funding for essential wraparound operations and the costs of services, as evidenced by our Behavioral Health and Wellness Budget FY25-26 (Appendix CK, Column B). Our DMH Performance Report FY25-26 YTD Template (Appendix CL) indicates our contract buckets. Our funding for Wraparound is comprised of “MHSA Full Service Partnership MC (Column B16),” “MHSA Full Service Partnership Non-MC (Column B19),” and “Specialized Foster Care Wraparound Non-C (Column B11). Funding resources for flex funds are comprised of “Specialized Foster Care Wraparound Invoice” (Column B38)” and “MHSA Full Service Partnership Invoice” (Column B39). This funding structure gives us the flexibility to meet the individualized needs of youth and families without being limited to only what Medi-Cal pays for.
Funds are managed on an ongoing basis by HFW program leadership in collaboration with CII’s Finance Department. Budgets are reviewed on a monthly basis to compare forecasted amounts to actual amounts. We use our DMH Performance Report Year to Date Template (Appendix CL) to support this process. This monthly review also ensures that:
• Caseload sizes remain manageable to support high-fidelity practice. The average caseloads per each member of the HFW team is captured in our Intensive Behavioral Health Supervisor Manual (Appendix VV, Page, page 118). Caseload sizes are reviewed via the Tableau Caseload Log (Appendix BI, Roster section on left-hand side).
• Resources are sufficient to cover field-based service delivery, such as reimbursement for staff mileage, parking, and mobile technology such as cell phone usage.
• Fiscal staff ensure reimbursable activities are correctly billed, maximizing allowable utilization to support service continuity.
(b) CII’s fiscal planning process also ensures adequate resources for required HFW staffing and workforce development. Our budget incorporates costs associated with all required HFW roles. Under our current Statement of Work with LAC DMH (Appendix AO: Core Direct Service Team Staffing, Pages 11-15), we budget for the following positions, which collectively cover the 7 required roles and functions from Workforce Development standard 9.3 (Appendix BO: CII Team Member Flyer).
• Clinical Supervisors (In addition to a Clinical Supervisor role, our HFW leadership roles also include: a Program Supervisor, Senior Clinical Supervisor, and Clinical Program Manager).
• Facilitator (we call this position an Intensive Care Coordinator)
• Clinician
• Child and Family Specialist (we call this position an Intensive Home-Based Service (IHBS) Worker)
• Parent Partner
In addition to these HFW positions, we also budget for a Quality Assurance team, led by the Director of Excellence. This team supports HFW workforce development through initial and ongoing trainings, individual coaching, and ongoing auditing of service delivery to ensure fidelity to the Wraparound model. This team also oversees our data collection, use, and Continuous Quality Improvement (CQI) process—ensuring that HFW staff receive timely feedback on their performance relative to their service provision.
Staffing ratios are routinely monitored by the Director of Intensive Behavioral Health and Senior Vice President of Behavioral Health and Wellness. We review timely engagement for youth and families (Appendix BH (Tableau Intensive Patient Communication Report) to determine if staffing is adequate to meet this fidelity indicator. We also monitor that supervision and coaching capacity is sufficient by tracking open positions, filled positions, and staff to supervisor ratio/assignments. We use our Intensive Staff List Excel tracking log (Appendix CY) for this monitoring.
In alignment with our Training Plan, workforce development investments include initial, annual, booster trainings, and ongoing trainings for all HFW staff. Our plan also includes role-specific development and population-specific trainings. While there are 52 weeks in a calendar year, CII budgets and sets billing expectations for full-time staff based on a 42-week service delivery model. The remaining 10 weeks are intentionally excluded to account for paid time off, required trainings, holidays, and other non-billable activities, ensuring realistic productivity expectations and compliance with HFW workforce development standards (Appendix VV: IBH Supervisor Manual, Page 30 – Clinical Direct Service Hours).
(c) Our fiscal practices also include budgeting the tools necessary for HFW data collection and management requirements. Given that these requirements are complex and extensive, we purchase and utilize a variety of software, systems, and supports in our day-to-day operations.
• Electronic Health Record System: Exym (Appendix B: Exym Manual)
• Outcome Measurement Tools: Team Observation Measure (TOM), version 2.0 (Appendix CU: TOM Contract).
• Healthcare Learning Platform: Relias (Appendix L: Employee Home Page)
• Data Management and Analytics Software: Tableau (Appendix ZZ: Intensive Behavioral Health: Tableau Dashboards Training)
8.2 Equitable Funding Across System Partners
N/A
8.3 Cost Savings are Reinvested
N/A
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
(a) In accordance with the County of Los Angeles Department of Mental Health (DMH) Child Welfare Division-Wraparound Program Policies and Procedures (Appendix AN, Pages 52-57), flex funds are available and reimbursable. Flex funding, referred to as Case Rate Services and Supports (CRSS) in our Statement of Work with DMH, are “any services or commodities that cannot be obtained or reimbursed through the child, youth, and/or family’s financial resources, community resources, and/or funding resources, including medical insurance” (Appendix AO; Case Rate Services (CRSS) Requirements, Pages 5-7). As per the county’s policies and procedures, “CRSS funds are allocated to each Contractor’s Agreement as an aggregate pool of funds based on the number of children or youths and families served and the approved County monthly dollar rate per child or youth (i.e. Case Rate)” (Appendix AN, p. 52).
(b1) Upon hire at Children’s Institute, all HFW leaders are trained in policies and procedures to access and manage flexible funds (Appendix T: Case Rate for Wraparound Power Point). This training covers the inclusion of flex funds for Indian child cases, as flex funds may be used to pay the Tribe for activities that address youth and family needs (Appendix T, Slide 8, Bullet Point 3). The process for timely access for families that meet urgent needs (Appendix T, Slides 10-18). This process begins with a discussion and agreement by all members of the Child and Family Team (CFT) of the need for flex funds. This decision is documented in the CFT meeting notes. The designated member of the CFT then completes the CRRS Supplement Information Form (Appendix DR: CRSS Supplemental Information Form) and forwards it to the CII supervisor for review.
(b2) The supervisor follows a defined approval process to approve or decline the case rate request. This decision is based on consideration of Maslow’s Hierarchy of Needs (Appendix T, Slide 4) as well as whether the funds meet the seven factors outlined in this standard (Appendix T, Slide 10). Per slide 17, Supervisor will review the forms with 24 hours of receipt and either approve or decline the request (Appendix T). If the Supervisor approves the Case Rate request, the team member will proceed with purchasing the item or service for the family within 7 calendar days. CII then submits the required documentation to the County to obtain reimbursement through their Wraparound Tracking System (WTS). Additional requirements are found on page 7 of our Statement of Work with DMH (Appendix AO: 2.4.5).
(b3) If the Supervisor denies the Case Rate Request, the Supervisor will schedule a treatment planning meeting with the four direct service staff of the HFW team to discuss the decline in detail, gather more information from the treatment team about the need and request, and decide whether to maintain the denial or change the decision to approval. If the Supervisor maintains the declination, Supervisor will provide an explanation for the declination and help the treatment team explore alternate strategies to support the client and family’s need. Treatment team will schedule a CFTM with the family to discuss the Case Rate declination and the alternate strategies that were identified to respond to the client and family’s need. If the family is not satisfied with the proposed alternate strategies, they are asked if they would like to appeal the Case Rate denial. If an appeal is requested, the Case Rate request is then reviewed by the Manager (or by their supervisor of the first reviewer) who provides a final decision on the request (Appendix T: Case Rate for Wraparound Power Point, Slide 18).
8.5 Collaborative Oversight of Flex Funds
(a) The Department of Mental Health in Los Angeles County allocates flex funds to CII on a fiscal year cycle. We then break down this amount across our Service Planning Areas (SPAs) to ensure equitable access across each SPA. Each fiscal year, our HFW leaders track and oversee the Monthly Goal for Flex Fund Usage per SPA (Appendix VV: Supervisor Manual, Page 45), with the intention of full utilization of these funds by the end of each fiscal year. To support this process, CII leaders are trained in using the Tableau system to generate and analyze a variety of reports related to flex funds (Appendix ZZ: Intensive Tableau Reports Power Point, Slides 73-91). For example, Slide 77 shows a report of spending across staff, clients, date, and category—as well as expenditures to date by SPA. The HFW Director and Clinical Program Managers are responsible for ensuring that Case Rate is distributed equitably to families.
The HFW team’s recommendation for flex funds is documented in the youth’s health record, as well as the CFT matrix (Appendix T: Case Rate for Wraparound Power Point, Slides 12-13). Our start-to-finish documentation guidelines are outlined in this Case Rate training and summarized on Slides 35. Once the CRRS Supplement Information Form is completed, spending is documented in the Wraparound Tracking System (WTS): Flex Fund Progress Note in the youth’s electronic health record. The designated staff selects the progress note that indicates the type/purpose of expenditure that was made (Appendix T, Slide 48). Within the progress note, staff document the date of purchase, expenditure type, expenditure amount, item(s)/service(s) purchased, and description of how the item(s)/service(s) support the client’s treatment goals (Appendix T, Slide 49). Staff then upload a copy of the receipt into the progress note and the CRRS is emailed to the Administrative Assistant (Appendix T, Slide 49).
As per our Statement of Work with DMH (Appendix AO), we claim CRSS in the DMH WTS system (Page 7, Bullet 2.4.5). This process is how we transparently communicate with DMH about our flex fund use and obtain reimbursement on funds spent. Our Administrative Assistant inputs flex fund expenditures in the WTS, and emails DMH with copies of the CRSS and receipts of spending (Appendix T, Slides 53-54). DMH then reviews all supporting documentation and makes a final decision as to “whether an expenditure is allowable and approved” (Appendix AN Los Angeles County Wraparound Policies and Procedures, Page 55, Second to last paragraph).
(b) Per the County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures (Appendix AN), any child or youth and family currently enrolled in Wraparound are eligible for flex funds. The policy notes, “CRSS funds are allocated to each Contractor’s Agreement as an aggregate pool of funds based on the number of children or youths and families served and the approved County monthly dollar rate per child or youth. Although funds are aggregated, expenditures shall be child or youth and family specific, and are not an entitlement” (Page 52). In accordance with this policy, we do not “reserve” or budget in advance flex funds amounts for specific families and/or purposes. We also do not place any restrictions on how much is utilized per child (Appendix T: Case Rate for Wraparound Power Point, Slide 15). Instead, our use of flex funds is driven by the unique needs and strengths of each family being actively served in our HFW program – as well as through the collaborative CFT meeting process. All requests are evaluated on an individual family basis, using the seven factors noted in Standard 8.4.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
(a) As per the Los Angeles County Wraparound Policies and Procedures (Appendix AN), we as a contractor are allocated “a specified amount of funding for Wraparound [flex funds] invoices” As a contractor, we must ensure that this funding is not exceeded (Page 56). As per our Statement of Work, this funding is separate from outpatient and outreach services that are claimed/reimbursed under Medi-Cal as a Specialty Mental Health Services (Appendix AO, 2.1, p. 2).
(b) In the many years (more than a decade) that we’ve provided Wraparound, our annual allocation of flex funds from DMH has generally been sufficient to meet the needs of our families. If flex funds run low or are fully utilized, we then explore alternative funding options. For example, clients and families who are unhoused and have Medi-Cal through one of six Los Angeles Managed Care Plans are eligible to receive Community Supports. These supports can help families with applying for and securing housing, including deposits to cover move-in costs (Appendix BT: Flex Fund Training, Slide 8). Additional ways to access flex funds—including the enlistment of our Volunteer & Community Engagement Department—are showcased in our Flex Fund Training (Appendix BT, Slide 4). We also team with the other formal System of Care supports—such as Department of Children and Family Services (DCFS)—to see if they have funding available to support the family.
(c) As noted in 8.6(a), we receive an annual allotment of flex funds from the Department of Mental Health. This pool of money is distinct from the requirements of other funding sources. In fact, our case rate is allocated exclusively to “support the child or youth and family’s care, service plan, and/or recovery goals as per the CFT matrix” (Appendix AO: DMH Wraparound SOW, 2.4.2. Page 6). The funds are flexible in use and designed to meet a broad range of needs—including housing subsidies, operational housing supports, and items necessary for daily living, travel, housing/moving expenses, transportation, respite care for caregivers, and family support services. Prohibited uses of the case rates are very limited—for example, illegal substances/activities, tobacco; and alcohol (Appendix AO: DMH Wraparound SOW, 2.4.4, Page 6).
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
“At CII we take pride in our constant commitment to workplace diversity and inclusivity. We foster an environment that respects and celebrates the inspiring cultures and diversity of our staff and communities we serve” (Appendix Q, Employee Handbook, Page 12, First paragraph).
(a) We monitor the demographic composition of the HFW population we serve through our Tableau Intensive Slot Report (Appendix EJ: Tableau BHW Intensive Slot Utilization Summary Statistics Report – Demographic Aggregate data). This report captures and consolidates the demographic information we collect through our Electronic Health Record System on these 4 data points: Race/Ethnicity; Gender; Primary Language; and Zip Code. We also monitor the demographic composition of our HFW staff to evaluate if it is reflective of the families we serve. This monitoring is done through our CII Staff Demographics tracker (Appendix BS). There is a separate Excel tab for Intensive Behavioral Staff counts by gender, language, and race/ethnicity. When we have open positions in our HFW program, our HFW leaders use these reports to identify any staffing gaps and then recruit and hire according to population needs (Appendix VV: Intensive Behavioral Health Supervisor Manual, Culturally Responsive Workforce Section, Page 66). As an example, our Statement of Work with LAC DMH (Appendix AO) requires that we “ensure there are sufficient number of bilingual staff to meet the language needs of the communities to be served (Page 15, Section 5.6.3). Currently, 11.37 percent of HFW families we serve identify Spanish as their primary language (Appendix EJ: Tableau BHW Intensive Slot Utilization Summary Statistics Report – Demographic Aggregate data). As such, all of our HFW job descriptions include “Spanish/ English bilingual preferred” as an “other qualification” (for example, Appendix U: Intensive Care Coordinator Job Description, Page 2, Other Qualifications, Bullet Point 4).
(b) When CII is unable to recruit/hire staff who reflect a family’s specific cultural, racial, and/or linguistic background, a structured set of procedures ensure that families receive cultural representation through alternative means. These procedures begin at the point of intake, when the therapist identifies any cultural and/or linguistic needs using the IP-CANS (Appendix F: Cultural Factors Module, p. 28) and the Same Day Services Assessment (SDA) (Appendix C). The SDA supports this process through its question “Was assessment conducted in language other than English?” and its “SPECIAL SERVICE NEEDS: Cultural Considerations” section (Appendix C, Top of Page 1). When a gap between the family’s cultural and/or language needs and the collective background of the HFW team is identified, the Supervisor and Clinical Program Manager (CPM) collaborate with the family to determine the most appropriate method of ensuring cultural representation (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 60).
This process includes engaging the family’s natural supports, such as extended family members, faith-based mentors, or other community connections, who can participate in Child and Family Team Meetings (CFTMs), assist with interpretation when appropriate, or help contextualize cultural practices, values, and decision-making preferences. Natural supports are identified with the family’s permission and invited into the HFW process in the manner preferred by the family (Appendix CD: Child and Family Team Meeting Training, Slides 5-6). The HFW team also engages formal supports who have cultural insight relevant to the family. Supervisors may also coordinate involvement from school cultural liaisons, faith-based leaders, community-based organizations, and/or culturally aligned service providers who have established relationships with the family. These formal supports remain active members of the CFTMs as long as the family finds their involvement helpful (Appendix CD: Child and Family Team Meeting Training, Slide 7).
(c) We follow Los Angeles County Department of Mental Health’s (DMH) Policy 200.03, which states that “language interpreter and translation services, interpretation and sign language services are available free of charge to clients and family members” (Appendix AI: LAC DMH Language Access Plan, Page 5, Section D., Paragraph 2, Sentence 2). When unable to provide services in the family’s language, the HFW supervisor immediately arranges interpretation services. For Interpreter Services for the Deaf and Hard of Hearing Community, we utilize the Language Assistance Services (LAS) Unit housed in the County’s Anti-Racism, Inclusion, Solidarity, and Empowerment (ARISE) Division. We specifically follow the access protocols in LAC DMH Cultural Competency Policies and Procedures (Appendix DP, Page 1, P & P 200.03). For Language Translation and Interpreter Services, we have a contract with WorldWide Interpreters for on-demand interpretation (Appendix I: WorldWide Interpreters Business Associate Agreement). In addition, we track and account for “preferred language used in this encounter” in all of our progress notes (Appendix EP: EXYM note template with preferred language). We also report our use of translators in a quarterly report to DMH (Appendix EQ: LE Language Access Tracker for Paid Interpretation Services).
9.2 Tribally Responsive Workforce
(a) CII is not currently serving any Indian children in our HFW program, and it is rare that we receive this type of referral. That being said, our HFW Training Plan (Appendix DT, Page 5) recognizes the value of a tribally responsive workforce, and our goal is to ensure that our staff are prepared in the event of such a referral. For example, our CII Supervisors and Managers provide a one-hour internal training, ICWA & Tribal Engagement, that all HFW staff receive within 30 days of hire (Appendix BU). The training content includes but is not limited to: the purpose of and provisions of ICWA, including tribal sovereignty (Slides 2-17); teaming with tribes, as partners (Slides 18-28); and resources for working with this population (Slide 29). The HFW staff’s direct supervisor uses our Intensive Behavioral Health Onboarding Checklist (Appendix R, Page 1, Clinical Trainings, Check Box 7) to ensure training completion.
Additionally, upon hire, all HFW staff are registered for the next available UC Davis Resource Center for Family-Focused Practices (RCFFP) training: Indian Child Welfare Act (ICWA) Overview & Tribal Engagement in Teaming Best Practices. We track registration through our Onboarding Checklist (Appendix R, Page 3, UC Davis RCFFP, Checkbox 2) and attendance via Tracking Attendance for ICWA Training Tableau Training Time report (Appendix BP).
(b) We acknowledge that teaming is an indigenous-based practice model and that interdependence is at the core of Native American history and values (Appendix BU: ICWA & Tribal Engagement Training, Slide 19). Starting at the point of intake, the Intensive Care Coordinator leads the HFW team in building respectful and engaging partnerships with the child’s Tribal representative or Tribal affiliation. The ICC extends formal invitations to Tribal representatives to join Child and Family Team meetings, and the HFW supervisor leads the team in implementing teaming best practices, as outlined in our internal training (Appendix BU: Slides 20-28). These practices address culture-specific ways of identifying team members, preparing for CFT meetings, structuring the meetings, and ongoing engagement strategies. Additionally, the team enlists the resources noted in the training (Appendix BU, Slide 29) as needed and on a case-by-case basis to engage tribal representatives.
HFW supervisors review cases involving Indian children to ensure adherence to ICWA requirements, Tribal engagement expectations, and culturally responsive service delivery. This oversight is facilitated by their Supervisor Guide and Note Template (Appendix DK, Page 3). This guide includes a Clinical Review section that prompts the supervisor to “Consider if the following Wraparound Principles are being
incorporated in treatment” across 1-3 families per supervision (Appendix DK, Page 2). Question 6 asks: “Are referrals, natural supports, and interventions relevant to and respectful of the youth and family’s culture?” (Appendix DK, Page 3).
9.3 Flexible and Creative Work Environment
At CII, we are committed to “empowering our team members to collaborate, create and innovate, and to develop leaders at every level” (Appendix Q: 2025 Employee Handbook, Page 5, Bullet Point 2). One of our core values is innovation, as we “seek inventive solutions grounded in best practices and rigorous analysis. We are committed to excellence, impact, and sustainability in all we do” (Appendix Q: 2025 Employee Handbook, Page 5, Section Our Values: Innovation). Our leadership has specific processes or initiatives to engage all staff in the following areas:
(a) In demonstration of our commitment to Program Quality and Improvement, we created the position of Director of Excellence in December of 2024 (Appendix DQ: Director of Excellence Job Description). This role “leads quality assurance and operational excellence across CII’s program portfolio” and “ensures that clinical and child welfare services operate at the highest standards by promoting best practices and driving continuous improvement” (Appendix DQ, Page 1, Summary). This role facilitates a program quality and improvement culture that includes the following elements: “the courage to try and learn from mistakes; humility to acknowledge areas of improvement; a culture of safety via a trauma informed lens; openness to give and receive feedback; integration of quality data; a persistent desire for excellence; and celebrations of successes” (Appendix EF: CQI Plan Behavioral Health and Wellness _ HFW, Page 4, Our Mission for CQI, Paragraph 2). A critical component of creating this culture is trainings, which intentionally shift language away from “complying with requirements” to how these requirements can help CII fulfill its “North Star” – i.e. mission. As an example, see our Outcome Measure Application (OMH) training (Appendix LL, Slides 3-6).
In addition, the Director of Excellence, along with our Quality Assurance Team, facilitates monthly Quality Assurance Meetings that are 90 minutes in duration. These meetings are incorporated into our overarching HFW Training Plan (Appendix DT, Page 8, Table 9.3a). Please see Appendix DH (CII BHW Leadership Quality Assurance October Meeting Minutes) for an example of the content of these meetings. All HFW Supervisors and Managers participate in these meetings. The Director of Intensive Behavioral Health attends each meeting and ensures all leaders are present. Director follows-up individually with any supervisors and managers to ensure they understand and implement the information that was discussed.
(b) One of our four core values is Partnership. Meaning, “We have the greatest impact when we collaborate with families, community partners and colleagues who are dedicated to the success of the young people we serve” (Appendix Q: 2025 Employee Handbook, Page 5, Our Values: Partnership). Part of this value is to “promote a spirit of teamwork” (Appendix Q, Page 14, Open Door, Sentence 2) across our entire organization. As part of our HFW Training Plan (Appendix DT, Page 9, Table 9.3b), all of HFW Supervisors and Managers receive annual training in Barry Posner and Jim Kouzes’ 5 Practices of Exemplary Leadership (Appendix DE). This one-hour training is facilitated by the CII Director or Managers and tracked using our HFW Leadership Training Tracking Log (Appendix DF). A key component of this leadership approach is that leaders foster collaboration and build a spirted team through an “Encourage the Heart” approach (Appendix DE, Slide 17).
We also create cohesion at the agency-wide level, with, for example, our monthly Townhall Meetings (Appendix BQ: October 2025 Town Hall Presentation). These meetings are 75 minutes, conducted via Zoom, and typically facilitated by Executive Leadership. All CII staff are invited for this meeting, and attendees range in the hundreds. Additionally, a recap email is sent (Appendix AP: October 2025 Town Hall Email Recap) to ensure all staff receive the presented information. Of particular relevance to the principle of cohesion is the Staff Acknowledgement segment, which provides ample space and time for employees to recognize the work of others (Appendix BQ, Slides 13-35).
(c) As per its 2025 Employee Handbook (Appendix Q, Pages 14-15), we have a formal Open Door policy. As per this policy, “CII encourages open communications between employees and management so that all parties understand and respect the other’s perspective (Page 14, Open Door, Paragraph 2, Sentence 1). Employees with questions and concerns are encouraged to speak to their supervisor. However, employees who are uncomfortable doing so may talk to their division head, or HR. Staff may also use STOPit (Appendix UU), an anonymous reporting tool, to raise issues related to workplace culture, safety, ethics, or conduct (Appendix Q, Page 15, Top). Our open door policy is backed up by a No Retaliation Policy as “CII strictly prohibits retaliation, coercion, or intimidation against any person who has, in good faith,” communicated concerns (Appendix Q, Page 20, No Retaliation).
HFW Supervisors engage in ongoing two-way communication with staff through weekly individual supervision, weekly group supervision, and routine check-ins (Appendix VV: Intensive Behavioral Health Supervisor Manual, Supervision of Direct Service Staff, Pages 136-142)—creating reliable spaces for discussing cases, workload, training needs, and staff well-being. Our supervision of direct service staff begins with the establishment of a positive relationship. At CII, we recognize that “supervisors have to take intentional steps to build rapport, incorporate strength-based feedback, and create safe spaces for open communication” (Appendix VV, Bottom of Page 137-138). Additionally, all HFW Supervisors and Managers annually participate in a one-hour training on the Insights Discovery Color Energy model (Appendix DG: Insights Discovery Color Energy Training). This training includes a self-assessment and a four color model (Appendix VV, Slides 8-11) to help our leaders understand their style, their strengths and the value they bring to the team. The training includes a discussion around how our leaders can adapt their “color energy” to improve their communication with others (Appendix VV, Slide 13). Managers update and utilize HFW Training Tracking Log (Appendix DF) to track supervisors’ completion of this training.
(d) At CII, creating a clear sense of mission and compliance with the HFW model begins immediately upon hire. HFW supervisory and direct service staff receive extensive training in the principles, values, phases, and activities of HFW. In addition to the required UC Davis Wraparound 101: Foundations of Fidelity training, staff also participate in an internal one-hour training on Child Family Team Meetings (Appendix CD). This training includes an overview of the Wrap principles – summarized in a table (Slide 9) that staff can use as a valuable reference. Staff also attend three trainings provided by the Los Angeles County Department of Mental Health: Wraparound 101; Wraparound: Roles Definition and Teaming; and California Standards (Appendix R: Intensive Behavior Health Onboarding Checklist, Pages 3-4). Upon hire, staff also receive our Employee Handbook, so they connect the HFW model with the agency’s overarching Mission and North Start (Appendix Q, CEO Welcome Message, Page 2). HFW fidelity is reinforced annually through our Wraparound Annual Training (Appendix BK).
In terms of day-to-day practice, collective responsibility for the HFW philosophy is embedded into our one-hour weekly individual supervisions, which are facilitated by our HFW Managers and Supervisors. Our leaders “incorporate the principles of High-Fidelity Wraparound into supervision by modeling and embodying these principles and helping their supervisees conceptualize and deliver services grounded in these principles” (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 137, Supervision of Direct Service Staff, Sentence 4). This practice is supported by a structured Supervision Guide and Note Template (Appendix DK), which includes a “Clinical Review” section (Pages 2-3). This section prompts the supervisor to pick 1-3 clients to check in on and consider if the ten Wraparound Principles are being incorporated in treatment. This infusion of HFW into actual practice with families is tracked and monitored via supervision notes.
9.4 Hiring, Performance Evaluation, and Job Descriptions
(a) We incorporate the 7 roles or functions of the HFW team into our staffing profile. In compliance with our current DMH Wraparound Statement of Work (Appendix AO), we are required to meet the following staffing requirements: Executive Director and Program Manager (Page 10, 5.2 and 5.3); Clinical Supervisor (Page 11, 5.4.2); Facilitator (Page 12, 5.4.3); Clinician (Page 13, 5.4.4); Child and Family Specialist (Page 13, 5.4.5); and Parent Partner (Page 14, 5.4.6). We refer to our Facilitators with the job title of Intensive Care Coordinators (ICCs), and our Child and Family Specialists with the job title of Intensive Home-Based Services (IBHS) Workers. In order to maintain compliance with our current Wraparound contract and additionally meet HFW certification standards, we have updated and enhanced the job descriptions for each position to incorporate all 7 roles or functions, as outlined here:
1. Youth Partner (IHBS Worker) (Appendix X: Job Description)
2. Parent Partner (Appendix V: Job Description)
3. HFW Facilitator (ICC) (Appendix U: Job Description)
4. Family Specialist (Therapist) (Appendix W: Job Description)
5. Fidelity Coach (Clinical Supervisor, Program Supervisor, and Senior Clinical Supervisor) (Appendices Z, Y, and AA, respectively: Job Descriptions)
6. Clinical Supervisor (licensed) (Senior Clinical Supervisor) (Appendix AA)
7. HFW Supervisor/Manager (license not required) (Clinical Program Manager) (Appendix BB)
These roles are captured in a family-friendly way using our CII Team Member Flyer (Appendix BO).
(b) Our job description templates at CII are broken down into the following sections: a Summary of Duties (role purpose); Essential Duties (functions); Education and Experience and Other Qualifications (qualities including skills, competencies, and attributes). We embed staffing standards from the Wraparound Standards Toolkit into each of our HFW job descriptions. As an example, our Parent Partner job description includes the following role purpose: “Serves as a peer mentor and advocate to caregivers of children, supports caregivers in advocating for their needs, navigating child-serving systems, building trust and engagement, reducing stigma about mental health, promoting stabilization, strengthening family relationships, and offering hope grounded in lived experience” (Appendix V: Parent Partner Job Description, Page 1, Duties: Summary).
Parent Partner role functions, consistent with Wraparound Standards, include
• Uses lived experience to establish rapport, normalize family experiences, and increase caregiver engagement in behavioral health, educational, and social service systems (Appendix V: Page 1, Essential Duties, Bullet Point 3).
• Supports families in navigating and advocating within child-serving systems such as child-welfare, juvenile justice, Regional Center, and school-based support (Bullet Point 4).
• Participates in Child and Family Team Meetings (CFTMs), modeling effective communication and supporting system navigations (Bullet Point 7).
Parent Partner qualities, consistent with Wraparound Standards, include:
• Lived experience caregiving within child serving systems such as mental health, child welfare, juvenile justice, Regional Center, or IEP required (Appendix V: Page 2: Education and Experience, Bullet Point 2).
• Sensitivity to service population’s cultural and socioeconomic characteristics (Page 2: Other Qualifications, Bullet Point 6).
• Flexible and resilient, adapting plans based on client and family needs (Page 2: Other Qualifications, Bullet Point 10).
HFW Parent Partner skills, competencies, and attributes, consistent with Wraparound standards, include:
• Using independent judgement and discretion during home visits to determine family strengths and needs, providing psychoeducation and support in accessing community resources (Appendix V: Page 1, Essential Duties, Bullet Point 2).
• Participates in Child and Family Team Meetings (CFTMs), modeling effective communication and supporting system navigations (Page 1, Essential Duties, Bullet Point 7).
• Demonstrates Alignment with High-Fidelity Wraparound Principles (Page 2, Other Qualifications, Bullet Point 7).
(c) Our job descriptions for our HFW positions are specific to HFW and reflect the attitudes, skills, knowledge, and experience most likely to identify individuals who will be successful in the position. For example, all job descriptions list available to assist with “resolving crisis after business hours” as an essential duty (Appendix X: IHBS Worker Job Description, Page 2, Bullet Point 1). Other qualifications across all roles include:
• Service clients in the community of Los Angeles County (Appendix X: Page 2, Other Qualifications, Bullet Point 2).
• Alignment with High-Fidelity Wraparound principles (Appendix X: Page 2, Other Qualifications, Bullet Point 7).
• Flexible and resilient, adapting plans based on client and family needs (Appendix X: Page 2, Other Qualifications, Bullet Point 10).
• Excellent verbal and written communication skills (Appendix X: Page 2, Other Qualifications, Bullet Point 8).
Essential duties for all roles highlight the importance of a strengths-based approach and relationship-building. For example, IHBS Workers “always utilizes a strengths-based and youth-guided approach” (Appendix X, Page 1, Essential Duties, Bullet Point 2). These Workers also “demonstrate strong youth engagement and the ability to build trusting, developmentally appropriate relationships” (Appendix X, Page 1, Essential Duties, Bullet Point 2).
(d) Our philosophy is that job interviews are a crucial part of the hiring process. Along with getting to know each candidate as a person, supervisors and Clinical Program Managers (CPMs) use interviews to learn more about the applicant’s background and skills and whether they will be a good fit for Intensive Behavioral Health. As such, we have an entire section in our Intensive Behavioral Health Supervisor Manual dedicated to Interviewing Questions and Hiring (Appendix VV: Pages 62-68). This section includes the Structure of Interviews (Page 62), General Questions (Pages 62-63), and specific questions in the following domains: Teamwork (Page 63), Legal and Ethical (Page 63), Crisis Intervention (Pages 63-64), Trauma-Responsive & Relationship Building (Page 64), Professionalism and Boundaries (Page 65), and Lived Experience (Page 65). These questions provide opportunities that allow candidates to demonstrate specific attitudes and skills essential to the position. For example, how the candidate establishes good relationships with teams (Page 63, Question 12), builds trust with a young person who may be resistant to opening up (Page 64, Question 19), responds to self-harm behavior (Page 64, Question 23), and balances sharing their own lived experience with keeping the focus on the youth who is being mentored (Page 65, Question 31). After each interview, Supervisors and CPMs write up interview notes in our Work Day system. They also use our High-Fidelity Hiring Expectations (Appendix VV: Intensive Behavioral Health Supervisor Manual, Pages 66-67) to reflect on the candidate’s fit for the specific role they are applying for. Based on this reflection and the candidate’s responses to the interview questions, leaders then communicate with our HR department as to whether they want to offer the position to the applicant (Page 62, Step 4, Bullet Point 3).
(e) Upon hire, all staff receive and must acknowledge the policies and practices outlined in our Employee Handbook (Appendix Q). This Handbook describes general indicators of Professional Conduct (Pages 45-46)—including but not limited to: respectful, courteous, and collaborative interactions with others; responsiveness to mentoring and direction from supervisors; and maintaining professional relationships with clients
and their families—including being strictly forbidden from developing personal
and close friendships or relationships with clients or client families.
Employees are also provided with clear expectations for their performance in our HFW program, as well as guidelines for their specific role. For example, Supervisors utilize “Team Roles and Responsibilities” (Appendix VV: Intensive Behavioral Health Supervisor Manual) in their direct supervision of HFW staff. This process ensures that each employee understands their unique role in HFW the team at large (Pages 144 – 147), while also being clear about role-specific performance expectations, feedback and coaching for each member of the team (Pages 144 – 147). Supervisors ensure that each staff understands, for example, their caseload expectations, turn-around time for documentation, Direct Service Expectations, as well as their overall role with families, including their specific role in Child and Family Team Meetings.
As per its Employee Handbook (Appendix Q), we conduct ongoing “performance evaluations, including professional development plans, to provide both supervisors and employees with the opportunity to discuss job tasks, identify and correct weaknesses, encourage, and recognize strengths, and discuss positive, purposeful approaches for meeting identified goals “ (Page 51, Performance Reviews). CII conducts formal Performance Evaluations every 6 months (typically in April and October) and Performance Check-Ins every 6 months (typically in January and August) (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 93).
Performance Evaluations assess staff across the following Performance Review Competencies (Appendix SS): 1. Teamwork and Service Excellence (all staff); 2. Time Management and Productivity (all staff); 3. Work Quality and Accountability (all staff); 4. Knowledge, Skills, and Development (all staff); 5. Workplace Culture (all staff); 6. Wage and Hour (all staff); 7. Strategic Thinking and Impact (Supervisors and CPMs only); 8. Leadership (Supervisors and CPMs only). Supervisors utilize a Proficiency Rating (Ineffective, Developing, Effective, or Highly Effective) across each area of competency (Appendix RR: Completing a Performance Review, Page 2, Section 5). Supervisors and Clinical Program Managers evaluate staff performance by highlighting strengths, successes, and achievements and identifying areas for growth. Supervisors engage staff in reflective discussion on how the supervisor can provide ongoing coaching, training, and direct field support to further the staff’s professional growth. The technical steps for completing this process in our Workday System are found in Appendix RR (Completing a Performance Review).
As for Performance Check-Ins, staff and supervisors collaboratively identify professional development goals and discuss strategies, support, and resources the supervisor can provide to help the staff achieve those goals (Appendix TT). Check-Ins function as a complement to formal evaluations and reinforce ongoing supervision, growth planning, and alignment with HFW practice expectations. The technical steps for completing this process in our Workday System are found in the Intensive Behavioral Health Supervisor Manual (Appendix VV, Pages 93-100).
9.5 Workforce Stability
(a) Our Employee Handbook (Appendix Q) includes our compensation policies and practices. As per our Handbook, “When determining salary ranges, CII’s objective, within budget constraints, is to provide employees with pay that: Is comparable with salaries for similar positions in the nonprofit/human services field (adjusting for LA County or California); Is equitable in relation to salaries for positions with comparable scope and responsibility within CII; Provides salary recognition in relation to performance; and Attracts and retains quality employees necessary to achieve the
Mission. CII reviews compensation on a regular basis and adjusts salary ranges
periodically as permitted by the budget. Additionally, we comply with California’s pay transparency and pay scale disclosure law. We support pay transparency as a way to drive equitable compensation across industries in the market as well as a tool for employees to make informed decisions about their career” (Page 43, Compensation).
(b) We establish and monitor caseload standards to ensure that they result in manageable workloads for staff, prevent burnout, and ensure effective service delivery. For example, caseload expectations are aligned with the intensity of HFW services, the complex needs of the youth and families we serve, and the role of each HFW team member. Standard HFW caseload expectations include: 10 families for therapists; 15 families for Intensive Care Coordinators; 10 families for Intensive Home- Based Services (IHBS) workers; and 12-15 families for Parent Partners (Appendix AQ: Professional Development Training, Slide 24). All HFW supervisors attend a Professional Development Training (Appendix AQ) upon hire, which includes how we keep workloads manageable for staff. Strategies include, for example, allowing a “ramp up” period for new hires to meet their Direct Service Expectations (DSE) (Appendix AQ, Slide 21), which are adjusted for specific roles (Slide 22). Supervisors provide a variety of “tips” for staff in achieving their DSE – including documenting all work related to clients (Slide 23). We ensure completion of this training through our Onboarding Checklist (Appendix R, Page 1, Program Overview: Orientations Section).
HFW direct service staff receive a BHW Tableau Reports training (Appendix DY). The purpose of this training is to empower our staff with data to problem-solve gaps and provide opportunities in care. The training includes how to access and utilize reports on their DSE (Slides 31 and 32). Additionally, our Supervision Guide and Note Template (Appendix DK) ensures routine check-in and support around DSE during weekly supervision (Page 3-4, Administrative Check-In).
(c) We have an “Internal Mobility” policy that clearly communicates our promotion/advancement structures (Appendix Q: Employee Handbook, Page 27). Employees may be eligible for transfer or promotion if they: Have worked in their current position at CII for more than 6 months; Have not received a Performance Improvement Plan (PIP) and/or performance counseling within the past year; Comply with agency requirements including but not limited to: Immunization and Tuberculosis screening protocols; Mandatory training; and Accurate and timely timesheet submission (Appendix Q, Page 27, Internal Mobility). Open positions and job descriptions are easily accessible to all employees and are posted on our website, as well as our internal job board (Appendix Q, Pages 27–28).
We also ensure that promotion/advancement structures are not prohibitive for those with lived experience. In our Employee Handbook, we make a point of explicitly stating that as an organization, we “value lived experience” (Appendix Q, Page 4, Our Commitments, Bullet Point 3). We take pride in our constant commitment to workplace diversity and inclusivity, and we foster an environment that respects and celebrates the inspiring cultures and diversity of our staff and communities we serve (Appendix Q, Page 12, Equal Employment Opportunities, Sentence 2). For example, our Parent Partners and Intensive Home-Based Services (IHBS) Workers (i.e. Youth Partners) may advance to the role of Intensive Care Coordination (ICC) if they have a bachelor’s degree or a minimum of three years’ experience working with high-risk youth (Appendix U: ICC Job Description, Education & Experience section, Page 2). In terms of lived experience within child serving systems, our job description for Parent Partners allows that individuals are eligible for hire one year after their case is closed (Appendix V: Parent Partner Job Description, Education & Experience section, Page 2, Bullet point 2).
In compliance with federal and state Equal Employment Opportunity laws, we also prohibit discrimination in the workplace based on an employee’s “protected characteristics” (Appendix Q: 2025 Employee Handbook, Page 45, Standards of Conduct). This anti-discrimination policy extends to all aspects of our employment practices, including awarding promotions (Appendix Q: Page 12, Last Paragraph of Equal Employment Opportunities Section).
(d) We strongly encourage staff to develop their skills through continuing education opportunities that are closely tied to the professional development plans they make with their supervisor. As such, we offer learning and leadership opportunities through our Education Reimbursement Policy (Appendix Q: 2025 Employee Handbook, Pages 43-44). For example, we host many training sessions that staff can participate in which also offer continuing education credit. Additionally, we reimburse tuition costs for job-advancing college courses for regular full-time employees at a rate of up to $1,500 per school session, up to a maximum of $4,500 per calendar year. Our eligibility criteria for this type of reimbursement is found in our Employee Handbook (Appendix Q, Page 44, Second Paragraph).
Additionally, whenever possible and subject to budget approval, we offer Cost of Living Adjustments (COLA) to full-time employees who have been with us for at least one year. For example, effective January 1 of 2026, eligible staff received a 2.5 percent increase (Appendix FR: COLA Increase).
9.6 High Fidelity Training Plan
(b) We recognize the critical value of training staff in the High Fidelity Wraparound model. Our comprehensive HFW Training Plan (Appendix DT) not only lays the foundation for model fidelity and positive outcomes for families, but it also supports the ongoing professional growth and wellbeing of our HFW workforce. We developed this Training Plan to correspond with this certification standard, as well as the 9.7 Community-based Training Program and 9.8 Coaching and Supervision standards. This Plan is broken down into the following sections: A. Initial HFW Training (all staff); B. Trainings for Populations with Specific and Unique Needs; C. Initial HFW Training (leaders); D. Ongoing Leadership Trainings and Initiatives; E. Ongoing Training, Supervision, and Coaching (all staff); F. Facilitator-Specific Training; and G. Community-Based Training (Appendix DT, Page 2, Table of Contents). Our description of practice for each specific training standard is broken down into the following elements: Method; Facilitator; Role(s); Frequency and Duration; Evidence; and Monitoring. Our Plan includes a grid with the definitions of each component (Appendix DT, Page 3).
(c) On an annual basis, all direct service staff attend the one-hour Wraparound Booster Training (Appendix BK). The Booster is facilitated by CII Supervisors and Managers, and all staff are trained at the same time annually for the booster training between July-September of each year. The training covers the following topics: the ten Wraparound principles; the four phases of Wraparound; discussion of strengths and underlying needs; and partnering with natural and formal supports (Appendix BK, Slide 2). In addition, the specific roles of the Wraparound team are reviewed (Slides 5-6) and attendees are asked to not only describe their role, but the roles of all team members (Slide 7). Attendees also participate in an activity where they describe how outcome measures can be used by each member of the team (Slide 19). This annual booster is tracked in Relias (Appendix GE: Relias Wraparound Booster Training Tracker).
(d) Our HFW Training Plan (Appendix DT) describes our Initial HFW Training for Leaders and Ongoing Leadership Trainings and Initiatives (Appendix DT: HFW Training Plan, Section D, Pages 7-10). Within the first 90 days of employment, all HFW Supervisors receive 8 initial hours of training, specific to their leadership role. This training is facilitated by our Director and Managers, using our Intensive Behavioral Health Supervisor Manual (Appendix VV). This Manual covers a broad range of supervisory duties and responsibilities, including but not limited to: Child and Family Team Meetings (Pages 16-18), Cultivating External Partnerships (Page 29), and Offboarding of Staff, including a warm handoff for transfer cases (Page 78, Bullet Point 3). Managers utilize the HFW Training Tracking Log (Appendix DF) to track supervisors’ completion of this training
An example of an ongoing training we offer our leaders is our Goleman Leadership Style Training (Appendix DI). This one-hour training is facilitated annually by our Director and Managers. The training includes reflection on the role of a leader, understanding the six Goleman’s Leadership Styles, and asking supervisors to apply their identified leadership style to their current role as a leader (Appendix DI, Slide 2). Managers update and utilize HFW Training Tracking Log (Appendix DF) to track supervisors’ completion of this training (Appendix DT, Page 8, Section 9.6d).
(e) Our HFW Supervisors and Managers provide a one-hour internal training, ICWA & Tribal Engagement (Appendix BU), that all HFW staff receive within 30 days of hire. The HFW staff’s direct supervisor uses our Intensive Behavioral Health Onboarding Checklist (Appendix R, Page 1, Clinical Trainings, Check Box 7) to ensure training completion. Additionally, upon hire, all HFW staff are registered for the next available UC Davis Resource Center for Family-Focused Practices (RCFFP) training: Indian Child Welfare Act (ICWA) Overview & Tribal Engagement in Teaming Best Practices. We track registration through our Onboarding Checklist (Appendix R, Page 3, UC Davis RCFFP, Checkbox 2) and attendance via Tracking Attendance for ICWA Training Tableau Training Time report (Appendix BP).
We provide additional trainings to support populations with specific and unique needs. For example, all new hires are trained in “Clinical Learning Pathways for Trauma Informed Strategies for Working with Individuals with Intellectual and Developmental Disabilities.” This is a 4-hour webinar sponsored by L.A. County DMH (Appendix DT: CII High Fidelity Wraparound Training Plan, Page 6, Section 9.6e). Our supervisors use Intensive Behavioral Health Onboarding Checklist (Appendix R, Page 4, DMH Child Welfare Division Trainings, Check Box 14) to monitor training completion.
Our Continuous Quality Improvement Plan is the primary mechanism we have in place to identify trainings relative to populations with specific and unique needs. As an example, we use our Quality Assurance Review Tool (Appendix M) to evaluate that our Plans of Care and Safety Plans are considerate of culture (HFW Tab, Lines 29, 40, and 51). We use trends from the “D. For Future Improvement” column across all QARs to identify training needs for staff across specific populations and cultures. Our CQI Plan (Appendix EF) notes that our interventions can include training to “address knowledge gaps (for example, provide trainings on populations with specific and unique needs)” (Page 9, Phase 4, Bullet Point 2). Our CQI BHW Meeting Note Template (Appendix ET) includes training as an example of a CQI intervention (Page 3, 4. Identify Interventions, Row 1, Middle Check Box).
9.7 Community-based Training Program
(a) Youth, families and peer partners with current or prior Wraparound experience are incorporated into the delivery of our Annual Wraparound Booster Training (Appendix BK). Our Parent Partners and IHBS Workers support the facilitation of this training—specifically covering the topics of Family Voice and Choice and the Strengths-Based approach (Appendix BK: Slides 10-12). HFW Supervisors ensure this standard is met by formally adding a professional development goal for each Parent Partner and IHBS worker that they will co-facilitate this training. An example of this check-in goal can be found in Appendix EH (bottom of Page 2). Upon addition of the goal, the Supervisor monitors on a quarterly basis to ensure completion.
(b) At least once a year, our HFW program sponsors a 2-hour training that provides an Overview of Wraparound (Appendix EO: Overview of Wraparound Training). Community Members; Caregivers & Family Advocates; and Clients receiving support services are invited to attend (Appendix ED: Overview of Wraparound Training Flyer: “Who Should Attend” section). We will be offering this training next on Thursday, April 9, 2026—with a focus on “how Wraparound fosters teamwork across caregivers, clients, and service providers to build strong support system” (Appendix ED: “About This Training” Section, Second sentence). The brochure is shared with our Community Partners at our Community Conversation meetings held at our Otis Booth and Watts offices; emailed to our HFW Learning Collaborative; and given to current clients and families during sessions (Appendix DT: CII High Fidelity Wraparound Training Plan, Page 17, 9.7b). The training is facilitated by our Facilitators, HFW Managers, Supervisors, Parent Partners, and Intensive Home-Based Services (IHBS) Workers (Appendix DT: Page 17, 9.7b). We monitor attendance via a sign-in sheet from Zoom.
9.8 Coaching and Supervision
(a) Upon onboarding, we offer all HFW staff a comprehensive initial apprenticeship on all facets of the HFW model. We capture and track all of initial trainings through our Intensive Behavior Health Onboarding Checklist (Appendix R)—which includes scheduling shadow sessions with team members (Page 5, Section “Shadowing,” Check Box 1). Our clinical trainings (Appendix R, Page 1, Bottom) include, for example, learning about the Child and Family Team Meeting process (Appendix CD); effective use of flex funds (Appendix T); and crisis assessment and intervention (Appendix AJ). HFW principles are covered in Slides 8 and 9 of the CFTM training (Appendix CD). Upon onboarding, our staff register for the next available UC Davis Wraparound 101 and ICWA trainings (Appendix R, Page 3). In addition, staff watch three training videos from the Los Angeles County Department of Mental Health (DMH): Wraparound 101; Wraparound: Roles Definition and Teaming; and California Standards (Appendix R, Bottom of Page 3).
The first few months of each employee’s onboarding with us is intentionally designed to support this apprenticeship. As per our Onboarding of Staff protocols, new hires have 4 calendar weeks of zero Direct Service Expectations (SDE). During their first 30 days, we expect them to be in training, shadowing intakes and sessions with seasoned therapists, receiving transfer cases and beginning to receive their own intakes to open. New hires have the next 4 calendar weeks at 50% DSE expectations—allowing additional time for learning and practicing (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 113, “Ramping New Hires,” Bullet points 1-4).
(b) Our supervisors provide weekly individual supervision to each of their supervisees that is a minimum of 1 hour in duration (Appendix VV: Intensive Behavioral Health Supervisor Manual, Frequency of Individual Supervision, Bottom of Page 138). Our supervisors have an open door policy for their supervisees where the supervisees can go to their supervisor for questions, help, and support outside of their scheduled individual supervision (Appendix VV, Page 139, Bullet Point 4). Supervisors document and track each individual supervision meeting through our Supervision Guide and Note Template (Appendix DK).
In addition, we offer group supervision to HFW direct service staff. Expectations for group supervision are as follows:
• Unlicensed therapists must attend group supervision weekly that is 2 hours in duration.
• Parent Partners must attend group supervision monthly that is 1 hour in duration.
• Intensive Home-Based Services (IHBS) workers must attend group supervision monthly that is 1 hour in duration.
• Intensive Care Coordinators (ICC) must attend group supervision monthly that is 1 hour in duration. (Page 139, Frequency of Group Supervision section, last Bullet Point).
Supervisors record and monitor attendance through two tracking sheets: Group Supervisions Attendance Tracker (Appendix ER) and All Staff & Clinical Program Meetings Attendance Tracker (Appendix ES).
For direct service staff who are on call during after-hours, if they receive a crisis call then they will contact the designated on-call supervisor for support, consultation, and guidance. The on-call supervisor can contact the on-call Clinical Program Manager (CPM) for additional support as needed. If staff need to go into the field to deescalate a crisis in person, supervisor must inform the CPM before staff are sent into the field. There will always be two staff (e.g. both on-call staff) who are sent into the field to de-escalate a crisis. Once staff are on site and they determine that the client is at immediate danger to self/other or grave disability, the on-call supervisor will go into the field to conduct a LPS assessment (Appendix VV: Supervisor Manual, Page 89, Last 2 Paragraphs).
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
(e) N/A (Providers only)
10.2 Evaluation Metrics & Outcomes
We have a formal Continuous Quality Improvement (CQI) Plan at the agency-wide level (Appendix DM), as well as at the Behavioral Health and Wellness (BHW) level (Appendix EF). We believe that CQI is everyone’s responsibility. Our BHW CQI process is led by our Director of Excellence, who plays a critical role in engaging and motivating all staff in program quality and improvement (Appendix EF, Bottom of Page 4-5). Our Quality Assurance Team, BHW Leadership, Research and Evaluation Center, BHW staff, non-BHW program support, and external stakeholders all serve as key collaborators in this process (Appendix EF, Pages 6-7). The elements of our CQI culture include: the courage to try and learn from mistakes; humility to acknowledge areas of improvement; a culture of safety via a trauma-informed lens; openness to give and receive feedback; integration of quality data; a persistent desire for excellence; and celebration of successes (Appendix EF, Page 4).
Our High Fidelity Wraparound CQI Subcommittee meets at least quarterly to utilize collected HFW data for program evaluation and improvement (Appendix EF, Bottom of Page 7). We recognize that the provision of High Fidelity Wraparound is associated with multiple, complex, and interconnected standards and requirements—especially in terms of fidelity indicators and expected outcomes. As such, our approach to HFW CQI utilizes a very strategic, clearly-defined, and attainable process to hone our improvement efforts across this very vast landscape (Appendix EF, Page 13, CQI Approach for HFW, Paragraph 1).
The CQI BHW HFW Meeting Agenda template (Appendix EB) and CQI BHW HFW Meeting Minutes and Notes template (Appendix EU) were intentionally created to organize and structure this process and help us consider a very large amount of data. Our CQI HFW Plan includes a table of all the data we collect across the following categories: Demographic, System Barriers, Youth and Family Feedback, Fidelity Indicators, Expected Outcomes, Plan of Care, Crisis and Safety Plan, and Transitions (Appendix EF, Pages 19-26). This table also references the specific reports we use to inform our program practice (Last column on the right). Discussions of data during HFW CQI meetings are structured to support decision-making across a wide range of data points and program priorities – with family feedback given priority and extra consideration (Appendix EF, Page 7, Paragraph 2). Our CQI HFM meeting minutes and note template includes a way to identify our CQI interventions across the following practice levels: Family, Program, and Community (Appendix EU, Page 4, Section 5, Level of Action Column, Second from the left).
(a) Individual and group supervision, as well as our clinical program meetings, are the vehicle for improvement of HFW direct practice with our youth and families (Appendix VV: Intensive Behavioral Health Supervisor Manual, Bottom of Page 137 – 142). Our supervisors facilitate supervisions and clinical program meetings using four key strategies—one of them being outcome-based. To provide accurate feedback to supervisees, supervisors use data and outcomes to support their observations and analysis and help recognize the amazing work that their staff are providing to clients and families. Additionally, an outcome-based approach helps to identify interventions and practices that their supervisees can learn to improve effectiveness and quality of services (Appendix VV: Intensive Behavioral Health Supervisor Manual, Page 143 Tableau Report).
As a few examples, our Individual Supervision Guide and Note Template (Appendix DK) prompts supervisors to give staff timely feedback from data or reports relevant to their service provision. For example, supervision begins with a Clinical Check-in around Emergent Needs/Concerns. It includes the question: “When was the last crisis event?” and refers the supervisor to the Outcome Measure Application (OMA) Key Event Change (KEC) report (Appendix BE: Tableau BHW Intensive Emergency Visits). This report shows ER visits and PRMT contact for a specific client and includes the dates (Bottom half of report). For the Clinical Review section (Appendix DK, Page 2), supervisors pick 1-3 clients to discuss in terms of fidelity to Wraparound Principles. The form notes, “If a Quality Assurance Report (QAR) was completed, use the HFW tab to support your supervision.” Through this tool, Supervisors collect data on the degree to which HFW principles and practices are being reflected in the youth record (Appendix M: QAR Tool – HFW tab). They are then able to provide specific and timely feedback to staff—related to, for example, timely engagement, CFT meetings and Plans of Care, Safety Plans, Crisis Response, transition, and if actions taken are based on outcomes (Appendix M, HFW Tab, Rows highlighted in yellow).
Our CQI BHW HFW Meeting Minutes and Notes Template (Appendix EU) is designed to support the use of data to identify staff training needs. For example, the template provides “training” as a potential intervention for CQI purposes (Page 4, Section 4). To provide a concrete example, one of our supervisors commented that our Tableau BHW Discharge Summary Report (Appendix BG) shows “Not Applicable” as the Discharge Reason Response in 31% of closed cases. This data tells us that our staff need additional training in understanding the meaning of various discharge reasons, as well as why accuracy in these selections are key in evaluating our HFW outcomes.
(b) We define CQI as an ongoing, systematic process where teams use data to identify problems in how a service or process works, test small changes to improve it, measure whether the change made things better, and then repeat the cycle to keep improving. Our quarterly CQI HFW Subcommittee meetings are a critical space for us to live out this process. For example, our CQI HFW Meeting Agenda (Appendix EB) allocates time to review data. This time includes reviewing key reports for noticeable trends and issues, as well as seeing where we are (baseline), where we want to be (target), and then tracking our set targets (Appendix EB: Page 1, Section 2: Review Data). Our CQI BHW HFW Meeting Minutes and Notes Template (Appendix EU) ensures that we are held accountable in reviewing the broad range of data we collect and that we implement and follow-through with our improvement plans. For example, our CQI BHW HFW Meeting Minutes and Notes Template (Appendix EU) includes a list of all data points across HFW standards—including but not limited to Demographics, Youth and Family Feedback, Fidelity Indicators, and Expected Outcomes (Appendix EU, Page 3, Section 2, Table). This table includes a “*” next to information/data that is directly from the family, so we can give family feedback priority and extra consideration. Through this table, we are able to hold a big picture view of all our data “puzzle pieces” in developing CQI intervention plans. The template itself also includes definitions of the HFW data standards, for ease of access and consideration (Appendix EU, Bottom of Page 5-7). The template also includes examples of interventions (Page 8) to support us in creating and implementing our action plan (Section 5, Bottom of Page 4-5). This plan includes the action item, level of action, person responsible, deadline, and notes. At the start of every meeting, we review the action items from the previous meeting minutes and update the plan accordingly.
(c) As part of our HFW CQI Plan, we use data to identify and communicate system barriers to the Community Leadership Team (Appendix EF: CQI Plan Behavioral Health and Wellness _ HFW, Page 20). As an example, we monitor the availability and use of flex funding through our Tableau WTS Flex Fund Utilization (Appendix YY). This report captures how much of our annual funding we’ve utilized so far, by Service Provider Area (SPA), as well as the dollar amounts we have remaining. The report also displays usage by the Wraparound Tracking System (WTS) domain, so we can easily access the purpose of the spending. This report is referenced on our CQI BHW HFW Meeting Minutes and Notes Template (Appendix EU, Section 2: Review Data, HFW Standard Column (on the left), Second Checkbox). We can communicate this information to the Community Leadership Team—especially if we are concerned about insufficient flex funds to meet our family’s needs (Standard 7.2, Item 5).
As another example, our Family Experience Calls (Appendix DD) provide a mechanism for families to participate in decisions regarding local HFW implementation. Each HFW supervisor makes two calls a month to two families actively receiving HFW from Children’s Institute. Question 26 specifically asks, “How could CFT meetings be improved? For example, if you could change one thing about these meetings, what would it be?” (Appendix DD: FEC, Page 6, Last question). The composition and process of the Child and Family Team, and its emphasis on youth and family as key decision-makers, is essential to HFW expected outcomes. In addition, CFTs are intended to bring together professionals and agencies across the Children’s System of Care to support each family’s Plan of Care. This question helps us know, at the local level, if families are experiencing these meetings as intended. We will collect, organize, and communicate this feedback as part of our participation in the county’s Community Leadership Team – allowing families’ voices and preferences to be lifted up in our local decision making.
Fidelity Indicators
1.1 Timely Engagement and Planning
366.26 WIC Report & ALL documents of each Child, practice name Permanently Reunify Modified as Needed for Family . All Dependency documents & all written by the children’s Mother personally.
1.2 Led by Youth and Families
Non supervised Home Visits & any all Visitation Priorities & privileges w/ meaningful incentives that motivates
1.3 Strength-Based
Focused on solutions, rather than dwelling on negative events ; not limited to addressing any issue needing care & resolved good outcomes. Use all mothers recommended advice, etc or notes written in appropriate intention
1.4 Needs Driven
All, any and Relevant, children’s input, participation & relevances
1.5 Individualized
All, see matters, etc. Modify clarify readdress review & improved
1.6 Use of Natural and Community Based Supports
Use case documents written by mother respectively
1.7 Culturally Respectful and Relevant
Documents… All relevant, combined, generated by mother, etc.
1.8 High-Quality Team Planning and Problem Solving
All written documents written by mother
1.9 Outcomes Based Process
All written documents written by mother, etc. Relevant
1.10 Persistence
All written documents written by mother respectively
1.11 Transitions as a part of the Fourth Phase of HFW
All written documents written by mother respectively
Expected Outcomes
2.1 Youth and Family Satisfaction
All written documents written by mother
2.2 Improved School Functioning
All written documents written by mother respectively
2.3 Improved Functioning in the Community
All mothers recommended advice, and all mothers written documents written by mother supporting successful solutions
2.4 Improved Interpersonal Functioning
All mothers written documents written by mother respectively
2.5 Increased Caregiver Confidence
All mothers written documents written by mother respectively
2.6 Stable and Least Restrictive Living Environment
All mothers written documents written by mother respectively
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
All mothers written documents written by mother respectively
2.8 Reduction in Crisis Visits
All mothers written documents written by mother respectively
2.9 Positive Exit from HFW
All mothers written documents written by mother respectively
Engagement
3.1 Orientation
All mothers written documents written by mother respectively
3.2 Safety and Crisis stabilization
All mothers written documents written by mother respectively
3.3 Strengths, Needs, Culture and Vision Discovery
All mothers written documents written by mother respectively
3.4 Engage All Team Members
All mothers written documents written by mother respectively
3.5 Arrange Meeting Logistics
All mothers written documents written by mother respectively
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
All mothers written documents written by mother respectively
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
All mothers written documents written by mother respectively
4.3 Develop an Individualized Child or Youth and Family Plan
All mothers written documents written by mother respectively
4.4 Develop a Crisis and Safety Plan
All mothers written documents written by mother respectively
Implementation
5.1 Implement The Plan of Care
All mothers written documents written by mother respectively
5.2 Review and Update The Plan of Care
All mothers written documents written by mother respectively
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
All mothers written documents written by mother respectively
Transition
6.1 Develop a Transition Plan
All mothers written documents written by mother respectively
6.2 Develop a Post-Transition Safety Plan
All mothers written documents written by mother respectively
6.3 Create a Commencement and Celebrate Success
All mothers written documents written by mother respectively, a celebration, party, court supporting successful solutions services, lawsuit’s with kids Voice all included, supporting by Speaking Mothers Verbally Communication practices
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
All mothers written documents written by mother respectively
7.2 Community Leadership Team
All mothers written documents written by mother respectively
7.3 Eligibility and Equal Access
All mothers written documents written by mother respectively
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
All mothers written documents written by mother respectively
8.2 Equitable Funding Across System Partners
All mothers written documents written by mother respectively
8.3 Cost Savings are Reinvested
All mothers written documents written by mother respectively
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
All mothers written documents written by mother respectively
8.5 Collaborative Oversight of Flex Funds
Jasmine. Guzman has written documents of each supporting successful solutions documents written by mother, which is the mothers name stated here as the mothers written documents written by mother respectively
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
All mothers written documents written by mother respectively
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
All mothers written documents written by mother respectively
9.2 Tribally Responsive Workforce
All mothers written documents written by mother respectively
9.3 Flexible and Creative Work Environment
All mothers written documents written by mother respectively
9.4 Hiring, Performance Evaluation, and Job Descriptions
All mothers written documents written by mother respectively ,& relevant supporting forms required, etc.
9.5 Workforce Stability
All mothers written documents written by mother respectively
9.6 High Fidelity Training Plan
All mothers written documents written by mother respectively
9.7 Community-based Training Program
All mothers written documents written by mother respectively
9.8 Coaching and Supervision
All mothers written documents written by mother respectively
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
All mothers written documents written by mother respectively
10.2 Evaluation Metrics & Outcomes
All mothers written documents written by mother respectively
Fidelity Indicators
1.1 Timely Engagement and Planning
(a) Upon assignment, the Wraparound team is provided with the referral form, the youth’s most recent psychological assessment, and the current IEP (if available). To ensure timely initiation of services, the Family Facilitator contacts the family within 72 hours of the youth’s acceptance by IPC (or within 24 hours if the family is experiencing an immediate crisis). This initial outreach is conducted to address any urgent safety concerns and to schedule the intake appointment.
(b) The High Fidelity Wraparound (HFW) team initiates development of the Plan of Care upon engagement, beginning with the Meet and Greet (the first Child and Family Team meeting), during which the team collaboratively establishes the mission and vision statement. Strengths and needs are identified through ongoing conversation and through completion of a formal strengths and needs assessment.
The Plan of Care is finalized within the first 30 days of service. The Program Manager, Clinical Supervisor, and Coaches monitor progress toward this timeline and provide training and coaching as needed to ensure compliance with this standard.
(c) At a minimum of every 30 days, and more frequently as needed, the Family Facilitator reviews the Plan of Care during a Child and Family Team meeting. The team evaluates progress toward identified strategies and action steps, updates and refines strengths and needs, and explores additional or expanded resources to support the youth and family. (Family Facilitator Task List, pg. 1)
(d) The Plan of Care is formally revised every 90 days to reflect progress achieved and emerging needs. The Family Facilitator addresses the review and revisions during a Child and Family Team meeting, updates the Plan of Care accordingly, and uploads the revised document to the Electronic Health Record. Related Facilitator responsibilities are outlined in the Family Facilitator Task List (Family Facilitator Task List, pg. 1).
(e) Plans of Care and Safety Plans are submitted to the Clinical Supervisor and/or Program Manager for review and signature following execution by the youth, family, and Child and Family Team members. Upon final approval, the Family Facilitator transmits the Plan of Care to the referring party via secure email.
Program Administration and the Program Manager maintain an ongoing tracking system to monitor completion of required documentation. The tracking tool is updated upon receipt of finalized documents, and monthly notifications are distributed to staff to monitor and ensure timeliness. In addition, quarterly reports detailing Plan of Care completion data are prepared and submitted to Child Welfare Services (CWS) and Probation.
(f) New staff are provided in-house Wraparound Training. Individual trainings are listed in Casa Pacifica’s High Fidelity Training Plan (High Fidelity Training Plan, pg. 3-8) with comprehensive training in the Wraparound Process and philosophy, staff roles, and programmatic and agency policies and procedures. All items on the Training Checklist are to be completed within the first 30 days of employment. Training includes, and is not limited to, the following subjects: v. Wraparound Process including Engagement (Casa Pacifica Policy and Procedure Manual, pg. 20)
Additional training for new staff emphasizes strategies for engaging and motivating individuals who may initially present as disengaged.
All Wraparound staff are required to participate in weekly group case review, monthly role-specific group supervision, and individual clinical supervision provided by licensed clinical supervisors (Policy and Procedure Manuel, pg. 27). Individual clinical supervision occurs weekly or biweekly, depending on staff need, stage of training, licensure status, and level of experience. The purpose of individual supervision is to provide tailored clinical guidance and support regarding appropriate interventions to enhance family engagement and improve Wraparound outcomes.
Role-specific group supervision is conducted monthly and attended by staff within the same role (e.g., Parent Partners, Family Facilitators, and Child and Family Specialists). These sessions focus on addressing role-specific strengths and challenges, sharing intervention strategies, and receiving targeted clinical direction and peer support related to cases.
Ongoing training and team meetings reinforce Wraparound’s 10 principles, including a strengths-based, individualized, and persistent approach to addressing barriers to engagement. The team also considers factors such as service location, time of day, cultural responsiveness, and the intentional inclusion of team members with lived experience to foster trust, rapport, and meaningful participation.
1.2 Led by Youth and Families
(a) Family and youth perspectives are intentionally elicited and prioritized throughout all phases of the Wraparound process. Planning is grounded in the family’s voice and choice, with the team consistently offering meaningful options to ensure that the Plan of Care reflects the family’s values, preferences, and cultural context.
As part of Plan of Care development, the Child and Family Team collaboratively establishes a Mission Statement that articulates the family’s vision for their future and defines what successful completion of the Wraparound process will look like. The team also develops a comprehensive strengths and needs inventory (Strengths and Needs Assessment, pg. 72) that identifies the assets of the youth, family members, natural supports, and Wraparound team members. This strengths-based foundation guides service planning and reinforces Wraparound’s commitment to building on existing capacities throughout the course of care.
(b) Across all four phases of the Wraparound process, team members continuously assess and document progress, evolving needs, identified strengths, safety risks, barriers to service delivery, and the ongoing necessity of services. This information is routinely shared with collaborating partners—including Probation, Social Services, Behavioral Health, and educational providers—to promote coordinated care and alignment of interventions.
Assessments and associated timelines are conducted in a strengths-based, trauma-informed, and culturally responsive manner, with family members serving as the primary source of information. The assessment process is designed not only to obtain essential clinical and functional data, but also to develop a comprehensive understanding of the youth’s and family’s lived experiences, perspectives, and broader community context.
Information gathered supports the identification of contributing factors, systemic influences, behavioral patterns, and barriers to change that impact the family’s daily functioning and contributed to the need for Wraparound services (Policy and Procedure Manual, pg. 22).
(c) All Wraparound staff are required to participate in weekly group case review, monthly role specific group supervision and individual clinical supervision weekly and/or every other week provided by licensed clinical supervisors (page 30). Individual clinical supervision is provided weekly or every other week depending on staff need, where they are in the training process, licensure status, etc. The purpose of individual supervision to receive individual clinical guidance and support around clinically appropriate interventions to utilize with families in order to improve Wraparound outcomes. Role specific group supervision is provided monthly and is attended by role specific individuals (parent partner, family facilitators, and child/family specialists). The purpose of role specific group supervision is to discuss strengths and challenges specific to the role, share interventions ideas among the role and get support and specific clinical direction on cases.
(d) Casa Pacifica utilizes the Wraparound Fidelity Index (WFI) and the Team Observation Measure (TOM) to systematically gather and evaluate feedback from youth and families regarding the quality and fidelity of Wraparound service delivery.
In addition, Casa Pacifica administers Youth Services Surveys (YSS) at the conclusion of services to obtain structured feedback related to service implementation, engagement, and overall satisfaction (Youth Services Survey, pg. 50 ).
To further assess outcomes and sustained impact, the agency conducts follow-up calls at three (3) and six (6) months post-discharge to gather information regarding current functioning, ongoing needs, and continued satisfaction with services received (Wraparound Follow Up Survey, pg. 51). In addition, we also measure if they have maintained their level of placement, if they have any instances with law enforcement, psychiatric hospitalizations, and if they are engaged in purposeful activities.
1.3 Strength-Based
(a) As part of developing the Plan of Care, the Child and Family Team (CFT) collaborates to create a Mission Statement that reflects the family’s vision for their future and clearly defines what success will look like upon completion of the Wraparound process. This mission serves as the guiding framework for service planning and implementation.
The team utilizes a comprehensive strengths and needs inventory (Strength and Needs Assessment, pg.72) in partnership with family members, natural supports, and Wraparound team members, to ensure that planning and interventions are grounded in Wraparound’s strength-based philosophy. This collaborative approach reinforces family voice and choice while building upon existing capacities and resources.
Parent Partners complete Connection Map (Connection Map, pg. 52) and Echo Map (Policy and Procedure, pg. 26) with caregivers to assess and identify natural supports, strengthening informal networks and promoting long-term sustainability beyond formal service involvement.
(b) The strengths inventory is in the Plan of Care and is reviewed/expanded every 30 days. The team reviews the completed CANS to gather identified strengths. If the CANS is due and Wraparound holds the case, they are responsible for completing that and the HFW team collaborates to review identified strengths.
(c) All Wraparound staff are required to participate in weekly group case review, monthly role-specific group supervision, and individual clinical supervision on a weekly and/or biweekly basis, provided by licensed clinical supervisors (see page 30, Policies & Procedures). This structure ensures ongoing clinical oversight, adherence to best practices, and alignment with High Fidelity Wraparound standards.
Casa Pacifica has designated coaches for the Parent Partner, Family Facilitator, and Family Specialist roles. These coaches meet monthly to conduct programmatic reviews aligned with fidelity standards and to support continuous quality improvement efforts. Coaches also conduct regular shadowing to provide direct feedback, skill development, and practice-based coaching.
Staff are required to attend annual, booster, and ongoing role-specific trainings to maintain competency and fidelity. Additionally, staff participate in trainings offered through UC Davis related to Wraparound growth, implementation, and system improvement initiatives.
(d) Casa Pacifica utilizes the Wraparound Fidelity Index (WFI) and the Team Observation Measure (TOM) to systematically gather and evaluate feedback from youth and families regarding the quality and fidelity of Wraparound service delivery in a strength based perspective. Information gathered is reviewed regularly and integrated into trainings and ongoing coaching.
In addition, Casa Pacifica administers Youth Services Surveys (YSS) at the conclusion of services to obtain structured feedback related to service implementation, engagement, and overall satisfaction (Youth Services Survey, pg. 50).
To further assess outcomes and sustained impact, the agency conducts follow-up calls at three (3) and six (6) months post-discharge to gather information regarding current functioning, ongoing needs, and continued satisfaction with services received (Wraparound Follow Up Survey, pg. 51).
1.4 Needs Driven
(a) Through the Meet and Greet, Comprehensive Assessment/Timeline Meetings, IP CANS, Pediatric Symptom Checklist –35. and open-ended conversations, and a strength and needs inventory, (Strength and Needs Assessment, pg. 72) needs are identified during the engagement phase of treatment. After identifying the various areas of needs, the team will prioritize those needs and, in collaboration with the youth and family, develop strength-based, culturally competent and trauma informed strategies to meet those needs. Ideally, the strategies developed will be inclusive of natural supports, community resources and team members (Policy and Procedure Manual, pg.23).
(b) Through role-specific shadowing, weekly clinical supervision, and weekly case review, the team consistently reviews and applies the ten principles and standards of High Fidelity Wraparound, including the use of the strengths and needs inventory to guide individualized planning.
Feedback gathered from youth and families through the Team Observation Measure (TOM), Wraparound Fidelity Index (WFI), and Youth Services Survey (YSS), in addition to direct observations and ongoing dialogue regarding emerging needs, informs continuous assessment and service adjustments. Staff collaboratively review identified needs and behavioral patterns to ensure interventions remain responsive and aligned with the family’s goals.
The team meets regularly to review ongoing needs and concerns with the shared understanding that behaviors serve a function. Using this framework, the team identifies appropriate supports, strategies, and resources designed to meet underlying needs in safer and more adaptive ways, promoting long-term stability and success for youth and families.
(c) The IP CANS is completed every 6 months. The most recent CANS is reviewed upon the start of services by the treatment team to review needs identified in the last re-assessment. If the CANS has not been completed, Wraparound will complete the intake IP-CANS. Needs identified in the IP CANS will be reviewed at intake and throughout CFT meetings to ensure needs are being met through problem solving, skills development, identifying natural supports, and empowering families.
(d) At the start of services, the youth, family, and the Child and Family Team develop team agreements, youth and family vision, a mission statement, and then benchmarks for success (Plan of Care, pg. 71). These identified benchmarks are reviewed regularly (30 days if not more) within the Plan of Care Revisions. The Child and Family Team will collaborate with the youth, family, referring party, when benchmarks have been met and transition will be discussed and implemented.
1.5 Individualized
(a) Casa Pacifica’s forms and documentation allow for individualization rather than relying on checkboxes. The forms provide space for a narrative to document youth and family responses in their own words. During the development of the Plan of Care (POC), the team gathers comprehensive information to ensure the creation of an individualized, strength-based plan within the first 30 days of service. The POC is actively implemented, continuously monitored, and revised as needed to reflect the evolving needs, strengths, and goals of the youth and family. At a minimum, the team reviews the POC every 30 days during the Child and Family Team (CFT) meeting, with additional reviews conducted as clinically indicated.
A preliminary safety and crisis plan is initiated during the initial meet-and-greet. An individualized crisis plan is then developed based on information obtained through a structured risk assessment, including identified risk factors, protective factors, natural supports, personalized coping strategies, and emergency contact information. This plan is regularly reviewed and updated to ensure relevance and effectiveness.
(b) Staff receive initial training on the 10 Principles of High Fidelity Wraparound, with a strong emphasis on individualization, family voice and choice, strengths-based planning, and cultural responsiveness across all aspects of service delivery (Training Plan, pg.3-8).
Ongoing support is provided through booster trainings, reflective supervision, and field-based coaching to reinforce fidelity to the model. Through these structures, staff are supported in developing and implementing creative, flexible strategies that are tailored to each youth and family’s unique strengths, needs, vision, and circumstances, ensuring Plans of Care remain individualized and team-driven.
(c) Facilitators receive role-specific training focused on integrating the 10 Principles of High Fidelity Wraparound into all aspects of their role, including effective implementation of Child and Family Team (CFT) meetings. Training emphasizes practical strategies to elevate family voice and choice, develop and document a family-driven vision in the youth and family’s own words, and intentionally integrate culture, identity, values, and natural supports into the Wraparound process and Plan of Care. (Training Plan, pg. 3-8).
Through ongoing reflective supervision, the Clinical Supervisor reviews Plans of Care to ensure meaningful individualization and alignment with the youth and family’s strengths, preferences, and cultural context. Supervision includes examining how culture, values, and preferences are reflected in strategies, as well as problem-solving barriers to full customization (Supervision Form, pg. 53).
Coaching includes direct observation of facilitation practice and review of feedback from fidelity tools such as the Wraparound Fidelity Index (WFI) and Team Observation Measure (TOM). Facilitators receive structured feedback related to facilitation skills, team leadership, protection of family voice, and reframing traditional services into creative, individualized, team-driven strategies.
Ongoing and booster trainings are embedded within role-specific professional development and may focus on fidelity enhancement, strengthening team-driven interventions, addressing implicit bias, and reducing systemic barriers to individualization to ensure continuous quality improvement and adherence to HFW standards.
(d) Facilitators review the Plan of Care at a minimum of every 30 days to ensure alignment with High Fidelity Wraparound standards and the evolving needs of the youth and family. During these reviews, the team evaluates progress toward identified outcomes, ensuring that goals remain functional, measurable, and directly connected to the family’s vision. Individualized strengths are intentionally highlighted and linked to strategies to reinforce a strengths-based approach.
Progress made by the youth and family is clearly documented in objective and meaningful terms, celebrated within Child and Family Team (CFT) meetings, and used to inform next steps. This recognition supports motivation, reinforces protective factors, and sustains team engagement.
Barriers, unmet needs, and emerging challenges are also explored collaboratively during plan reviews. The Facilitator guides the team in problem-solving and developing creative, individualized, and team-generated strategies to reduce barriers and enhance success. This includes the exploration of families community and support networks (Connections Map, pg. 52).
(e) Casa Pacifica administers the Youth Services Survey (YSS) to families upon discharge to gather structured feedback regarding their experience of individualization and participation in services. Survey items assess the extent to which youth and families felt they helped choose their treatment goals, select services, and actively participate in their own treatment. In addition to scaled responses, youth and families are provided the opportunity to share qualitative feedback in their own words through a narrative (Youth Services Survey, pg. 50). YSS results are reviewed monthly during all-staff meetings to identify trends, strengths, and areas for growth related to fidelity and individualization. When indicated, targeted booster trainings and practice enhancements are developed to address identified needs.
To further assess fidelity to High Fidelity Wraparound, the program also utilizes the Wraparound Fidelity Index (WFI) and the Team Observation Measure (TOM). Fidelity data are reviewed monthly by the Program Manager, Clinical Supervisor, and designated coaches. Based on data analysis, the leadership team determines and implements appropriate quality improvement strategies, which may include focused coaching, additional training, facilitated observations, or corrective action plans to ensure continued adherence to fidelity standards.
1.6 Use of Natural and Community Based Supports
(a) A core component of High Fidelity Wraparound is the development and strengthening of natural support networks. The Wraparound Team collaborates with families to identify and address any current or potential negative influences within their social support systems, while also exploring strategies to expand and leverage existing natural supports. These supports are intentionally incorporated to sustain positive changes beyond the duration of formal services. To promote independence and self-sufficiency, the team engages families in a customized Strength & Needs Assessment, (Strength and Needs Assessment, pg. 72) a structured tool designed to identify and access natural, social, and community supports that are low- or no-cost and aligned with the family’s unique needs. Prior to implementation, the team may conduct targeted research to identify appropriate community-based services and resources that support the family’s goals.
When natural and community resources have been fully explored or are insufficient to meet critical needs, flex funds or staff time may be utilized as a last-resort intervention to ensure that families can achieve necessary outcomes, consistent with HFW principles of individualized, strengths-based, and family-driven planning (Policy and Procedure Manual, pg. 31).
(b) During initial training, the concept and use of natural supports are introduced, with content reinforced and expanded through role-specific training (Training Plan, pg. 3-8). For example, the Parent Partner works with families to complete a Connections Map (Connections Map, pg. 52), identifying the strengths and potential of existing natural supports. Staff also have access to an extensive, continually updated resource list embedded within the program SharePoint, which can be expanded by the team to reflect new or emerging community resources.
Staff engage in weekly two-hour case review meetings to discuss current cases, focusing on the unique strengths, needs, and natural supports of each family. These meetings provide opportunities for collaborative problem-solving, skill-sharing, and strategic resource alignment tailored to the family’s individualized circumstances.
In addition, staff meet monthly with their Coach to review progress and discuss ongoing professional growth in the area of natural supports. Coaching is delivered through observation, direct feedback, and collaborative exploration of natural and community resources that may benefit the family. When appropriate, community partners are invited to share information regarding their services to enhance team knowledge and resource utilization.
Ongoing and booster trainings are provided as needed to address identified gaps, reinforce best practices, and strengthen staff capacity to engage, expand, and leverage natural supports in alignment with High Fidelity Wraparound principles.
(c) Every 30 days the team will review the POC in CFT meetings, or more as needed, which is where the team will continue assessing natural supports inventory developed and expand on. The Parent Partner also completes a connections map to assess current natural supports from caregivers and will continue to expand upon this throughout services. (Connections Map, pg. 52).
(d) Casa Pacifica will utilize the Wraparound Fidelity Index (WFI) to assess whether natural supports are consistently identified, engaged, and meaningfully involved in planning and service delivery. In addition, the Team Observation Measure (TOM) will also be implemented to evaluate the facilitation of Child and Family Team meetings and the extent to which natural supports are actively incorporated into the delivery of individualized services.
While the agency’s Youth Services Survey (YSS) does not explicitly measure natural supports, items related to life functioning (Youth Services Survey, pg. 50, #16–21) provide valuable insight into whether natural supports have been introduced or expanded to address underlying needs that may contribute to functional impairments.
The Wraparound Leadership Team, including the Program Manager, Clinical Supervisor, and Coaches, reviews fidelity and outcome data monthly. Findings are then used to inform ongoing professional development, including targeted training during monthly all-staff meetings or the implementation of booster trainings as indicated by identified needs.
1.7 Culturally Respectful and Relevant
(a) Strengths, needs, and cultural considerations are identified and explored through a variety of assessment tools and processes including; the CalAim Clinical Assessment, Timeline Meetings (which gather family preferences, individual and family attributes, and historical context), Risk Screening (Risk Screening, pg. 55-57), Health History Questionnaire (Health History Questionnaire, pg. 58-65), Pediatric Symptom Checklist (Pediatric Symptom Checklist, pg. 66), and the Strengths and Needs Inventory (Strength and Needs Assessment, pg. 72). Information gathered through these tools is integrated into the Plan of Care and aligned with the family’s vision statement to ensure individualized, goal-driven planning. The family’s cultural and diversity needs are systematically considered throughout the Wraparound process. This may include providing translators or bilingual team members, connecting the family with community supports and activities that reflect their culture or identity, and ensuring that all interventions, supports, and resources provided by the Wraparound Team are consistent with the family’s values and cultural context. These efforts ensure that planning and service delivery are culturally responsive and family driven.
(b) Upon hire staff receive initial trainings regarding cultural competency. This includes county requirements, agency trainings, trainings provided by UC Davis, and specific program trainings (Training Plan, pg. 3-8). Trainings include a variety of topics including LGBTQ+, CESEC, Latinx, Indian Child Welfare Act, etc. All staff received trauma informed annual trainings that are required for county and agency cultural competency. Booster and Ongoing training through UCDavis, outside agencies (e.g. the Catalyst Center), and Wraparound specific trainings can be integrated based on special populations served. This includes topics such as implicit bias, gang culture, and substance abuse.
(c) Through the use of the Youth Services Survey (YSS), the Wraparound Fidelity Index (WFI), and the Team Observation Measure (TOM), youth and families provide feedback on the cultural relevance, responsiveness, and respectfulness of services. The YSS includes structured questions using a Likert scale that specifically assess respect for cultural and spiritual beliefs, as well as a narrative section for families to provide detailed qualitative feedback in their own words.
Data collected from these tools are reviewed monthly by the Wraparound Leadership Team, including the Program Manager, Clinical Supervisor, and Coaches. This review informs ongoing quality improvement and professional development, guiding the design of targeted trainings—either incorporated into the monthly All-Staff meeting or delivered as focused Booster Trainings.
1.8 High-Quality Team Planning and Problem Solving
(a) During an intake meeting, Wraparound team members complete consent forms including Informed Consent, Wraparound Program Agreement, and County Mental Health Consents, and Universal Releases of Information with other County contracted agencies and identified natural and logical supports (Intake Packet, pg.89-107). In the Initial meet and greet meeting with the family, Wraparound reviews the 10 principles of Wraparound, defines roles and responsibilities, and reviews participant agreements and confidentiality (10 Principles of Wraparound, pg. 108). During each CFT meeting, notes are taken that include participants intended outcomes for the meeting, strengths, needs, and planned action steps. CFT minutes are distributed to all child family team members in a weekly update email and uploaded to the electronic health record (CFT minutes, pg. 67- 69).
(b) the Wraparound Fidelity Index (WFI) will be administered with youth and families to assess the fidelity of Wraparound services and the extent to which family voice, choice, and engagement are incorporated. In addition, the Program Manager and Coaches will observe the facilitation of Child and Family Team (CFT) meetings and provide targeted feedback during monthly supervision sessions, identifying areas for professional growth and skill development (Supervision Log, pg. 53-54).
The Youth Services Survey (YSS), administered at the conclusion of services, provides youth and families with the opportunity to offer structured feedback regarding their engagement in services, as well as a narrative section for personalized commentary. Data from these tools are used to inform coaching, supervision, and expand on staff’s professional development (Youth Services Survey, pg.50).
(c) The Wraparound Leadership Team, comprised of the Program Manager, Clinical Supervisor, and Coaches, meets weekly to review and support the implementation of the Wraparound system (Leadership Minutes, pg.120-121). On a monthly basis, data from the Wraparound Fidelity Index (WFI), Team Observation Measure (TOM), and Youth Services Survey (YSS) are systematically reviewed to assess fidelity, family engagement, and service quality. This review is supplemented by additional information, including leadership observations, staff feedback from supervision, and other relevant performance measurements. During these reviews, the Leadership Team not only identifies opportunities for ongoing staff training and professional development, but also evaluates systems and processes to enhance family engagement and strengthen team-based collaboration.
Quality improvement activities are further evaluated through quarterly WIT Leadership meetings conducted in collaboration with the Department of Child Welfare Services, Behavioral Wellness, and Probation (WIT Leadership Agenda, pp. 124–125). During these meetings, both quarterly and annual reports are reviewed, with a focused analysis of outcome measures, including placement stability and other key performance indicators (Quarterly Reports, pp. 83–85). The review process also includes monitoring the absence of new Child Welfare Services (CWS) reports for both current and former Wraparound participants, as an indicator of sustained stability.
In addition, Casa Pacifica presents quarterly data to Executive Leadership and the Board of Directors. These reports include analysis of client demographics, service utilization, and movement to lower or least restrictive levels of care, supporting ongoing organizational oversight and continuous quality improvement (Wraparound Scorecard, pg. 170).
(d) During each Child and Family Team (CFT) meeting, detailed minutes are documented, capturing participants, intended meeting outcomes, identified strengths and needs, and planned action steps (Child and Family Team Meeting Minutes, pg. 67-69). Meeting notes are distributed to all CFT members—including the referring party, therapist, and natural supports—via a weekly update email and are also uploaded to the electronic health record (EHR) for accessibility and continuity (Weekly Email Template, pg. 70).
The team utilizes the previous meeting’s notes during subsequent CFT meetings to review progress on action items and ensure accountability (CFT Minutes, pg.67-69). Pre-and post-CFT meetings are conducted as needed to monitor completion of Wraparound tasks and address any emerging needs. The Plan of Care (POC) is formally reviewed at least every 30 days, with action items and goals documented and communicated through the weekly update email and the EHR (Plan of Care, pg.71-78).
1.9 Outcomes Based Process
(a) The Plan of Care allows the youth and family to identify specific goals related to the 12 domains – 1. Psychological Emotional, 2. Family/Relationships, 3. Safety/Crisis, 4. Legal, 5. Substance Use/Addiction, 6. Educational/Vocational, 7. Health/Medical, 8. Home/A Place to Live, 9. Daily Living/Life Skills, 10. Cultural/Spiritual, 11. Financial, 12. Social/Recreational. The youth and family will then identify a specific need statement. From there, the Facilitator will encourage team collaboration to identify strengths related to this specific needs statement. After identifying the various areas of needs, the team will prioritize those needs and develop strength-based, culturally competent and trauma-informed strategies to meet them. Ideally, the strategies developed will be inclusive of natural supports, community resources and team members. SMART goals are developed based on the strategies identified. The team will expand upon this identifying an outcome statement (how we know the goal has been met) and assign action steps, the team member responsible, and a target completion date. (Plan Of Care, pg. 73).
(b) Once the initial Plan of Care (POC) has been completed—within the first 30 days of service—the Family Facilitator revisits the POC at a minimum of every 30 days. During these reviews, strategies and action steps are evaluated and updated to reflect the youth and family’s progress, changing needs, and evolving priorities. The Facilitator also identifies and highlights strengths that have been deepened or newly developed as a result of service implementation, skill development, and the expansion of natural and community supports. POC strategies and action items are communicated in the weekly updates to the Child and Family Team (CFT) and are continuously revised based on ongoing progress. (Weekly Email Template, pg. 70).
(c) Team meetings are regularly scheduled to help support the collaboration between Wraparound and treatment team members (referring party, therapist, natural supports, etc.). Action items and strategies can be adjusted, alongside collaboration with youth and family in Child Family Team meetings.
(d) If Casa Pacifica serves as the Case Manager, the IP-CANS is completed within six months of the most recent assessment. For clients without a current IP-CANS, Wraparound will complete the intake assessment. When Behavioral Wellness (County Mental Health) holds the case, they are responsible for completing the IP-CANS; however, Wraparound continues to review the assessment as a key tool for identifying youth and family needs and strengths.
Responsibility for tracking IP-CANS completion will be designated to Child Welfare and Probation. Currently Behavioral Wellness is responsible for tracking within their electronic health record and Casa Pacifica supports this when holding the case.
(e) Wraparound staff support the review of the IP-CANS with the youth and family—either during a Child and Family Team (CFT) meeting or in individual sessions—ensuring that information is presented in a strengths-based, clear, and family-understandable manner. The IP-CANS serves as a building block alongside the Plan of Care, strengths and needs inventories, and any additional assessment tools utilized to review the youth/families progress with services.
1.10 Persistence
(a) Wraparound services are of limited duration and focused on resolving the pressing issues that precipitated the need for service. The team discusses termination with the client and family from the very first intake session, to ensure the family is aware of the time limited nature of Wraparound, as well as the reasons around fading out and ending. When the family reaches a point where they feel confident that they have enough supports and resources in place to meet current and future needs, “graduation” discussions begin, and completion of formal Wraparound support takes place. In order to close a case, it must be agreed upon by all Interagency Placement Committee team members. Feedback about readiness for closure is also obtained from the referring party and all participating parties. At times, unplanned terminations do occur. An unplanned termination can be the result of a family choosing to no longer participate in services, AWOL, incarceration for a significant period of time (over one month) or a client being moved to a higher level of care. In these circumstances, the Wraparound team members attempt to schedule a closure visit with the client/family to provide them with contact information for various resources that can be used to support the family, along with reminding the family of the “Once Wraparound, Always Wraparound” philosophy. The Wraparound team will also coordinate with the referring party and IPC team members to discuss ongoing needs and make a plan for coordination of care for ongoing services. Wraparound has a “no reject, no eject” policy and does not ask families to leave the program. If a family leaves Wraparound of their own accord, every effort is made to connect the family to beneficial services. Examples of this may include helping a referring party locate appropriate residential care, community resources, foster families, lower-level group homes, other family members who will provide respite or offer a home to a youth, psychiatric assistance, counseling, medical care, parenting skills, support groups, etc. (Policy and Procedure Manual, pg. 29).
(b) All staff receive supervision on a weekly basis, provided through individual sessions, group sessions, or a combination of both. These supervision forums serve as structured opportunities to discuss challenges that may arise in service delivery, including interventions, countertransference, difficulties establishing rapport, and maintaining professionalism and appropriate boundaries with youth and families (Individual Supervision Log, pg.53-54 & Group Supervision Log, pg. 118-119).
In addition, all staff participate in weekly Case Review meetings, which provide a collaborative forum to address challenges, identify barriers to service, and gain insight from the collective experience of the Wraparound team. These meetings support staff growth, problem-solving, and the consistent implementation of individualized, strengths-based, and family-driven Wraparound services.
(c) All staff receive initial training in crisis navigation, de-escalation strategies, and safety planning to ensure preparedness in responding to complex and high-risk situations. Facilitators receive additional, role-specific training in Child and Family Team (CFT) facilitation, including strategies to effectively manage diverse team dynamics, address conflict, and maintain alignment with High Fidelity Wraparound principles of family voice and choice (Training Plan, pg.5-6).
Casa Pacifica utilizes structured Team Agreements at the beginning of each CFT meeting to clarify roles, establish shared expectations, and promote respectful, collaborative engagement (Wraparound CFT Group Agreement, pg. 79). Facilitators are trained in the intentional use of Team Agreements, reflective practice, and structured brainstorming tools to guide effective problem-solving and Plan of Care revisions when challenges arise.
To further strengthen facilitation skills, Casa Pacifica incorporates external professional development opportunities to expand the Facilitator’s toolbox of strategies and interventions, including trainings offered by organizations such as UC Davis, the Catalyst Center, Behavioral Wellness, CDSS, etc.
Following crisis events, the Program Manager and Clinical Supervisor conduct follow-up calls with the family to gather feedback regarding their experience and identify opportunities for improvement. Information obtained from these follow-ups is integrated into ongoing staff development and quality improvement efforts, while also informing the continued individualization of crisis planning and response to ensure services remain strengths-based, culturally responsive, and family-driven (Crisis Satisfaction Survey, pg. 169)
Facilitators meet bi-monthly as a group to discuss role-specific needs. This also serves as an opportunity for the Coach and Clinical Supervisor to provide ongoing training related to the fidelity of their facilitation skills.
1.11 Transitions as a part of the Fourth Phase of HFW
(a) Casa Pacifica ensures that closure of services is timely and within clinical consideration. The team discusses termination with the client and family from the very first intake session, to ensure the family is aware of the time limited nature of Wraparound, as well as the reasons around fading out and ending. When the family reaches a point where they feel confident that they have enough supports and resources in place to meet current and future needs, benchmarks of success have been met, “graduation” discussions begin, and completion of formal Wraparound support takes place.
(b) When the family reaches a point where they feel confident that they have enough supports and resources in place to meet current and future needs, “graduation” discussions begin, and completion of formal Wraparound support takes place. “Graduations” are developed with the client and family, based on what they request to celebrate their success. During the graduation process, the youth and their family are provided with copies of all plans and interventions used during the process, Safety and Crisis plans are updated, and procedures for reaching out to the supports in the event that the team needs to re-convene (Post Transition Safety & Set Back Prevention Plan, pg. 86-87). The entire CFT team, including the referring party is engaged in graduation. If members are not present at the planning of a graduation, the Family Facilitator will notify the absent members, with the youth and family’s approval. (Policy and Procedure Manual, pg. 28).
Expected Outcomes
2.1 Youth and Family Satisfaction
Casa Pacifica administers a Youth Services Survey (YSS) at the end of services to evaluate satisfaction with services. We have a service delivery goal that 90% of children/youth state overall satisfaction with Wraparound Services at the dime of closure/graduation (Youth Services Survey pg. 50). In conjunction with the YSS, Casa Pacifica will be implementing the Wraparound Fidelity Index (WFI) and the Team Observation Measure (TOM) to ensure that all principles are being assessed and met throughout the implementation of the service.
In the case of an American Indian Child the Indian Child Welfare Act (ICWA) representative, as well as other natural supports, will be invited to the Child and Family Team Meetings (CFT) with consent of the youth and family. These participants could be included in WFI interviews. The Program Manager and/or Facilitator can also have direct conversations exploring any systemic barriers and satisfaction. (Casa Pacifica ICWA Policy, pg. 45-49).
2.2 Improved School Functioning
Casa Pacifica utilizes the Integrated Practice-Child and Adolescent Needs and Strengths (IP-CANS), which is completed at intake into specialty mental health services and updated at least every six months thereafter. The IP-CANS assesses multiple life domains via fifty indicators of need (school, home, relationships), plus twelve trauma indicators to inform service planning and monitor progress over time and is completed by the child and family Team.
In addition to IP-CANS data, academic functioning is monitored through collaboration with schools, support of Individualized Education Plans (IEPs), and tracking progress toward IEP goals. As part of the Medi-Cal contract requirements under CalAIM, Casa Pacifica develops both a Wraparound Plan of Care and an interdisciplinary treatment plan. When an academic impairment is identified as the result of a mental health diagnosis, staff develop SMART goals targeting functional areas such as improving focus, attendance, task completion, or behavior regulation. Progress toward these goals is reviewed during individual youth and caregiver sessions and incorporated into ongoing treatment planning (Policy and Procedure Manual, pg. 20).
For youth who are not enrolled in school, vocational or employment-related goals may be developed to address functional life domain needs. These goals are integrated into the Plan of Care and documented within the Electronic Health Record (EHR), ensuring alignment between mental health treatment objectives and Fidelity Standards.
Casa Pacifica is currently developing a formal reporting mechanism within its EHR to systematically track attendance trends and academic functioning outcomes. As well as integrate data collected from the WFI.
Additionally, the Youth Services Survey administered at discharge includes a Likert-scale item assessing whether the youth or caregiver perceives improvement in school or work functioning. This feedback contributes to overall outcome monitoring and quality improvement efforts (Youth Services Survey, pg. 50).
2.3 Improved Functioning in the Community
Casa Pacifica systematically monitors service disruptions, including incarcerations, elopements, and psychiatric hospitalizations, to assess stability and continuity of care. In addition, the organization tracks youth engagement in meaningful activities through its monthly reporting process (Monthly Report, pg. 80). Indicators of meaningful engagement include school attendance, employment, and participation in structured or pro-social community activities.
Casa Pacifica is also in the process of implementing the Wraparound Fidelity Index (WFI), which will provide additional data regarding youth and family perceptions of community functioning.
2.4 Improved Interpersonal Functioning
Casa Pacifica is in the process of implementing the Wraparound Fidelity Index (WFI), which provides data related to interpersonal functioning and overall fidelity to the Wraparound model. Findings from the WFI will be incorporated into formal reports to measure model adherence and to identify emerging or ongoing areas of need.
Additionally, the IP-CANS includes a Life Functioning domain that assesses a youth’s functioning across daily living, home, school, and social environments. As the case-holding agency, Casa Pacifica is responsible for completing and reviewing the IP-CANS in accordance with required timelines. The assessment is used to inform treatment planning, guide interventions, and address identified areas for improvement.
Through the development of the Plan of Care (POC), the Wraparound team is trained to conceptualize areas of functioning as underlying needs rather than deficits. Goals and action steps are developed through this needs-based lens and are aligned with strengths, cultural considerations, and family voice and choice. POC goals are reviewed monthly with the youth and family to monitor progress, evaluate effectiveness, and make adjustments as needed (Plan of Care, pg. 71-78).
The Youth Services Survey, provided to youth and families at the end of services, also assess areas of interpersonal functioning from both the youth and the caregivers perspective (Youth Services Survey, pg. 50, #’s 16-21).
2.5 Increased Caregiver Confidence
Through the implementation of the Wraparound Fidelity Index (WFI), Casa Pacifica will collect data related to caregiver confidence and overall perceptions of the Wraparound process. This information will support evaluation of fidelity to the model and inform quality improvement efforts.
The IP-CANS includes a Caregiver Resources and Needs domain, which assesses caregiver strengths as well as areas requiring additional support. This domain helps guide individualized planning and targeted interventions to enhance caregiver capacity and stability.
In addition, the Youth Satisfaction Survey (YSS) is administered to caregivers at discharge. The YSS includes Likert-scale items such as, “I am better at handling daily life,” and “I am better able to cope when things go wrong” (Youth Services Survey, pg. 50). Responses provide measurable data regarding caregiver confidence and perceived outcomes at the conclusion of services.
2.6 Stable and Least Restrictive Living Environment
Within the contract for SB-163, data is gathered monthly related to permanency and placement changes. Information gathered is provided in quarterly data related to permanency goals:
• 80% of children/youth will maintain community placement (parent/guardian/home-based family placement) at three-month follow‐up point (after services have ended).
• Less than 5% of clients will have new primary out of home placements while in the Wraparound program.
• Discharges: 85% or more of clients will be discharge to a lateral or lower level of care than at intake and 15% or less of clients will be discharged to a higher level of care.
• Less than 5% of clients will be incarcerated during any quarter.
• Less than 5% of clients will be admitted to an acute psychiatric facility during any quarter.
• At least 95% of clients will have stable and/or permanent housing. (Quarterly Reports, pg. 83-85)
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Through the implementation of the Wraparound Fidelity Index (WFI), Casa Pacifica will collect data relevant to this standard, including measures that reflect youth and caregiver perceptions of service effectiveness and overall functioning.
In addition, the agency tracks psychiatric hospitalizations monthly to monitor service stability and risk indicators. These data are analyzed and reported quarterly in alignment with established permanency and stability benchmarks. Specifically, Casa Pacifica maintains a performance standard that fewer than 5% of clients will be admitted to an acute psychiatric facility during any given quarter. This data is reviewed to inform continuous quality improvement efforts and ensure adherence to organizational and contractual expectations (Policy and Procedure Manual, pg. 13).
2.8 Reduction in Crisis Visits
The youth’s electronic health record (EHR) generates automated notifications to the Wraparound Supervisor when a crisis contact occurs, ensuring timely oversight and response. Quarterly data reporting includes the number of clients placed on psychiatric holds, hospital discharges, and whether a follow-up appointment occurred within seven days of discharge (Quarterly Reports, pg. 83-84).
Casa Pacifica maintains consistent communication with caregivers throughout a youth’s hospitalization and provides post-discharge support as clinically indicated. This may include individual sessions, safety planning, coordination of care, and ongoing crisis support to promote stabilization and continuity of services.
Through the implementation of the Wraparound Fidelity Index (WFI), additional outcome and fidelity data will be collected and integrated into agency reporting processes. The IP-CANS assesses youth mental health and emotional needs, with identified areas for improvement reviewed collaboratively by the Wraparound team to inform treatment planning. The Youth Satisfaction Survey (YSS) further captures youth and caregiver perceptions of progress, including Likert-scale items such as, “I am better able to cope when things go wrong,” and “I am better at handling daily life,” which provide measurable indicators of perceived improvement (Youth Services Survey, pg. 50).
2.9 Positive Exit from HFW
Wraparound services are of limited duration and focused on resolving the pressing issues that precipitated the need for service. The team discusses termination with the client and family from the very first intake session, to ensure the family is aware of the time limited nature of Wraparound, as well as the reasons around fading out and ending.
Transitions are constantly taking place throughout the Wraparound process. When a strategy using the support of Wraparound staff or other formal supports is identified to meet a specific need, the CFT should always be looking towards how the need will be met in the future using informal supports and community resources, including taking the physical and psychosocial needs for continuing care into account, and helping the family to identify strategies for maintaining the positive changes following the termination of services. Transitions also include planning for case closure which begins at intake and takes place throughout the Wraparound process. During the graduation process, the youth and their family are provided with copies of all plans and interventions used during the process, engage in a setback prevention plan, Safety and Crisis plans are updated, and procedures for reaching out to the supports in the event that the team needs to re-convene.
At times, unplanned terminations do occur. An unplanned termination can be the result of a family choosing to no longer participate in services, AWOL, incarceration for a significant period of time (over one month) or a client being moved to a higher level of care. In these circumstances, the Wraparound team members attempt to schedule a closure visit with the client/family to provide them with contact information for various resources that can be used to support the family, along with reminding the family of the “Once Wraparound, Always Wraparound” philosophy. The Wraparound team will also coordinate with the referring party and IPC team members to discuss ongoing needs and make a plan for coordination of care for ongoing services (Post Transition and Setback Prevention Plan, pg. 86-87).
Casa Pacifica completes discharge forms that gather information related to reason for discharge and placement at discharge. More comprehensive information is detailed in the electronic health record. This data is provided in quarterly data regarding reasons for discharge. (Avatar Discharge Form SB Wraparound, pg. 88). Data is tracked and reviewed by direct leadership staff, executive leadership, Department of Social Services, Probation, Santa Barbara County Behavioral Wellness, and Casa Pacifica’s Board of Directors (Quarterly Reports, pg. 83-85 & Wraparound Scorecard, pg. 170).
Engagement
3.1 Orientation
Engagement begins with an initial outreach call from the Family Facilitator and/or the referring agency case manager to the family within 72 hours of program acceptance (or within 24 hours if the family is experiencing an immediate crisis), following the Interagency Placement Committee meeting. During this initial contact, the Facilitator coordinates an intake appointment to complete all required documentation, including informed consent for services, grievance procedures, privacy rights, program agreements, alternative communication consents, and consent to transport (Intake Packet, pg. 89-107). The Facilitator also provides a detailed overview of services, including team roles, service frequency and intensity, and begins development of an initial safety plan. The Parent Partner participates in the intake alongside the Facilitator to enhance engagement and rapport through lived caregiver experience. Following intake, the team coordinates an initial “Meet and Greet.”
The Meet and Greet includes members of the Wraparound team, the youth, caregiver(s), the referring party, and any additional participants identified by the family. When applicable, this includes coordination with an Indian Child Welfare Act (ICWA) representative or Tribal support for youth who are eligible under ICWA. The team makes a good faith effort to conduct this meeting face-to-face within seven days of acceptance into Wraparound. Meetings are scheduled at times convenient for the family, and staff maintain flexible schedules to meet family needs (Meet and Greet Packet, pg. 108 & 113).
During the Meet and Greet, team members facilitate an age-appropriate discussion regarding the circumstances that led to the referral for Wraparound services. The phases of Wraparound are reviewed, along with the 10 Principles of Wraparound (handouts provided). The team begins identifying family and youth strengths, underlying needs, safety concerns, family values, and potential natural supports to participate in the Child and Family Team (CFT). Clear explanations of each team member’s role are provided to ensure transparency and shared understanding. The “no secrets” policy is also reviewed, clarifying what information will be shared with the referring agency to support family preservation and stabilization efforts.
Following the Meet and Greet, the Facilitator schedules either a comprehensive assessment or a “Timeline” meeting. If no current comprehensive assessment exists, the Facilitator completes one with the family, typically through two separate sessions: an individual meeting with the youth and a separate meeting with the caregiver. If a recent comprehensive assessment has already been completed by another mental health provider, the team conducts Timeline meetings instead—one with the Facilitator, Parent Partner, and caregiver, and another with the Facilitator, Child and Family Specialist, and youth. The purpose of these meetings is to obtain a detailed developmental history, assess current functioning, identify strengths and needs, and explore family history and cultural considerations to inform individualized service planning.
3.2 Safety and Crisis stabilization
(a) A safety plan is initiated during the first sessions with the family. At intake—typically conducted with the caregiver—the Wraparound crisis response process is reviewed in detail, including clear guidance regarding whom to contact in the event of a crisis. This plan also reviews individualized and specific interventions based on current needs (e.g. safety sweeping, etc.).
(b) During the Meet and Greet and subsequent individual meetings with the youth and caregivers, the HFW safety plan is further developed to include identified triggers, family and youth strengths, coping strategies, and natural supports. The plan is individualized to meet the specific needs of the family and outlines structured responses across the escalation continuum (early warning signs, active crisis, and de-escalation/recovery phases). Both proactive and reactive strategies are explored to promote stabilization and reduce risk (Safety Plan, pg. 109-112).
Information gathered through the safety planning process is also used to identify skill deficits, resource needs, and areas where Wraparound services can provide targeted support. The safety plan is reviewed and updated on an ongoing basis to reflect changes in risk level, progress toward goals, and the family’s current phase of treatment.
(c) Wraparound families have 24/7 crisis response services. Every effort is made to have at least two members of the assigned respond to the crisis Friday – Sunday. Crisis shifts are rotated throughout the Wraparound Program. Staff assigned to the Crisis Hotline include Parent Partners, Family Specialists, Family Facilitators, and Youth Partners. When feasible, staff participate in shadowing team meetings to build rapport with youth and caregivers and to gain familiarity with identified strengths, needs, and safety considerations. This practice promotes continuity of care and informed crisis response.
Families are provided with 24/7 hotline contact information at the initial meeting. This information is included in the Care Coordination brochure and on staff business cards. Additionally, the Family Facilitator sends a weekly reminder each Thursday via text message to reinforce awareness of available 24/7 crisis support.
3.3 Strengths, Needs, Culture and Vision Discovery
(a) A Plan of Care (POC) is completed within the first 30 days and then reviewed and revised based on the client, family, and treatment teams observations regarding services (Plan of Care, pg. 71-78).
Within the POC the team reviews:
1. Team Agreements (how can we work together for a positive and productive process?)
2. Youth and Family Vision (What will it look like when we have met our goals as a family? Defining their best future state with purpose, telling what the youth/family wants)
3. The Mission Statement (What do we need to accomplish during our time as a team?)
4. Benchmarks for Transition from Wraparound (How will we know it’s time to graduate from Wraparound?).
(b) During Child and Family Team (CFT) meetings, individual sessions (1:1s), and Timeline meetings, strengths and needs are systematically assessed and documented across all Life Domains (Strength and Needs Assessment, pg. 72). In partnership with the family, the team collaboratively identifies and incorporates strengths and needs into the Plan of Care (POC). Strengths are clearly articulated and reframed to be descriptive, functional, and contextualized within the family’s lived experience. Needs are individualized and assessed across life domains, basic needs, and underlying drivers. They are defined as the underlying “why” behind behaviors, distinct from goals and strategies.
The Plan of Care is formally reviewed at minimum every 90 days, with best practice efforts to review and update every 30 days to ensure responsiveness and alignment with current needs. The visual representation of the family’s strengths and needs is individualized and tailored to promote clarity, engagement, and shared understanding. As new team members join, the updated Plan of Care is shared to ensure continuity and alignment across providers.
3.4 Engage All Team Members
(a) Embedded into the Strengths, Needs, and Discovery is an Echo Map to explore and identify natural supports. In addition, the Parent Partner completes a connections map with the caregiver to also explore natural supports (Connections Map, pg. 52). These will be scanned into the youth’s electronic health record, as well as copies will be provided to the youth/caregiver.
(b) As Children’s System of Care (CSOC) partners and other supports are identified, they are integrated into the Child and Family Team with informed family consent. When new members join the team, the Facilitator provides a New Member Packet that includes the current Plan of Care, descriptions of Wraparound team roles, the 10 Principles of High Fidelity Wraparound, and any additional documentation necessary to promote alignment, shared understanding, and continuity of care.
(c) Through the initial use of Echo Mapping and Collaboration Mapping, the Wraparound team systematically identifies existing formal and natural supports. When the youth is identified as an Indian Child, the team intentionally explores available Tribal resources and actively facilitates their inclusion as collaborative partners, consistent with culturally responsive practice.
As new members join the Child and Family Team (CFT), roles and responsibilities are clearly defined and communicated to ensure shared understanding and coordinated service delivery. The team collaborates closely with the family to identify additional resources to address unmet needs and supports timely referrals and linkages to appropriate formal and natural supports. Assigned roles, action steps, and responsibilities are documented in the CFT meeting minutes to ensure accountability and continuity of care (Child and Family Team Meeting Minutes, pg. 67-69).
(d) Casa Pacifica documents participation in Child and Family Team (CFT) meetings through detailed meeting minutes. These minutes are uploaded into the youth’s electronic health record and distributed to all team participants via a weekly communication. This communication summarizes recent participation, highlights identified strengths, and outlines current needs and action steps, ensuring ongoing transparency, coordination, and alignment across the team (Child and Family Team Meeting Minutes, pg. 67-69).
3.5 Arrange Meeting Logistics
(a) Meetings are scheduled around the availability of the family and staff are flexible in their work schedules to meet the youth/family needs.
(b) During the hiring process, interview questions assess candidates’ availability and flexibility to meet the scheduling needs of youth and families (Interview Questions, pg. 162-168, 172-173). Expectations regarding responsive scheduling and family-centered engagement are clearly communicated.
Initial and ongoing training reinforce standards related to accessibility, engagement, and accommodating family availability. Additionally, weekly case consultations and individual supervision sessions provide structured opportunities for staff to identify and address barriers to engagement. Teams collaboratively problem-solve strategies to enhance participation, ensure consistent contact, and strengthen youth and family involvement in services (Individual Supervision Log, pg.53-54 & Group Supervision Log, pg. 118-119).
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
During the Meet and Greet, as well as regularly throughout the implementation of Child Family Team (CFT) meetings, the Family Facilitator will review the team agreements (Team Agreements, pg. 79). The Family Facilitator will also review these team agreements when there are new members to the CFT. During initial CFT meetings the group focuses on identifying the family’s vision and collaboratively develop a strength-based mission statement (Plan Of Care, pg. 71-78). During this process, the team also establishes preliminary benchmarks and criteria to guide eventual transition from Wraparound services. The team completes a comprehensive Strengths, Needs, and Culture Discovery to ensure services are individualized, culturally responsive, and reflective of family voice and choice (Strength and Needs Assessment, pg.73). Additionally, Wraparound staff complete or review the Integrated Practice-Child and Adolescent Needs and Strengths (IP-CANS) assessment (if not previously completed by another provider) to assess identified strengths and needs across fifty domains such as behavioral/emotional needs, life functioning, risk behaviors, cultural factors, strengths, and caregiver resources and twelve trauma indicators. The CFT team uses this information to inform service planning and intervention strategies as well as strengths upon which to further build. Within the first 30 days of enrollment, the Facilitator drafts the Plan of Care based on information gathered through team meetings, individual contacts, and collateral input. The completed Plan of Care is reviewed with the family to ensure accuracy and alignment with their vision.
(a) Within the first 30 days of service initiation, the team conducts individual meetings and Child and Family Team (CFT) meetings to gather comprehensive information regarding the youth and family’s strengths. The High Fidelity Wraparound (HFW) team actively engages the youth, caregivers, and external supports in identifying strengths that are descriptive, functional, and contextual in nature. This information is documented in a Strengths and Needs Assessment (Strength and Needs Assessment, pg. 72) which is integrated into the individualized Plan of Care to ensure services are grounded in identified assets and family voice. A copy of the completed document is provided to the youth and family, and the finalized version is uploaded into the electronic health record.
(b) Individual and family strengths are continuously identified and documented through individual contact and CFT meetings. This is done formally through a Strength, Needs, and Cultural Discovery, as well as informally (e.g. through 1:1 conversations). These strengths are incorporated into interventions, expanded resources/natural supports, the plan of care, and highlighted to support engagement and progress. The Plan of Care is reviewed and updated with the Child Family Team on a monthly basis to reflect ongoing growth, changing needs, and progress toward goals (Plan of Care, pg. 71-78).
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
(a) The High Fidelity Wraparound (HFW) team conducts pre-CFT and post-CFT meetings to review information gathered and coordinate next steps. Information is collected through individual youth sessions, Parent Partner sessions, and Child and Family Team (CFT) meetings to ensure a comprehensive and balanced understanding of strengths and needs. During this process, the team distinguishes between underlying and basic needs, focusing on identifying each need and collaborating on strategies to address them. Emphasis is placed on clearly identifying each need and collaboratively developing strategies to work towards meeting those needs including linkage to community resources, development of natural supports, and coordination with formal service providers.
During CFT meetings, the Facilitator partners with the family and team members to prioritize three to five key needs, with consideration given to any legal mandates or court-ordered requirements. The Facilitator ensures that identified need statements are clear, concise, individualized, strength-informed, and enduring in nature. These prioritized need statements are documented within the Strengths, Needs, and Culture Discovery, shared with the youth and caregiver, and incorporated into the individualized Plan of Care (Strength and Needs Assessment, pg. 72) to guide intervention and service delivery.
(b) Within each individualized need, the plan of care breaks down the Life Domain, the desired outcome Statement (how we know when the goal is met) and strengths specifically related to this outcome. Strategies are identified and then expanded into specific action items to support the overall goal. The Facilitator ensures that the outcome statements include the words will or is, are linked to the need, strength based, and are SMART (specific, measurable, achievable, relevant, and time-bound) (Plan of Care, pg. 71-78).
(c) The Plan of Care is collaborative and driven by the youth and the family. All other supports are included in the CFT meetings with the consent of the youth and family. The Plan of Care is put together by the Facilitator, reviewed with the entire CFT team, open for feedback, and then consented by the team. The initial copy is provided to the team and uploaded into the Electronic Health Record.
(d) The working Plan of Care (POC) is maintained on a secure shared drive within the client’s designated folder while the team collaborates to develop and refine key components, including the family’s vision and mission, identified strengths and needs, and measurable outcome statements. Upon completion and consent from the youth and family, finalized copies are distributed to the youth, caregiver, referring party, and extended supports (as authorized), and are uploaded into the Electronic Health Record within SmartCare through Santa Barbara County.
The team utilizes the working POC as a living document, reviewing and revising it at minimum every 30 days— or more frequently as clinically indicated—during Child and Family Team (CFT) meetings. Ongoing collaboration occurs both with the family and internally through pre- and post-CFT meetings to develop and adjust interventions and strategies aligned with achieving POC goals. All meetings and service activities are documented in progress notes within the county’s electronic health record.
(e) In addition to comprehensive onboarding, Facilitators follow a role specific training plan related to the facilitation of the Phases of Wraparound, in addition to all required HFW trainings. Facilitators are also required to attend the UC Davis Plan of Care Skills Lab (Training Plan, pg. 6-8). The Facilitators meet bi-monthly as a team to discuss programmatic and clinical skill development, including ongoing discussions around the development of the Plan of Care. The topics are determined based on leadership observation, youth/family feedback, and identified needs from the facilitators. As Casa Pacifica integrates the Wraparound Fidelity Index (WFI) and Team Observation Measure, (TOM), that data will also drive ongoing and booster trainings specific to the role of the facilitator. Facilitators meet weekly for clinical supervision as well as monthly for programmatic supervision with the Facilitator Coach.
(f) The development of the High Fidelity Wraparound Plan of Care (POC) includes natural and external supports based on the request of the caregiver/youth. If there are any concerns/barriers to this, the Wraparound team will meet to discuss strategies to support youth/families engagement and completion of the Plan of Care (e.g. an art activity to explores strengths/needs). The initial POC is developed within the first 30 days and then revisited/revised every 30 days (sooner if needed), (Plan of Care, pg. 71- 78).
4.3 Develop an Individualized Child or Youth and Family Plan
(a) Facilitators participate in role-specific booster trainings every other month to strengthen core competencies associated with High Fidelity Wraparound practice. Training topics are informed by multiple data sources, including Youth Services Survey results (direct feedback collected from youth and families at discharge), findings from the Wraparound Fidelity Index (WFI), Team Observation Measure (TOM) data, and themes identified through supervision, direct observation, and staff requests for additional support (Youth Services Survey, pg. 50).
Casa Pacifica develops targeted, role-specific booster trainings to reinforce collaborative planning skills, effective facilitation of Child and Family Teams, strategy development, and alignment with High Fidelity Wraparound standards. In addition, Casa Pacifica incorporates relevant trainings and implementation guidance released by UC Davis to ensure ongoing alignment with state-level expectations and best practices.
This structured, data-informed training approach ensures Facilitators continuously strengthen their ability to guide teams in identifying underlying needs, prioritizing focus areas, selecting strengths-based strategies, and developing clear, measurable action steps.
(b) The development of the Plan of Care incorporates and prioritizes all applicable legal mandates to ensure compliance with court orders and child welfare or probation requirements. The youth’s assigned Social Worker and/or Probation Officer are actively included in the collaborative development process to support alignment with mandated conditions and system expectations. Through extensive exploration of natural supports and additional formal service providers, Casa Pacifica engages identified supports—upon obtaining appropriate consent from the youth and caregiver—in the development of goals and objectives. When appropriate, specific tasks and action steps are assigned to team members to promote shared accountability and empower the utilization of natural supports for long term success of goals.
(c) The finalized Plan of Care is uploaded into the electronic health record within SmartCare through Santa Barbara County, where it is accessible to authorized county mental health providers. A working copy is also maintained on Casa Pacifica’s secure shared drive for Wraparound team access to support ongoing collaboration and updates.
Copies of the finalized Plan of Care are provided to the youth and family. Additional copies are distributed to other treatment providers or supports, as authorized through signed consent by the family.
(d) The Fidelity Coach observes staff and reviews the development of Plans of Care, providing strength-based feedback when standards are not being fully met. The HFW Manager collaborates with the Fidelity Coach to offer ongoing training and support related to Plan of Care development and program expectations. During weekly or bi-weekly supervision, the Clinical Supervisor supports the Facilitator’s clinical growth and skill-building (e.g., engagement tools and strategies), including the integration of clinical goals. Additional tools used to inform ongoing and booster trainings include the Wraparound Fidelity Index, the Team Observation Measure, and the Youth Services Survey, administered at discharge to gather family feedback (Policy and Procedure Manual, pg. 24-25).
4.4 Develop a Crisis and Safety Plan
(a) During the initial meeting, the Facilitator, Clinical Supervisor, and Parent Partner meet with the caregiver to review informed consents, policies, and procedures. At this time, the team begins gathering information from the caregiver regarding family strengths, current needs, and safety considerations. An initial safety plan is created, which includes assessing risk of harm to self or others, identifying current responses and interventions, and outlining proactive and reactive strategies.
The caregiver is provided with a visual resource containing 24/7 crisis support numbers, including the Wrap team (Monday–Thursday), the Wraparound Hotline (Friday–Sunday), as well as county crisis hotlines and emergency response services (Care Coordination Flyer, pg. 114).
The safety plan is then further developed and individualized following the Meet and Greet (initial meeting with the youth and treatment providers) and initial 1:1 sessions with the youth and caregiver. Individual sessions are used to support engagement and allow for more comfortable information sharing. Once sufficient information has been gathered, the Facilitator develops a comprehensive safety plan and distributes copies to the youth, caregiver, treatment team, and referring party. The finalized plan is also uploaded to the client’s electronic health record with Santa Barbara County (Safety Plan, pg. 109-.112). Safety plans are re-assessed and revised regularly to best support current strengths, needs, and supports.
(b) Facilitators receive both initial and ongoing training specific to the development and implementation of individualized safety plans. Training emphasizes family voice and choice, ensuring that safety plans reflect the youth’s and caregiver’s own language, identified needs, and culturally responsive considerations. Plans are tailored to the unique strengths, risks, and circumstances of each family (Training Plan, pg. 4-7).
Program leadership utilizes fidelity and observation tools—including the Wraparound Fidelity Index (WFI) and the Team Observation Measure (TOM)—to evaluate practice quality and identify areas requiring additional skill development. Findings from these tools inform the development of targeted booster trainings to strengthen safety planning competencies.
Facilitators also have access to a clinician for consultation 24 hours a day, 7 days a week, to support ongoing clinical decision-making and professional growth. Safety planning is further reinforced through weekly clinical supervision, where safety plans are reviewed and assessed to ensure they remain relevant, responsive, and are individualized with the collaboration of the youth and family.
(c) Through ongoing observation with the HFW coach, information discussed within clinical supervision, and ongoing/booster trainings the HFW team is consistently reviewing crisis and safety plans. Following a crisis contact; the Clinical Supervisor or HFW Manager will contact the family to conduct a follow up call (enquiring about their experience and ongoing needs/concerns). Information gathered will be provided back to the staff, directly or as a team. As a response to this, system and processes can also be improved to best support the youth and caregiver, as well as the staff’s ability to support in a crisis.
Implementation
5.1 Implement The Plan of Care
(a) The High Fidelity Wraparound (HFW) team coordinates and facilitates the Child and Family Team (CFT) meetings on a weekly or bi-weekly basis, depending on the youth and family’s level of need and progress. Meetings are facilitated by the Family Facilitator to ensure adherence to Wraparound principles and effective team coordination.
Prior to each CFT meeting, the Family Facilitator reviews the previous meeting minutes, the current Plan of Care, and prepares a structured agenda to guide discussion and maintain focus on prioritized needs and outcomes.
During the meeting, the Family Specialist documents detailed minutes, including identified strengths, current areas of need or concern, progress toward established strategies, and updates on assigned action items. Action items from the previous meeting are reviewed to highlight successes, reinforce accomplishments, and collaboratively problem-solve any barriers impacting completion. New or revised action steps are documented in the meeting minutes with clearly identified responsible parties and timelines.
When Plan of Care strategies or tasks are successfully completed, progress is formally acknowledged within the meeting and celebrated to reinforce strengths and maintain team momentum. Copies of the finalized CFT minutes are distributed to the treatment team on a weekly basis to support transparency, accountability, and coordinated service delivery (Child and Family Team Meeting Minutes, pg. 67 & Family Facilitator Agenda, pg. 116).
(b) Staff receive foundational training in High Fidelity Wraparound (HFW) through High Fidelity 101 delivered by a certified trainer from UC Davis. In addition, team members participate in role-specific trainings that clarify their responsibilities in supporting the development, implementation, and ongoing monitoring of the Plan of Care (Training Plan, pg. 4-8).
The HFW Coach provides structured observation of Child and Family Team (CFT) meetings and offers direct coaching and feedback to ensure practice remains aligned with High Fidelity Wraparound principles. Observational findings are incorporated into individualized coaching plans, ongoing staff development, and targeted booster trainings to address identified areas of growth.
Program leadership utilizes multiple fidelity and feedback tools—including the Wraparound Fidelity Index (WFI), the Team Observation Measure (TOM), and Youth Services Survey results—to inform continuous quality improvement efforts. Data trends are reviewed to identify training needs and reinforce strengths-based, family-driven practice (Youth Services Survey, pg. 50).
Casa Pacifica intentionally trains and models a strengths-based perspective across all levels of the organization. Leadership reinforces this approach during consultation and case discussions by highlighting progress, celebrating small successes, and emphasizing the identification and application of youth and family strengths throughout service delivery.
5.2 Review and Update The Plan of Care
(a) The High Fidelity Wraparound (HFW) Team facilitates regular team meetings to review identified strengths, current needs or concerns, and progress on action items. During these meetings, the team collaboratively explores available resources, natural supports, and community-based services that may assist the youth and family in meeting prioritized needs and building upon existing strengths.
Ongoing communication is maintained through phone and email correspondence to ensure timely coordination of care. These communications include updates regarding strengths, emerging concerns, progress toward Plan of Care strategies, and assigned action steps.
On a weekly basis, formal treatment providers and team members receive a structured email update that includes Child and Family Team (CFT) meeting minutes, identified strengths, prioritized needs, current action items, and the date of the next scheduled meeting (Weekly Email Template, pg. 70). This process supports transparency, accountability, and consistent collaboration across systems involved in the youth’s care. All communication is documented with the youth’s electronic health record within SmartCare through Santa Barbara County.
(b) The Plan of Care is formally reviewed at minimum every 30 days, or more frequently as clinically indicated, during a Child and Family Team (CFT) meeting. This review includes reassessing identified strengths and needs, evaluating progress toward established outcome statements, and refining strategies and action steps to reflect the youth and family’s current circumstances (Plan of Care, pg. 71-78).
Completed tasks are documented within the Plan of Care, and progress is highlighted to reinforce accomplishments and guide next steps. When necessary, the Plan of Care is revised to ensure continued responsiveness to emerging needs, changes in legal mandates, or evolving family priorities. The updated Plan of Care is uploaded into the electronic health record within SmartCare through Santa Barbara County. Copies of the revised document are distributed to authorized team members to support coordinated and consistent implementation.
(c) Child and Family Team (CFT) minutes are completed during each CFT meeting (CFT Minutes, pg. 67-69). The minutes document attendance, review of prior action items and follow-up status, newly developed action steps based on team discussion, and any updates or revisions to the Plan of Care. This ensures accountability, transparency, and continuity of care.
Flexible fund utilization is discussed during CFT meetings when applicable, including consideration of identified needs, reinforcement of progress, or removal of barriers to goal achievement. When flexible funds are recommended, requests are submitted to the HFW Manager for review and approval (Flex Fund Request, pg. 127). Flexible fund expenditures are tracked internally and formally reported to Child Welfare on a semi-annual basis to ensure fiscal accountability and compliance.
All finalized CFT minutes are distributed to team members through a weekly email update to promote coordinated communication and alignment across formal and natural supports. The minutes are also uploaded into youth’s electronic health record.
(d) Forms are flexible to ensure that they remain individualized to the ongoing needs of the you, family, and Child and Family Team (CFT). Templates are designed to be updated and individualized based on strengths, needs, cultural considerations, etc. When adjustments are made, the revisions are made to ensure that they accurately reflect the youth/families voice and needs while maintaining alignment with High Fidelity Wraparound standards.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
(a) Team agreements are utilized at the start of services, revisited regularly, and when there are new members to the Child Family Team (CFT) (Wraparound CFT Group Agreement, pg. 79).
(b) Facilitators receive comprehensive training in coaching, engagement, and sustaining effective Child and Family Teams. Core training components include motivational interviewing, solution-focused techniques, team cohesion strategies, effective communication skills, and fostering connection among team members. This preparation ensures Facilitators are equipped to lead collaborative, strengths-based teams consistent with High Fidelity Wraparound principles. (Training Plan, pg. 5-7).
Ongoing professional development is provided by the HFW Coach and HFW Manager through individualized skill-building sessions, bi-monthly booster trainings, in-the-moment coaching, during observed meetings, and data collection from the Wraparound Fidelity Index and the Team Observation Measure. This model reinforces facilitation skills and promotes continuous improvement in team engagement and effectiveness.
The HFW Clinical Supervisor further strengthens team cohesion through clinical supervision, providing advanced guidance on relational dynamics, conflict resolution, trauma-informed engagement, and clinical interventions that support collaboration and alignment within the team.
(c) During weekly case consultation meetings, each High Fidelity Wraparound (HFW) team presents and discusses the identified needs of the youth and family. The full HFW team collaboratively brainstorms potential natural supports, community resources, and creative strategies to address prioritized needs and build upon strengths. Identified ideas are incorporated into action items for the upcoming Child and Family Team (CFT) meeting and are also assigned internal follow-up tasks to be reviewed at the subsequent weekly case consultation. This structure promotes accountability, shared problem-solving, and continuity of planning (Policy and Procedure Manual, pg. 38).
In addition, the HFW Coach’s, HFW Manager, HFW Clinical Supervisor meet weekly leadership meetings to review programmatic and clinical implementation in alignment with High Fidelity Wraparound standards and principles (Leadership Minutes, pg. 120). During these meetings, fidelity data, staff feedback, and emerging family needs are discussed, and the leadership team develops structured support plans to strengthen practice.
Support may include individualized coaching provided by the HFW Coach, focused clinical guidance through supervision, or targeted skill development delivered in group training during weekly case consultation. This multi-tiered approach ensures continuous quality improvement while supporting both staff development and positive outcomes for youth and families.
(d) When new members are integrated into the Child and Family Team (CFT), the High Fidelity Wraparound (HFW) team provides an overview of the Wraparound process, 10 principles, and the family’s established vision and priorities. Natural supports are invited to participate in CFT meetings to strengthen community connection and shared ownership of the Plan of Care.
The HFW team empowers the youth and caregiver to lead discussions related to outcome statements and progress toward tasks that support the family’s vision. This reinforces family voice and choice while promoting self-advocacy and shared accountability. New team members are provided with a copy of the current Plan of Care and offered an opportunity to ask questions to ensure clarity regarding goals, strategies, and assigned responsibilities.
During pre-CFT meetings, the HFW team proactively plans individualized engagement strategies tailored to the youth and family’s interests, cultural values, and preferences. Creative approaches—such as incorporating interactive activities, icebreakers, shared meals, or culturally meaningful practices.
Transition
6.1 Develop a Transition Plan
(a) Wraparound services are of limited duration and focused on resolving the pressing issues that precipitated the need for service. The team discusses termination with the client and family from the very first session, to ensure the family is aware. Transition planning is an ongoing process throughout the Wraparound experience, emphasizing sustainability and long-term success.
When strategies are implemented using the support of Wraparound staff or other formal providers, the Child and Family Team (CFT) concurrently consider how identified needs will be met in the future through informal supports, community resources, and family-led strategies. This includes attention to both physical and psychosocial considerations to ensure the family can maintain positive changes following the conclusion of formal services. Planning for case closure begins at intake and continues throughout the Wraparound process, supporting a seamless transition and continuity of care (Policy and Procedure Manual, pg. 28-29).
During the initial development of the Plan of Care, the team identifies benchmarks and indicators of success to guide progress monitoring. At minimum every 30 days, the Family Facilitator reviews the Plan of Care with the Wraparound team, referring parties, the family, and identified natural supports to highlight accomplishments and assess movement toward established benchmarks. As families achieve goals and demonstrate progress, the Family Facilitator initiates discussions during CFT meetings to formulate individualized transition plans. When the youth and family feel confident that adequate support and resources are in place to address current and anticipated needs, graduation discussions occur, marking the completion of formal Wraparound services and the transition to sustained, community-based supports.
(b) A Transition Plan (Transition Plan, pg. 122-123) is developed by the Family Facilitator in collaboration with the Child and Family Team (CFT) to ensure a structured and individualized approach to service completion. Information gathered during CFT meetings, including identified strengths, needs, strategies, and progress toward goals, is integrated into the Transition Plan to guide the family toward sustainable supports and continued success. The Transition Plan is reviewed with the youth and family, shared with natural/formal as appropriate, and uploaded into the youth’s electronic health record within SmartCare to ensure accessibility and continuity of care.
(c) The HFW Coach and HFW Manager provide ongoing supervision and guidance to facilitate the professional growth of Family Facilitators, including oversight of responsibilities across all phases of treatment, with a focus on effective transition planning that includes collaboration with the Child Family Team. Facilitators also participate in regular team trainings targeting role-specific responsibilities, skill development, and fidelity to High Fidelity Wraparound standards. The Facilitator Task List (Facilitator Task List, pg. 1) outlines step-by-step responsibilities for the transition phase, supporting consistent and structured implementation of the Transition Plan. Through the implementation of the Wraparound Fidelity Index and the Youth Services Survey (Youth Services Survey, pg. 50) the HFW Coach and Manager can review and build booster and ongoing trainings related to that feedback.
(d) Following graduation and celebration of services, Casa Pacifica provides up to 30 days of aftercare for all clients, including post adoption. This may include targeted case management and care coordination to ensure continuity and stability, as well as crisis support. This aftercare period is designed to reinforce progress made during services, monitor the effectiveness of the transition plan, and address any emerging needs.
Wraparound operates under the guiding principle, “Once Wrap, Always Wrap.” If additional support is needed after formal discharge, the team assists with linkage to appropriate community resources or service providers to promote sustained success. Youth and families are encouraged to also utilize the FURS hotline for support up to their twenty-first birthday if they are Child Welfare or Juvenile Justice involved.
The Wraparound team also coordinates with the referring party and Interagency Placement Committee (IPC) members to review ongoing needs and develop a plan for continued collaboration and service coordination. This ensures alignment across systems and supports a seamless transition to ongoing or step-down services when appropriate.
6.2 Develop a Post-Transition Safety Plan
(a) Upon initiation of termination discussions, the Family Facilitator collaborates with the youth, caregiver, and identified supports during a Child and Family Team (CFT) meeting to develop a comprehensive Post-Transition Safety and Setback Prevention Plan (Post Transition Safety and Setback Prevention Plan, pg. 86-87). This plan includes a review of the youth and family’s strengths, identification of potential triggers or early warning signs, proactive coping strategies and skill utilization, and clearly defined reactive steps should a crisis begin to emerge. The team also outlines identified natural and formal support systems available following Wraparound, addresses environmental and safety considerations, and documents relevant crisis contact numbers to ensure clarity and accessibility.
The finalized plan is provided to the youth and caregiver and shared with authorized formal and natural supports to promote coordinated response and sustained stability. A copy of the plan is uploaded into the youth’s electronic health record within SmartCare through Santa Barbara County to ensure documentation, continuity, and accessibility.
(b) Family Facilitators receive role-specific training during onboarding related to the development and implementation of Transition Plans and Post-Transition Safety and Setback Prevention Plans. This training emphasizes individualized planning, inclusion of family voice and choice, and alignment with High Fidelity Wraparound principles.
As a Facilitator begins working with a new family, the HFW Coach, HFW Manager, and HFW Clinical Supervisor provide structured support through coaching, direct observation, shadowing of meetings, and individualized feedback across each phase of the Wraparound process. This ensures Facilitators build competency and confidence in leading transition planning efforts.
Facilitators are trained to engage all treatment team members—formal and natural supports—in the development of the Post-Transition Safety and Setback Prevention Plan to ensure shared understanding and coordinated response following discharge. The template is intentionally designed to reflect the youth’s and caregiver’s own language, promoting accessibility, ownership, and usability.
Ongoing quality improvement is supported through direct observation, booster trainings, and the use of fidelity and feedback tools, including the Wraparound Fidelity Index (WFI), Team Observation Measure (TOM), and Youth Services Survey (YSS). Data from these sources is reviewed regularly to identify strengths in practice and inform targeted training and coaching to address emerging needs.
(c) The Transition Safety and Setback Prevention Plan is designed as a flexible template intended to be individualized using the youth’s and caregiver’s own language to ensure clarity, accessibility, and ease of use. The template serves as a structured framework; however, content is adapted to reflect each family’s unique strengths, needs, cultural considerations, and preferences. While the plan is currently available in English and Spanish, interpretation or translation into additional languages can be arranged as needed to ensure equitable access.
The plan includes a review of potential future triggers, early warning signs, proactive coping strategies, and clearly defined reactive steps should a crisis arise. Emphasis is placed on practical, family-driven strategies that can be implemented independently following the conclusion of Wraparound services.
Through direct observation and shadowing of meetings, ongoing supervision, and weekly team consultations, the HFW Coach, HFW Manager, and Clinical Supervisor provide continued guidance and skill development related to effective transition planning and safety plan development. This layered support structure promotes fidelity to High Fidelity Wraparound principles and ensures transition planning remains individualized, strengths-based, and clinically sound.
6.3 Create a Commencement and Celebrate Success
(a) Casa Pacifica follows the 10 principles of Wraparound throughout the phases of treatment. Cultural competence, family voice and choice, and individualization are center points in the planning and implementation of the conclusion of services, ensuring that any type of transitions out of Wraparound are experienced in a positive way by the youth and family. The Parent Partner, Family Specialist, and Youth Partner will work directly with the youth and caregivers to discuss what type of closure they would want based on their family values, culture, and beliefs. The HFW team then will meet to plan out in detail the final meeting/celebration/graduation as close to the youth and family’s wishes as possible.
(b) With the permission of the youth and family, the entire CFT team, including the referring party is engaged in the celebration. The celebration is coordinated/scheduled based on the youth/caregivers availability. Pending approval from the youth and caregiver, additional attendees are invited to celebrate and highlight the youth/family’s success. Wraparound will provide transportation if needed. Flex funds are also utilized to help support funding the celebration. During the celebration, the team will highlight participation, goal progression, developed strengths, etc. If they choose, youth and families are provided with a parent/client binder offering additional community resources outside of those resources utilized during the process and individualized to family needs (Policy and Procedure Manual, pg. 28-29), and the youth and/or caregiver may be presented with an individualized graduation certificate for achieving the goals they identified if appropriate. (Graduation Certificate Template, pg. 171).
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
(a) During the course of services, the Wraparound team utilizes the Wraparound Fidelity Index (WFI) to monitor the quality and integrity of High Fidelity Wraparound implementation. The WFI is used to assess adherence to core principles, identify areas for improvement, and ensure services remain individualized.
At discharge, Casa Pacifica administers the Youth Services Survey (YSS) to caregivers and youth ages 12 and older. The survey measures overall satisfaction as well as perceptions related to inclusion, cultural responsiveness, service implementation, and current functioning. Participants are also provided the opportunity to offer open-ended feedback in their own words regarding what was helpful, what could be improved, and whether they would recommend services (Youth Services Survey, pg. 50).
Survey results are reviewed by the leadership team, including the HFW Manager, Clinical Supervisor, and Coaches, to evaluate systemic trends, identify strengths in service delivery, and address system-level improvements related to implementation fidelity and family experience.
Following any crisis response, the High Fidelity Wraparound Manager or Clinical Supervisor contacts the family to assess their experience and gather direct feedback. This information is reviewed by the leadership team to identify learning opportunities and inform individualized coaching, targeted training, and potential system adjustments. This structured feedback loop supports continuous quality improvement and ensures services remain responsive to the voices and experiences of youth and families (Crisis Satisfaction Survey, pg. 169.
(b) Data collected from the Wraparound Fidelity Index (WFI) and Youth Services Survey (YSS) is reviewed by the Wraparound Leadership Team to evaluate service quality, fidelity to High Fidelity Wraparound principles, and overall family experience. Feedback is reviewed to identify strengths, areas for growth, and opportunities for system improvement. When feedback indicates a need for change, the Leadership Team develops and implements action plans, which may include targeted training, process revisions, or coaching supports.
As the contracted provider for SB-163, Aftercare, and Adoption Assistance, Casa Pacifica participates in quarterly contract monitoring meetings with Santa Barbara County Behavioral Wellness, Santa Barbara County Child Welfare Services, and Santa Barbara County Probation Department (WIT Leadership Agenda, pg. 124-125). These meetings include review of contract goals, performance outcomes, and implementation monitoring.
During these collaborative sessions, Casa Pacifica shares feedback from youth and families related to the referral process, service implementation, engagement experience, and quality improvement efforts. This partnership supports transparency, cross-system alignment, and continuous improvement in Wraparound service delivery.
Additionally, every quarter outcomes are gathered including if youth were able to maintain their level of placement upon discharge, with the goal being at least 85% of youth are discharged to a lateral or lower level of care/placement (Quarterly Reports, pg. 83-85).
7.2 Community Leadership Team
As the contracted provider for SB-163, Aftercare, and Adoption Assistance Wraparound services, Casa Pacifica participates in quarterly WIT Leadership meetings. These meetings include members of the Community Leadership Team, with representation from Santa Barbara County Behavioral Wellness, Santa Barbara County Probation Department, and Santa Barbara County Child Welfare Services. (WIT Leadership Agenda, pg. 124-125)
During WIT Leadership meetings, the team reviews overall program status, including current enrollment and waitlist data (Casa Pacifica is contracted for 15 Wraparound slots which include aftercare youth, open child welfare cases, families in voluntary family patience, adopted youth, and youth on probation), budget updates, service utilization trends, quarterly performance measures, and identified quality improvement initiatives. These meetings ensure contract compliance, fiscal oversight, and cross-system accountability.
In addition, Casa Pacifica attends the weekly Interagency Placement Committee (IPC) meeting. IPC is a multidisciplinary interagency committee composed of supervisory and/or line-level representatives from public and private agencies, including Casa Pacifica, the Department of Social Services (chair), Probation, Behavioral Wellness, Education, Community-Based Organizations (CBOs), and a Parent Partner (IPC Agenda, pg. 126). IPC meets weekly to collaboratively review and authorize Wraparound placement services for youth at risk of out-of-home placement and/or in need of services to support family reunification. The committee also works to ensure that children can safely remain in their homes without compromising the safety of family or community members. Casa Pacifica ensures that a Parent or Peer Partner attends IPC meetings to represent the voice of youth and families and to provide lived-experience perspective in service planning and decision-making.
7.3 Eligibility and Equal Access
(a) Referrals to Casa Pacifica are reviewed and approved through the Interagency Placement Committee (IPC). As noted previously, IPC evaluates each referral to determine the appropriate level of care based on the youth and family’s presenting needs and risk factors. Referrals submitted to IPC include comprehensive background information to support informed decision-making. This includes personal and identifying information; current behaviors; mental health status and treatment history; abuse and trauma history; substance use history; legal involvement; identified safety concerns or threats; critical risk assessment information; academic background; cultural and diversity considerations (including primary and secondary languages); relevant family history; identified service needs; and family expectations regarding services.
IPC members collaboratively review the information to ensure that urgent and emergent situations are prioritized, and cultural and linguistic needs are identified and addressed. The committee’s goal is to ensure youth and families have access to the most appropriate and least restrictive treatment resources available, with coordinated and responsive cross-system support. When a referral is determined not to meet eligibility criteria or when immediate service availability is limited, IPC coordinates with the referring party to ensure families receive referrals and connections to alternative appropriate resources. IPC approval requires consensus from representatives of Santa Barbara County Behavioral Wellness, Santa Barbara County Probation Department, and Santa Barbara County Child Welfare Services. If consensus cannot be reached, the decision is deferred to Wraparound Leadership for further review.
All clients are considered equitably in accordance with contract criteria. Under the current SB-163 contract, eligibility includes:
• The youth is at immediate risk of residential placement and would likely be placed if Wraparound services were not available.
• The youth has stepped down from a Short-Term Residential Therapeutic Program (STRTP) and is eligible for six months of Aftercare Wraparound.
• The youth is involved in at least one system of care:
o Child Welfare (Voluntary Family Maintenance or Welfare and Institutions Code 300)
o Juvenile Probation (Welfare and Institutions Code 601 or 602)
Adoption Assistance Wraparound services are also available to promote placement stabilization and prevent disruption for eligible families.
(b) Upon acceptance into Wraparound services, a multidisciplinary team consisting of a Family Facilitator, Parent Partner, and Family Specialist is assigned by the Leadership Team, including the HFW Manager, Clinical Supervisor, and Coaches. Team assignments are thoughtfully determined based on multiple factors to ensure appropriate fit and service alignment. Considerations include the youth and family’s identified needs and strengths, cultural and linguistic considerations, geographic location, staff expertise, case complexity, required level of supervision, intensity of service needs, and current staff caseloads (Policy and Procedure Manual, pg. 19-20).
Caseload distribution is reviewed carefully, recognizing that youth and families may be in varying phases of treatment and require differing levels of support (e.g., frequency of Child and Family Team meetings may shift from weekly to bi-weekly as progress occurs). This approach supports balanced workloads and responsive service delivery.
Wraparound services include 24/7 crisis support to ensure families have access to assistance when needed. Monday through Thursday, all assigned team members are available for crisis response and support. From Friday through Sunday, a designated on-call staff member provides crisis coverage. To promote continuity and effective response, staff shadow one another and maintain familiarity with assigned youth and families to ensure rapport, understanding of strengths and needs, and preparedness to provide informed crisis support.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
(a) Casa Pacifica is the sole provider for Wraparound Senate Bill 163 in Santa Barbara County through contracts with Santa Barbara County Department of Behavioral Wellness (BWELL) and Santa Barbara County Department of Social Services (DSS). The Department of Social Services has approved 15 slots for foster youth (WIC 300) or Adoption Assistance Program (AAP) eligible, and youth on formal probation (WIC 602), funded through two separate contracts. Senate Bill 163 (SB 163) (Chapter 795, Statutes of 1997) provides for the establishment to keep eligible foster care children/youth in, or return them to, permanent family settings (out of high level settings such as an STRTP) utilizing Wraparound Services, focusing on a collaborative approach to care that encourages coordination across agencies, disciplines, and communities to enhance outcomes for children and families. In the Wraparound model,. DSS “places” a child in a family home (rather than placing them in a group home) and uses funds (including flex funds) to provide “whatever it takes” to enhance safety, permanency, and well-being for children and youth consistent with state and federal mandates, while partnering with county mental health to ensure the youth’s mental health needs are addressed and treated. This is done both at the county’s mental health BWELL clinic (such as psychiatric care) and through Casa Pacifica’s Wraparound team (such as a mental health assessment and mental health interventions focused on addressing the youth’s functional impairments related to their mental health diagnosis). This collaborative approach between DSS and BWELL results in two contracts with Casa Pacifica in which both have shared fiscal responsibilities to ensure the youth and family’s needs are met to stabilize placement in a home. This funding structure ensures that all required Wraparound services, staffing, and supports are fully resourced and aligned with program standards.
(b) Casa Pacifica SB-163 Wraparound ensures that workforce development and staffing requirements align with High Fidelity Wraparound standards, including all roles and functions outlined in Workforce Development Standard 9.3. All positions necessary for effective service delivery. Each of Casa Pacifica’s Wraparound teams are currently comprised of a Family Facilitators, a Parent Partner, a Family Specialist, a HFW Coach, and then overseeing the case is a HFW Manager, and Clinical Supervisor. Additionally, the Wraparound program has employed a Youth Partner on the team that will serve in that role,
Staffing levels and caseload assignments are monitored to ensure teams can meet the intensity of service required for each youth and family. Leadership reviews workforce needs regularly to maintain coverage for all required functions, including participation in Child and Family Team meetings, crisis response, and ongoing coaching and supervision.
(c) Casa Pacifica participates in quarterly Wraparound Implementation Team (WIT) meetings with representatives from Probation, Behavioral Wellness, and Wraparound leadership, as well as other community stakeholders (Office of Education,) at times. The WIT agenda includes review of program status, budget, staffing, service utilization, adherence to High Fidelity Wraparound standards, quarterly performance measures, updates from the Interagency Placement Committee, and reports from the California Wraparound Advisory Committee. Quarterly reporting is aligned with contract goals for Behavioral Wellness and Child Welfare (WIT Leadership Agenda, pg. 124-125).
Casa Pacifica has integrated the IP-CANS as a measurement tool to assess youth needs, functioning, and outcomes.
Moving forward, for Fiscal Year 2026/2027, Casa Pacifica, Behavioral Wellness, Probation, and Child Welfare will collaborate to establish quarterly goals aligned with High Fidelity Wraparound principles, including fidelity indicators (WFI, TOM), academic functioning, and Youth Services Survey (YSS) results, to strengthen program evaluation, fidelity monitoring, and data-driven decision-making (Youth Services Survey, pg. 50). Casa Pacifica will be focused on developing new outcome measures and data tracking integrating the WFI, TOM, and any additional assessment tools.
8.2 Equitable Funding Across System Partners
8.3 Cost Savings are Reinvested
Any additional savings or discretionary funding is determined by Santa Barbara Department of Social Services. Casa Pacifica SB-163 Wraparound does not control or allocate these funds but ensures that services are delivered in alignment with contract requirements and High Fidelity Wraparound standards, using available resources to meet the individualized needs of youth and families.
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
(a) All youth and families participating in SB-163 Wraparound have access to flexible funds that are approved based on identified needs. The Parent Partner collaborates with the caregiver to develop an initial family budget no later than 10 days from the completion of the Plan of Care, covering six (6) months of estimated expense/needs, outlining the requested amount for the flex fund. This budget is submitted to Santa Barbara County Department of Social Services (DSS) for approval.
Once approved, Casa Pacifica internally tracks the allocation and use of flexible funds, unless a larger sum requires additional approval. In such cases, the Wraparound team may present the request at the weekly Interagency Placement Committee (IPC) meeting to obtain approval. Reconciliation of flexible fund spending is submitted to Santa Barbara County DSS every six months, along with a new approval request for the subsequent period. This process ensures that flexible funds are allocated transparently, equitably, and in alignment with family-identified needs (Flex Fund Requests and Budgets, pg. 127-134).
(b) To promote independence and self-sufficiency, the Wraparound Team engages families in a customized Resource Bank—a tool designed to address specific needs by identifying and expanding natural, social, and community supports that are low-cost or no-cost. Prior to utilizing the Resource Bank, the Wraparound Team may research appropriate community services to meet the family’s identified needs. Flexible funds or staff time are considered only as a last resort when natural and community supports have been exhausted.
When a need is identified, the team collaborates via phone, text, or team meeting to confirm the need and associated criteria. If the cost of meeting the need exceeds $20, the assigned team member submits a Flex Fund request to the Program Manager. The Program Manager has 24 hours to review and approve the request based on the documented criteria. For urgent needs, verbal consent from the Program Manager may be obtained to immediately address the request, followed by formal documentation. Ongoing or recurring needs are reviewed during Child and Family Team meetings, and referrals to financial or credit counseling resources may be incorporated into the Plan of Care when appropriate.
Flex Fund requests under $500 are approved by the Program Manager. Requests exceeding $500 require approval from both the Program Manager and the Director of Community-Based Services. The Interagency Placement Committee (IPC) is also consulted for approval of larger requests. If a request is denied, the family receives a clear, policy-based explanation. A trauma-informed appeal process is available, designed to be simple for families to understand and complete. Appeals are reviewed by the leadership team, with a secondary reviewer (e.g., Assistant Community Director) utilized when possible to ensure transparency and fairness.
8.5 Collaborative Oversight of Flex Funds
(a) Upon opening a client to Wraparound, an initial 60-day budget is developed to allow the family to access up to $1,000 in flexible funds prior to completion of the Plan of Care (Initial Budget, pg. 128). This initial budget is submitted to Santa Barbara County DSS for approval. Once the Plan of Care is developed and specific needs are identified, a 1–6 month budget is created. This budget accounts for funds expended during the first 30 days and allocates additional funds as needed to support ongoing goals and objectives. If further funds are required beyond the approved allocation, the Program Manager may seek additional approval from the Interagency Placement Committee (IPC) to ensure appropriate oversight and alignment with funding policies and Wraparound standards.
Reconciliation of flexible fund expenditures is submitted to Santa Barbara County DSS Services every six months, accompanied by a new approval request for the subsequent period. This process ensures that flexible funds are allocated transparently, equitably, and in alignment with family-identified needs.
Within the reconciliation, expenditures are summarized by specific domains, while Casa Pacifica maintains detailed, itemized records of all spending. Each flex fund request includes information documenting the purpose of the request and its alignment with High Fidelity Wraparound standards. Detailed itemized records and request documentation can be provided to Child Welfare or Probation upon request (Budget Reconciliation, pg. 132).
(b) Currently, Casa Pacifica budgets a designated amount for flex fund requests within the SB-163 contract. This allocation is based on estimated needs derived from the previous year’s spending with Santa Barbara County DSS. Casa Pacifica is actively collaborating with Child Welfare and Probation to discuss and clarify specific flex fund allocations, ensuring that funding levels are appropriate to meet family-identified needs while maintaining compliance with contract requirements and High Fidelity Wraparound standards.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
(a) Casa Pacifica SB-163 operates under two contracts to ensure that the program is able to do “whatever it takes” to keep eligible foster youth in, or return them to, permanent family settings by “placing” them into a family home rather than a high-level group home. Santa Barbara County Department of Social Services (DSS) contracts with Casa Pacifica to place an eligible youth (Welfare and Institutions Code 300, 602, or Adoptions Assistance Program eligible) into the Wraparound program, and Santa Barbara County Department of Behavioral Wellness (BWELL) partners with Casa Pacifica to assess and treat the youth’s mental health needs while in the program.
Casa Pacifica maintains ongoing communication with Behavioral Wellness, Probation, and Child Welfare to discuss funding strategies, including recommendations for braided funding. These discussions aim to optimize resource allocation, ensure sustainability, and support the provision of high-fidelity Wraparound services that meet the individualized needs of youth and families across a variety of funding streams. Currently, flex funds are funded through Santa Barbara County DSS. The Parent Partners with the families to develop a Family Budget within the first 30 days of services, who then works with the Child Family Team to determine an appropriate flex fund. That request is then sent to Santa Barbara DSS for approval. Reconciliation and new budget requests are submitted every 6 months.
(b) As previously noted, Casa Pacifica is collaborating with Santa Barbara County to explore alternative funding options to support sustainable Wraparound services. Quarterly WIT Leadership meetings provide a structured forum for these discussions, allowing county and Wraparound leadership to identify alternative funding sources based on current needs (WIT Leadership Agenda, pg. 124-125).
In addition, Casa Pacifica Wraparound demonstrates resourcefulness in utilization of natural supports and community resources to address identified needs. This approach ensures that youth and families have access to timely, individualized, and culturally responsive services, and promoting long-term sustainability.
Additionally, Casa Pacifica has had philanthropic donors over the years who have expressed a desire to help Casa Pacifica clients, and Wraparound has been able to draw down these funds during times of needs as well (gift cards during the holidays, household items, turkey dinners, etc.).
(c) SB 163 also provides services for AAP funded youth, so for those youth it would be N/A.
Although Casa Pacifica SB-163 Wraparound does not control external funding decisions, the program ensures that no single funding source restricts a family’s access to flexible funds needed to meet individualized goals. Flexible funds are used in alignment with High Fidelity Wraparound principles to address unique, urgent, or practical needs that support the youth and family’s well-being. The Wraparound team collaborates with families, natural supports, and system partners to identify gaps not covered by primary funding and provide resources—such as transportation, enrichment activities, or supplies, etc. necessary to achieve the Plan of Care outcomes. In addition, Wraparound has been able to utilize donations made to the agency to support these individualized needs, further ensuring that families have equitable access to resources.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
(a) Casa Pacifica is an equal opportunity employer committed to maintaining a diverse and inclusive workforce that reflects and meets the cultural and linguistic needs of the youth and families served. Recruitment and hiring practices are aligned with program needs, and available positions are posted based on identified service gaps (e.g., bilingual capacity).
The program strives to hire a workforce that matches the community that it serves. Currently, 62% the Wraparound program consists of bilingual/bicultural staff (Spanish and English), and over the past 12 months 59% of our clients identified as Hispanic/Latino/Latina. Additionally, Casa Pacifica has contracts with multiple interpretation agencies in order to provide in-person interpretation in any language needed, in particular two contracts with two different Mixteco agencies due to a high concentration of people speaking Mixteco in north Santa Barbara County. Additionally, Casa Pacifica contracts with the Language Line so that staff can utilize unplanned interpretation for crisis calls, crisis response, scheduling needs, etc. whenever needed. Lastly, Casa Pacifica works to translate all forms into the family’s language of origin. Lastly, Casa Pacifica’s Youth Services Survey provided to caregivers and the youth 12 and over at the end of services has specific questions around whether or not Casa Pacifica staff were sensitive to the youth and family’s cultural and ethnic background. This survey is examined and shared with both the individual staff if the staff is identified, as the entire program for feedback and training purposes once identifiable information is removed.
(b) The Program is committed to honoring and responding to the cultural, and linguistic identifies of your youth and families. When aligned representation from the team is not available, the program has a variety of strategies to ensure meaningful cultural representation is present.
Ways in which this is supported include but are not limited to:
• Identifying the families cultural identity, language preferences, and values during the initial strengths and needs assessment (Strength and Needs Assessment, pg. 72).
• Collaborating with families identified natural supports to include in the HFW team.
• The youth/family has access to interpretation, translated materials, and anything else needed to support full participation in planning and services.
• Adaptation of interventions and strategies to align with cultural values and traditions.
• Ongoing training, coaching, and supervision related to culturally responsive services and implementation related to HFW (Training Plan, pg. 3-8).
(c) Leadership does its best to match families with staff who speak the family’s language. When unable, a formal pre-approved certified Interpreter is utilized. Available interpretation providers include the Language Line, Ortiz-Schneider, and Herencia Indengia. Ortiz Schnieder and Homeland Language Services are available for planned meetings.
9.2 Tribally Responsive Workforce
(a) Staff are required to take the Indian Child Welfare Act (ICWA) Overview and Tribal Engagement in Teaming Best Practices through UC Davis. Ongoing and Booster Trainings can also be specifically related to ICWA and best practice standards. (Training Plan, pg. 3-8).
(b) When an Indian child is enrolled in HFW the Facilitator will:
a. Enquire with the family about their Tribal affiliation and cultural identity. This will also be integrated into the Strengths/Needs assessment and Plan of Care.
b. With the youth/caregiver’s consent, the team will reach out to appropriate Tribal representatives and invite them to team meetings.
c. Collaborate with the tribe to understand available services, natural supports, and resources.
For children referred to Casa Pacifica’s Wraparound program (Child Welfare/300 or Probation/601&602), it is the responsibility of the referring protection agency (Child Welfare Services and/or Probation) to ensure compliance with ICWA (Indian Child Welfare Act). For youth who are being considered for out of home placement, the county social worker completes an Indian Child Inquiry that is part of their petitions filed in court. The county social worker ensures the appropriate county staff member has the relevant information to track ICWA cases to ensure that proper notice has been given to relevant tribes and that when there is documentation their Indian status in our records. When that youth is referred and opened to Wraparound, Casa Pacifica Wraparound leadership staff will inquire of the social worker whether or not the youth was assessed for ICWA and note referring parties’ response on the Wraparound New Client Form (New Client Form, pg. 135-136). For families identified as in need for service, or families that require additional education on ICWA will be provided a copy of the “A Families Guide to the Indian Child Welfare Act.” Wraparound supervisors and staff are knowledgeable about job relevant provisions of ICWA as it is detailed in Casa Pacifica’s Indian Child and Welfare Act Policy. Upon identification, the Family Facilitator will connect with the assigned ICWA representative, with consent of the youth/family, and include them in team meetings, utilize them for information related to culture, traditions, and customs, and resources available (Casa Pacifica ICWA Policy and Procedure, pg. 45-49).
All information gathered will be utilized by the High Fidelity team and implementation of services (e.g. interventions implemented, strategies, etc.).
9.3 Flexible and Creative Work Environment
The Leadership team includes the Manager, Clinical Supervisor, and the HFW Coaches. The team meets weekly to discuss all aspects of the program including assigning new cases, staff cohesion, data gathered from the WFI, TOM, and Youth Services Surveys, compliance with HFW standards, and any additional programmatic needs. Leadership will also discuss ongoing and booster trainings and develop them as needed based on information reviewed (Leadership Agenda, pg. 120).
Engagement in each area includes:
(a) Program Quality and Improvement – The data gathered from the Wraparound Fidelity Index, Team Observation Measure, Youth Services Survey, and any other information observed by leadership will be reviewed within the leadership team. The leadership team will then develop a plan to support the staff depending on the needs. All Staff are required to participate in weekly group case consultation, bi- monthly role specific group supervision, and individual clinical supervision (weekly and/or every other week) provided by a licensed clinical supervisor. The purpose of Case Consultation is for team members to come together as a group and through an active and participatory discussion highlight progress on cases that are going well, identify and discuss cases that need support by utilizing team member’s knowledge and feedback for ideas on how to address barriers to goal progression and strategies to remove those barriers, and well as garner ideas for the development of a plan for next steps.
Additionally, during case consultation, one member from the team shares an intervention or resource to expand each other’s tool boxes. Any additional quality and improvement information will also be shared, and the staff are always encouraged to provide feedback. Role specific group supervision is provided bi-monthly and is attended by role specific individuals, HFW coach, and the Clinical Supervisor. The purpose of this is to discuss strengths and challenges related to the role, HFW standards, and share interventions/ideas among the roles. Leadership conducts monthly roundings with the staff to also gather feedback from them regarding ways to improve systems and processes.
(b) Cohesion – Casa Pacifica adheres to a set of Standards of Behaviors developed around Casa Pacifica’s values, which are a shared agreement on how we treat one another, how we serve our youth and families, as well as live out our mission. These standards were developed with collaboration of our agency leaders. As an agency from leadership down, we model these standards, which can create common language and cohesion. Each standard is inspired by four core values;
1. Respect: We value and show consideration for others. We assume positive intent. We are prompt, present, and prepared.
2. Integrity: We align our actions with our values. We build trust through transparency and honesty. We demonstrate personal responsibility.
3. Courage: We advocate for what is needed. We overcome obstacles to achieve our goals. We embrace change.
4. Compassion: We are sensitive to the needs of ourselves and others. We focus on strengths and resilience. We promote opportunities for joy and success.
(c) Open Communication – The Wraparound team has clinical support available 24/7. Staff are encouraged to reach out for case needs, clinical consultation, or support. Within identified teams, the staff have various ways that they are communicating based on their preference. Teams typically have a text message thread where they are providing updates and emails are sent following 1:1 sessions providing updates (Strengths, Needs, Planned Action). Team’s meet for pre and post CFT meetings to also discuss strengths, needs, planned action steps, and collaborate on resources. Teams also have a team meeting following the closure of a client to discuss team dynamics, communication, etc. to increase cohesion and communication in the future.
(d) Creating a clear sense of mission and compliance with HFW philosophy – High Fidelity standards, the 10 principles, and the phases of treatment are consistently reviewed with staff in all previously identified meetings. Based on the needs; ongoing or booster trainings will be developed to support areas of growth. This can be as a collective team in a weekly case, within role specific meetings, and individually with the coach.
9.4 Hiring, Performance Evaluation, and Job Descriptions
(a) Casa Pacifica currently employs full-time staff in the following roles: Parent Partner, Family Facilitator (High Fidelity Wraparound Facilitator), Child and Family Specialist (Family Specialist), and designated Leads for each role who function as High Fidelity Wraparound Coaches. The program is further supported by a Clinical Supervisor and a Program Manager who serves as the High Fidelity Wraparound Manager.
In addition, Casa Pacifica has developed the Youth Partner role. At present, several Parent Partners possess lived experience from their own youth and are well-positioned to support the Youth Partner function.
(b) All Job descriptions include the roles and responsibilities of the role, as well as aligned with HFW standards. (Job Descriptions, pgs. 137-160).
(c) Job descriptions reflect the attitude, skills, knowledge, experience to support successful employment, implementation of HFW Wraparound, and client care. (Job Descriptions, pgs. 137-160).
(d) When a position becomes available, Casa Pacifica’s Human Resources Department conducts an initial pre-screening of candidates to assess minimum qualifications and alignment with the requirements of the open role. The HR Department collaborates closely with the HFW Manager and provides detailed notes from the pre-screening process. (Phone Interview Questions, pg. 161).
The HFW Manager then reviews each applicant’s materials, including their application and resume, to evaluate relevant experience, skills, and knowledge that would support effective performance in the role and contribute to the agency’s ability to meet High Fidelity Wraparound standards.
Qualified candidates are interviewed by a panel consisting of the HFW Manager, Clinical Supervisor, and HFW Coach. This structured interview process is designed to assess competencies specific to the position. Casa Pacifica utilizes role-specific interview questions to ensure that candidate qualifications, values alignment, and skill sets are thoroughly evaluated in accordance with program standards and expectations (Role Specific Interview Questions, pg. 162-168 & 172-173).
(e) Casa Pacifica maintains a 90-day probationary period for all newly hired employees. During this introductory period, staff are oriented to the mission, objectives, and organizational culture of Casa Pacifica, as well as the specific expectations and responsibilities of their role. Throughout the 90-day period, the High Fidelity Wraparound (HFW) Manager, Clinical Supervisor, and role-specific HFW Coach assess performance, competency development, and overall suitability for the program.
Following the introductory period, Casa Pacifica conducts annual performance evaluations on a standardized cycle (April–March). Performance reviews are aligned with the employee’s job description and the standards of the High Fidelity Wraparound model to ensure accountability and fidelity to practice.
In addition to annual reviews, staff participate in monthly programmatic supervision with their role-specific Coach. Supervision includes structured feedback informed by shadowing, direct observation, and data gathered through fidelity and quality assurance tools, including the Team Observation Measure (TOM), the Wraparound Fidelity Index (WFI), and other relevant performance indicators. This process ensures ongoing professional development and adherence to HFW standards.
If an employee experiences difficulty meeting the expectations of their role, concerns are first addressed through direct feedback in supervision. If performance concerns persist, the HFW Manager, Clinical Supervisor, and role-specific Coach will meet to review identified areas of need and determine next steps. The employee will then participate in formal supervision, during which performance concerns are clearly outlined, and measurable goals are established to support improvement. Progress is tracked over a defined period, with follow-up supervision scheduled to evaluate growth.
If additional support is needed, the employee may be placed on a structured training plan (“train coach”), which outlines targeted professional development activities to build competency. If performance does not improve despite these supports, the employee may enter a formal corrective action process. Corrective action includes clearly defined expectations and timelines and communicates that failure to meet established standards may result in termination of employment.
9.5 Workforce Stability
(a) Casa Pacifica compensates employees in accordance with the work they perform, ensuring that wages for substantially similar work are equal when evaluated as a composite of skill, effort, responsibility, and performed under similar working conditions. Employees performing substantially similar work are paid at the same rate, regardless of gender, race, ethnicity, or any other protected classification.
The agency strictly prohibits pay discrimination between employees of different genders, races, or ethnicities who are performing substantially similar work, as defined by the California Fair Pay Act and applicable federal law. Compensation practices are designed to promote equity, transparency, and compliance with all legal standards.
To maintain fairness and remain a competitive employer, Casa Pacifica’s Human Resources Department periodically conducts salary analyses and comparable wage alignments as needed. These reviews help ensure that compensation remains equitable, responsive to cost-of-living considerations, and aligned with market standards.
(b) When assigning new cases to the High Fidelity Wraparound (HFW) team, the HFW Manager, Clinical Supervisor, and HFW Coaches collaborate to ensure assignments are equitable and aligned with each staff member’s capacity and availability. Case distribution is determined through a thoughtful review of multiple factors, including current caseload size, number of face-to-face sessions, clinical acuity of the youth and family, geographic location and associated travel time, and overall workload demands. This is monitored through time documented in their notes regarding billable and non-billable services. These variables are carefully considered to promote balanced workloads, maintain staff effectiveness, and ensure fidelity to the High Fidelity Wraparound model.
Current assignment expectations are as follows:
• Parent Partner: 8–10 families
• Family Specialist: 5 youth
• HFW Facilitator: 10 families
• Peer (Youth) Partner: 8 youth
(c) Casa Pacifica is an Equal Opportunity Employer. All qualified employees who meet the requirements of an open position are encouraged to apply and participate in the established hiring process. Employment decisions are made based on qualifications, experience, and organizational need, consistent with applicable federal and state employment laws. When positions become available, they are posted internally for a designated period to promote transparency and support employee advancement opportunities. This practice encourages professional growth, career development, and retention by providing current staff the opportunity to pursue advancement within the organization.
(d) When financially feasible, Casa Pacifica provides annual merit increases based on the outcomes of each employee’s annual performance evaluation and overall job performance. Merit adjustments are aligned with documented performance standards and organizational expectations.
Casa Pacifica has also invested in leadership development through succession planning initiatives. High-performing employees are identified through the performance review process and may be offered stretch assignments designed to expand their skills, increase responsibility, and support leadership development. These opportunities allow staff to gain experience in areas such as mentoring, project leadership, training support, and program development. Employees who demonstrate sustained performance and seniority within the program are recognized as senior staff and may be engaged in onboarding new employees, modeling best practices, and contributing to staff development efforts.
9.6 High Fidelity Training Plan
(a) Newly hired staff at Casa Pacifica receive comprehensive in-house Wraparound training delivered by staff certified in High Fidelity 101 through UC Davis. The training plan was developed in alignment with High Fidelity 101 content and California High Fidelity Wraparound Standards to ensure consistency, quality, and fidelity to the model.
Individual trainings are outlined in the attached Training Plan and include comprehensive instruction in the Wraparound philosophy and process, clearly defined staff roles, and relevant programmatic and agency policies and procedures. Role-specific training components are embedded within the curriculum to ensure staff are prepared to fulfill the unique functions of Family Facilitators, Parent Partners, Family Specialists, and Youth Partners. All items identified on the Training Checklist are completed within the first 30 days of employment (Training Plan, pgs. 3-8).
Training topics include, but are not limited to:
• The Wraparound Process
• The 10 Principles of Wraparound
• Phases of Wraparound
• Engagement and assessment tools
• Plan of Care development
• Needs identification and development of needs statements
• Risk assessments
• Documentation procedures and mandated reporting
• Transference and countertransference considerations
In addition to classroom-based and group training, newly hired staff participate in structured, on-the-job field training through shadowing experienced Family Facilitators, Family Specialists, and Parent Partners. This hands-on learning opportunity allows staff to observe and actively participate in the Wraparound process with families while receiving real-time guidance and feedback. Once assigned cases, the HFW Coach conducts ongoing shadowing and observation to provide individualized feedback, skill development, and fidelity monitoring throughout employment. Trainings and coaching are facilitated by the Program Manager, Clinical Supervisor, and HFW Coaches to ensure staff competency and adherence to High Fidelity Wraparound standards.
(b) Casa Pacifica provides ongoing internal and external professional development opportunities to ensure staff maintain competency and fidelity to the High Fidelity Wraparound (HFW) model. Training resources include external trainings through UC Davis, Catalyst Center, and Santa Barbara County Behavioral Wellness.
Staff are required to complete Casa Pacifica’s annual mandatory trainings, county Behavioral Wellness trainings, and a Fidelity 101 refresher course. In addition, staff participate in booster trainings and ongoing skill-building sessions to strengthen practice in alignment with HFW standards (Policy and Procedures Manual, pgs. 36-38).
Individual coaching is provided at minimum monthly through programmatic supervision, with a focus on fidelity, engagement strategies, documentation, and quality improvement. Staff also participate in weekly or bi-weekly individual clinical supervision to support clinical skill development and case consultation.
Role-specific meetings are held bi-monthly to deepen competencies, address emerging practice trends, and reinforce adherence to High Fidelity Wraparound standards.
(c) Ongoing and booster trainings are intentionally developed and implemented within both full-team and role-specific groups based on identified needs and performance trends. Training content is informed by feedback gathered through HFW Coach observations, review of CANS data, Wraparound Fidelity Index (WFI) results, Team Observation Measure (TOM) findings, Youth Services Survey (YSS) feedback, and direct input from youth and families. This data-driven approach ensures that professional development activities are responsive to fidelity indicators, outcome measures, and lived experience feedback (Youth Services Survey, pg. 50).
(d) As a staff promotes into a leadership position; coach, clinical supervisor, manager they are required to complete trainings for the role related to the leadership role and skills related to HFW. In addition, Casa Pacifica contracts with the Huron group that provides initial and continuing education related to Leadership. Casa Pacifica also utilizes UC Davis trainings related to expand knowledge and skills related to each role.
Fidelity Coach
– Wraparound Theory of Change
– Leadership/Coaching Skills
– Evaluation and Outcomes Monitoring
– Fidelity Tools
– Foundations of Coaching in Wraparound (UC Davis)
Clinical Supervisor
– Fidelity of Wraparound
– Supervising
– Building and Sustaining Team Culture
– Case Consultation – Principles and Values
– Clinical Documentation
– Billing Practices and Medi-Cal Requirements
– Data-driven Supervision and Quality Improvements
– Legal and Ethical Considerations
– Confidentiality
-System of Care and Coordination
– Supervising Care Coordination in Multi-Systems
– Clinicians in Wraparound (UC Davis Training)
– Huron Leadership Development Institute (Initial Onboarding and 1x per Quarter)
High Fidelity Wraparound Supervisor/Manager
– Wraparound Subject Matter
– Field Supervision and Evaluation
– Fidelity Tools
– Flex Funds
– Program Sustainability
– Referral Process
– System of Care and Community Partner Coordination and Collaboration
– Data-Driven Supervision and Quality Improvement Strategies
– Supervising for Fidelity and Outcomes
– Building and Sustaining Wraparound Culture
– Huron Leadership Development Institute (Initial Onboarding and 1x per Quarter)
(e) Staff are required to take the Indian Child Welfare Act (ICWA) Overview and Tribal Engagement in Teaming Best Practices through UC Davis. Ongoing and Booster Trainings can also be specifically related to ICWA and best practice standards. The Leadership team is rotating participation in the ECHO: ICWA & Tribal Engagement Series. Information gathered from these will also be integrated into weekly case supervision meetings.
9.7 Community-based Training Program
(a) Casa Pacifica assigns a designated HFW Coach to support each role within the Wraparound model, including a Lead Parent Partner who plays an integral role in workforce development. Within the training plan, the Lead Parent Partner shares lived experience as a “parent of the system,” highlighting what fostered respect, partnership, and effective engagement. The training includes real-life examples illustrating the phases of Wraparound and practical application of the model’s principles.
During onboarding, new staff shadow active cases to gain hands-on experience and learn directly from experienced Casa Pacifica team members, as well as from youth and families themselves. This experiential learning reinforces the family-driven and youth-guided nature of Wraparound. Parent Partners and Youth Peers also contribute to the development of ongoing and booster trainings by sharing insights, trends, and feedback gathered through their work with families.
(b) . Casa Pacifica provides training and outreach to community partners including Probation, Child Welfare, education partners, and community-based organizations to promote a shared understanding of High Fidelity Wraparound and team-based, collaborative practice. These trainings focus on the principles and phases of Wraparound, the role of Child and Family Teams, and strategies for cross-system coordination to support positive youth and family outcomes.
Wraparound also hosts a monthly All-Staff meeting, during which community partners may be invited to present information about their services, resources, and interventions. These meetings serve as a bidirectional learning opportunity: partners educate Casa Pacifica staff about available supports, and Casa Pacifica provides education on High Fidelity Wraparound practices and effective collaboration strategies.
Casa Pacifica Wraparound team members actively collaborate in community-level groups that focus on identifying service gaps, addressing systemic barriers, and improving outcomes for youth and families. Through participation in these forums, the program advocates for process improvements and strengthened cross-system coordination.
A designated Liaison, who also serves as a Parent Partner, attends the majority of these meetings. In this dual role, the Liaison brings a caregiver perspective grounded in lived experience and advocates for reducing barriers currently faced by families navigating multiple systems.
Casa Pacifica participates in several key community collaboratives, including the Interagency Placement Committee (IPC), Child Abuse Prevention Council, Foster Youth Services Program Executive Advisory Committee, Santa Maria-Bonita School District Collaboration/Partner Agency meetings, California Alliance of Child and Family Services Prevention Services forums, Children’s System of Care (CSOC), The Kids Network, Youthwell, The CBO Collaborative and CBO Coalition, Youthwell and the State Parent Partner Advisory Committee.
9.8 Coaching and Supervision
(a) Upon completion of initial onboarding, new staff continue to shadow experienced team members until a case is assigned. Once assigned, the HFW Coach provides individualized 1:1 support tailored to the staff member’s specific role. This includes guidance through initial engagement activities, documentation requirements, development of strengths and needs statements, preparation for Child and Family Team meetings, and other role-specific responsibilities.
The Coach, HFW Manager, and/or Clinical Supervisor conduct field-based shadowing and provide real-time feedback, skill development, and fidelity reinforcement. As staff progress through each phase of Wraparound, Engagement, Initial Plan Development, Implementation, and Transition, the Coach continues to observe practice and deliver targeted training aligned with High Fidelity Wraparound (HFW) standards and the staff member’s identified growth areas.
Flexible fund procedures are incorporated into onboarding training to ensure staff understand policies, approval processes, documentation standards, and alignment with family-driven planning. The Coach also provides individualized guidance on the appropriate and ethical use of flexible funds, ensuring that requests are directly tied to identified needs and consistent with High Fidelity Wraparound principles.
(b) Casa Pacifica’s Wraparound Program has 24/7 mobile crisis response designed to help support placement, there is a licensed clinician available for consultation 24/7.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
(a) Administration, in partnership with the Program Manager, extracts Continuous Quality Improvement (CQI) data monthly to monitor accuracy, timeliness, and areas for improvement. Findings are reviewed during weekly Leadership Team meetings to ensure documentation, service delivery data, and performance indicators remain current, accurate, and aligned with contract expectations. Identified areas of improvement are integrated into action planning, staff coaching, and system and process improvement.
Casa Pacifica will be implementing the Wraparound Fidelity Index (WFI) and the Team Observation Measure (TOM) to formally assess adherence to High Fidelity Wraparound standards. Fidelity data will be incorporated into ongoing CQI review processes and quarterly reporting to support continuous quality improvement and certification readiness. Casa Pacifica has been in communication regarding quarterly outcome measures being revised to match High Fidelity Standards, which they are open to.
Through Santa Barbara County’s Electronic Health Record system, Casa Pacifica can extract data related to the completion and outcomes of the IP-CANS and the Pediatric Symptom Checklist (PSC). These measures are used to evaluate changes in functioning, symptom reduction, and overall youth progress over time.
Santa Barbara Wraparound provides two distinct quarterly and annual reports: one to Santa Barbara Department of Behavioral Wellness and one to Department of Social Services as Wraparound Senate Bill -163 operates under two separate contracts (one funded through Department of Social Services and the other through the county’s MHP; the Department of Behavioral Wellness). Reports include service utilization, outcome data, fiscal updates, and documented improvements reflected in IP-CANS and PSC scores.
When gaps or areas for improvement are identified, the Leadership Team—including the Program Manager, Clinical Supervisor, HFW Coach, and other relevant leads—reviews the findings and develops a targeted plan to address the need. Interventions may include:
• Ongoing staff training incorporated into weekly case meetings
• Individual supervision and coaching to address skill development
• System or process improvements to enhance service delivery or documentation
• Adjustments to team workflow or supports to strengthen fidelity and outcomes
(b) CQI data will be evaluated and reviewed monthly. The Leadership Team including the Program Manager, Clinical Supervisor, HFW Coach, and other relevant leads—will analyze the data to identify trends, gaps, and opportunities for improvement. Based on this review, the team will explore system/process improvements, documentation, and other operational processes that support program fidelity and effectiveness. Recommendations and plans include revisions of or development of new strategies, development of booster trainings, etc. to ensure that the program is meeting the needs of youth and families in a responsive, high-quality manner.
(c) The effectiveness of Wraparound services with youth and families is continuously evaluated through the collection of formal outcome measures as well as ongoing informal feedback. Quantitative and qualitative data are compiled and utilized to conduct formal program evaluations on a quarterly and annual basis in collaboration with system partners, including Behavioral Wellness, Child Welfare, and Probation.
Quarterly data analysis includes review of outcome trends, service utilization, level of care changes, permanency outcomes, school engagement, justice involvement, and family satisfaction indicators. Findings are reviewed by the Wraparound Leadership Team to identify strengths, areas for improvement, and opportunities for program enhancement. Results are shared with Casa Pacifica’s executive leadership and Board of Directors for evaluation and review, and integrated into ongoing staff training, coaching, and supervision to ensure continuous quality improvement and fidelity to the High Fidelity Wraparound model.
Wraparound fidelity indicators, including measures such as the Wraparound Fidelity Index (WFI) and Team Observation Measure (TOM), are going to be incorporated into quarterly reporting to monitor adherence to model standards and inform system-level discussions. Demographic data is collected at admission to ensure equitable access, culturally responsive service delivery, and monitoring of service trends. Aggregate demographic and outcome data are shared with county partners through quarterly reports and participation in WIT (Wraparound Implementation Team) Leadership meetings to support transparency, accountability, and system alignment (WIT Leadership Agenda, pg. 124).
Fidelity Indicators
1.1 Timely Engagement and Planning
A. The facilitator contacts the family within 3 business days of receiving the case and arranges an Intake meeting (preferably in-person) with the family within 10 calendar days.
Name of Documentation and Page #’s: Engagement Phase 6a
B. Within 30 calendar days, the Wraparound Team develops an initial Plan of Care based on the identified prioritized needs of the family and the identified strengths of the family and Team.
Name of Documentation and Page #’s: Plan Development 6b ii a.
C. After the plan has been developed, the family’s Team reviews the Plan of Care at the Wraparound Family Team meetings held preferably weekly or bi-weekly, but not to exceed 30 days.
Name of Documentation and Page #’s: Implementation Phase 6a ii, Wraparound Team Meetings.
D. After each Wraparound Family Team Meeting, the Facilitator updates the plan of care and every 90 days provide an updated document to the Team Members.
Name of Documentation and Page #’s: Implementation Phase 6a vii 1, 2.
E. Supervisors review files at least once per quarter utilizing the Case File Checklist to ensure High Fidelity Wrapround timelines are being met, the information is utilized in individual supervision/ coaching and program CQI purposes.
Name of Documentation and Page #’s: Training Plan section 2 d and k, Supervision document, Wraparound File Review.
F. Wraparound Staff receive training in timely engagement strategies initially through the Youth for Change Wraparound Power Point, Relias trainings, UC Davis trainings, and in group supervision. In group supervision staff can address challenges they are having in meeting timelines or engagement with families or team members. They are regularly provided with additional engagement strategies. They also receive weekly or bi-weekly individual supervision/coaching for support.
Name of Documentation and Page #’s: Wraparound Training PowerPoint slides 25, 26 36 / Training Plan section 2 c and d.
1.2 Led by Youth and Families
A. The case Facilitator and Parent Partner meet with the family to explain the Wraparound Program and learn the families background and culture. They determine if there is any Native American heritage and if so involvement with the tribe: staff work with the family to begin to identify a Family Vision.
Name of Documentation and Page #’s: Engagement Phase 6d ii 1 a(d) , Plan Development Phase 6a ia (e).
B. The case Facilitator and Parent Partner meet with the family and discuss the family’s culture, background, needs and strengths to complete a Strength Needs and Cultural Discovery document. When completed, the Facilitator presents the document to the family for their signatures and provide a copy to them. The document is added to the youth’s electronic file. At Wraparound Family Team Meetings, the Team develops a Team Mission statement.
Name of Documentation and Page #’s: Engagement Phase 6b iv, di 1-3, Strengths Needs Family Culture document.
C. Supervisors/Coaches, Program Management periodically (at least quarterly) attend Wraparound Family Team meetings to observe staff in their work with families. Facilitators can request a supervisor or Program Manger to attend a meeting for additional support on challenging situations. Case files are reviewed quarterly by Supervisors/ Coaches, or Program Management utilizing the Quarterly File Review to ensure the case is meeting the standards of High-Fidelity. Information is shared with relevant staff through individual meetings with staff, generally in individual supervision or coaching sessions.
Name of Documentation and Page #’s: Training Plan section 2 d and k, Wraparound File Review section 2.
D. Youth for Change conduct an annual Satisfaction Survey of all clients in Wraparound. Feedback is asked at the end of every Wraparound meeting to make sure the families voice has been heard. Wraparound conducts WFi Ez surveys as the number of eligible clients allows, preferably every six months. When a case closes, the family is asked to provide a statement regarding their Wraparound experience; that information is provided to Program Management for Continuous Quality Improvement purposes.
Name of Documentation and Page #’s: Outcome Evaluation 6a i-iv, Wraparound Progress Notes, Youth Progress Notes.
1.3 Strength-Based
A. In the Strength Needs Culture Discovery the strengths of the family are identified and recorded. In the Plan of Care there is a Strengths Inventory section where the Facilitator records the strengths of the family and team members as additional strengths are identified; the Facilitator updates the Strengths Inventory. When there are new Team members, the Strengths Inventory is updated with the new members’ strengths.
Name of Documentation and Page #’s: Engagement Phase 6d 1-3, Wraparound Team Meeting 6a xii, Plan of Care.
B. The IP CANS is administered to the client by either a Youth For Change Clinician if one is assigned, or the Facilitator, and the results are utilized by the Team in the discussion of the needs and strengths of the client. The information is documented in the Strengths Inventory within the Plan of Care. The IP CANS are updated every 6 months or more if there has been a significant change. Strengths are identified within the IP CANS and shared as well as the progress of the youth and family.
Name of Documentation and Page #’s: Plan Development Phase 6b, Engagement Phase 6d i(1), YFC CANS Plan 2025.
C. Wraparound Staff participate in weekly group supervision where they receive training and re-enforcement of the importance of the provision of strength-based services for clients. Strength-based and solution-focused services are modeled during supervisions, monthly team meetings, Therapeutic Crisis Intervention Training/refresher and other Youth for Change trainings by sharing appreciations, what’s working, client success stories, and specific case staffing.
Name of Documentation and Page #’s: Supervision document, Training Plan section 2, Wraparound Supervision Template, Clinical Supervision form.
D. Youth for Change conducts an annual Satisfaction Survey, administered in English and/or Spanish, of all clients in all the programs including Wraparound. Additionally, Wraparound conducts WFi Ez surveys as the number of eligible clients allows, preferably every six months. When a case closes, the family is asked to provide a statement regarding their Wraparound experience. The information from the surveys is utilized for training and Continuous Quality Improvement purposes.
Name of Documentation and Page #’s: Outcomes Evaluation Policy 6a i-iv, Spanish-Satisfaction-Survey, Client Satisfaction Survey Results.
1.4 Needs Driven
A. During the initial Engagement Phase, the Facilitator, Parent Partner, and Clinician gather information to identify the underlying needs of the family prior to a Plan of Care being developed. At the initial Wraparound Family Team meeting, the underlying needs are reviewed with the Team and the needs are prioritized by the family and recorded in the Plan of Care by the Facilitator.
Name of Documentation and Page #’s: Engagement Phase 6d i(1), Plan Development Phase 6a iib(a).
B. Wraparound Staff participate in weekly group supervision where they receive training and re-enforcement of the importance of the provision of strength-based services for clients and keeping focused on underlying needs and not problem behaviors. Quarterly trainings are provided by the Supervisor/Coach based on the assessment of needs. Staff receive weekly or bi-weekly individual supervision/coaching, where cases and Plans of Care are reviewed to ensure underlying needs are being addressed in Team meetings. Supervisors/Coaches receive and review minutes of Family Team meetings to know what is occurring in meetings and insuring the meetings focus on the underlying needs and not problem behavior. Additionally, files are reviewed quarterly (minimally) to ensure underlying needs are being addressed. Supervisors/Coaches, Program Management periodically (at least quarterly) attend Wraparound Family Team meetings to observe staff in their work with families to ensure they are meeting standards of High-Fidelity Wraparound.
Name of Documentation and Page #’s: Training Plan section 2 a-k , Wraparound File Review , Therapeutic Crisis Intervention Training
C. The IP CANS is administered to the client by either a Youth For Change clinician if one is assigned, or the Facilitator, and the results are utilized by the Team in the discussion of the needs and strengths of the client. The information is documented in the Strengths Inventory in the Plan of Care.
Name of Documentation and Page #’s: Engagement Phase 6d i(1) , Plan Development Phase 6a ii b(a), YFC CANS Plan 2025.
D. As much as possible Youth For Change Wraparound works with the family until the identified needs are met. However, outside of Adoption cases, cases are referred by Child Welfare and Probation who may close the Wraparound case prior to all the needs in the Plan of Care being met. The Wraparound Team addresses transition planning at the start of the Wraparound process and engages the transition planning conversation throughout the phases.
Name of Documentation and Page #’s: Implementation Phase 6a ix, Transition Phase 6a.
1.5 Individualized
A. Plan forms are flexible and are easily individualized to meet the identified youth/family needs. Plans are reviewed and revised in the Wraparound Family Team Meeting.
Name of Documentation and Page #’s: Plan of Care document, Strength Needs Culture Discovery document, Meeting Minutes 1.
B. All Wraparound Staff participate in weekly group supervision where they receive training and re-enforcement of the importance of the provision of individualized, creative services for clients. Open dialogue allows staff to share ideas one with another. Quarterly trainings are also provided by the Supervisor/Coach based on the assessment of need. Staff (with the exception of Family Specialist/Youth Partner) receive weekly or bi-weekly individual supervision/coaching, where cases and Plans of Care are reviewed to ensure individualized needs, strengths, values and culture are being addressed in Team meetings, as well as the principle of family voice- family choice is the priority in decision making by the Team. Staff at any time can access a supervisor, program manager, or director for supervision and are trained in how to get a hold of them.
Name of Documentation and Page #’s: Training Plan section 2 a-k, Wraparound Supervision Template, Clinical Supervision form.
C. Facilitators receive weekly Group Supervision and weekly or bi-weekly individual supervision/coaching focus primarily on individual cases. Plans of Care are reviewed regarding the strategies being utilized to meet the identified prioritized needs for the family, it is and the provision of the Wraparound services.
Name of Documentation and Page #’s: Training Plan section 2 a-k, Supervision document.
D. Supervisors/Coaches receive and review minutes of Family Team meetings to know what is occurring in meetings and ensure the meetings focus on the individualized needs, strengths and outcomes. Supervisors/Coaches and/or Program Management at least quarterly review the case files to ensure High Fidelity Wraparound is being provided, reviews of Plans of Care for inclusion of underlying needs, strengths, strategies and outcomes are a part of the process.
Name of Documentation and Page #’s: Training Plan section 2 k, Wraparound File Review section 3 v.
E. The Wraparound Facilitator asks for feedback at the end of the Child and Family team meeting to ensure their voice has been heard and needs addressed. Youth for Change conducts an annual Satisfaction Survey of all clients in all the programs including Wraparound. Wraparound conducts WFi Ez surveys as the number of eligible clients allows, preferably every six months with provides families a opportunity to provide feedback regarding the customized services they received. When a case closes, the family is asked to provide a statement regarding their Wraparound experience; that information is provided to Program Management for Continuous Quality Improvement and training purposes.
Name of Documentation and Page #’s: Outcome Evaluation 6a i-iv, Training Plan sections 2 k and 6 a.
1.6 Use of Natural and Community Based Supports
A. The Plan of Care document contains a section for a Natural/ Community Supports Inventory. The section is completed by the Facilitator and updated and discussed as part of the agenda for Wraparound Family Team meetings. Clinicians complete eco-maps with the family to identify natural support and relationships and share with the team to incorporate into the plan. The Wraparound program provides family activity days and are encouraged to bring their natural supports.
Name of Documentation and Page #’s: Plan of Care document, Implementation Phase 6a iii, Engagement Phase 6b.
B. Wraparound Staff participate in weekly group supervision where they receive training and re-enforcement of the importance of the identification and utilization of Natural/Community supports for the sustainability for families. Quarterly trainings are also provided by the Supervisor/Coach on topics selected based on the assessment of need. Staff (with the exception of Family Specialist/Youth Partner) receive weekly or bi-weekly individual supervision/coaching, where cases and Plans of Care are reviewed to ensure Natural/Community Services are being utilized and are being addressed in Team meetings.
Name of Documentation and Page #’s: Training Plan section 2 k.
C. Supervisors/Coaches receive and review minutes of Family Team meetings to know what is occurring in meetings and ensure meetings focus on the identification of Natural / Community Supports. The family’s file is reviewed by Supervisor/Coaches or Program Management at least quarterly to ensure Natural / Community Support as identified and updated in the Plan of Care.
Name of Documentation and Page #’s: Training Plan section 2 a-k, Wraparound File Review section 3 k.
D. Youth for Change Wraparound utilizes WFI Ez surveys which covers the Natural Community Supports information from clients. This information is provided to all Wraparound staff and utilized in Continued Quality Improvement planning and supervision and coaching.
Name of Documentation and Page #’s: Outcome Evaluation 6a i-iv, Training Plan sections 2 k and 6 a.
1.7 Culturally Respectful and Relevant
A. The Facilitator completes a Strength Needs Cultural Discovery document within 25 days of meeting with the family. The document is provided to the family for review and signature and then placed in the electronic file. The Strength Needs Culture Discovery is shared with the family’s team.
Name of Documentation and Page #’s: Strength Needs Culture Discovery document, Engagement Phase 6d 1-3.
B. Wraparound Staff participate in weekly group supervision where they receive training and re-enforcement of the importance of focusing on the culture of the family in the provision of respectful and relevant services. Quarterly trainings are also provided by the Supervisor/Coach based on the assessment of need. Staff receive weekly or bi-weekly individual/group supervision/coaching, where cases are reviewed to ensure services are relevant and respectful of the culture of the family.
Name of Documentation and Page #’s: Training Plan section 2 a-k, Supervision document, Wraparound Supervision Template
C. Youth for Change Wraparound utilizes WFI Ez surveys which includes questions regarding respectful and culturally relevant services the family received. The information from clients is provided to all Wraparound staff and utilized in Continued Quality Improvement planning and training needs purposes.
Name of Documentation and Page #’s: Outcome Evaluation 6a i-iv, Training Plan sections 2 k and 6 a.
1.8 High-Quality Team Planning and Problem Solving
A. In the Plan Development Phase, the Team identifies team agreements, focusing primarily on conduct in meetings, but including anything the team wants to include. The team agreements are recorded in Plan of Care for the family and reviewed in the Wraparound Family Team meeting.
Name of Documentation and Page #’s: Plan of Care document, Plan Development Phase 6a ia (b), Engagement Phase 6b v.
B. Youth for Change Wraparound utilizes WFI Ez surveys which addresses teamwork questions; additionally, part of the Wraparound Family Team meeting agenda is asking for suggestions for improvement. Supervisors/Coaches, Program Management attend Wraparound Family Team meetings to observe staff in their work with families on a quarterly basis.
Name of Documentation and Page #’s: Outcome Evaluation 6a-c, Training Plan section 2 k., WFI EZ Summary page 1,2
C. Information from WFI Ez surveys is shared with staff in a monthly staff meeting after the results have been received synthesized for presentation. The information is utilized in the Continued Quality Improvement plans and in additional training focus in group or individual supervision/coaching.
Name of Documentation and Page #’s: Outcome Evaluation 6d, Training Plan section 6 a.
D. Plans of Care are reviewed at least quarterly by Supervisor/Coaches or Program Management to ensure High Fidelity Wraparound standards are being met. Minutes of Wraparound Family Team Meetings are sent to Supervisor / Coaches and Program Management for review after each meeting.
Name of Documentation and Page #’s: Training Plan section 2 k, Wraparound File Review section 3, Implementation Phase 6a vii (1).
1.9 Outcomes Based Process
A. The Youth for Change Wraparound Plan of Care contains sections to record identified strategies, projected dates for completion and specific measurable goals for the strategies to meet the prioritized needs of the family.
Name of Documentation and Page #’s: Plan of Care document, Plan Development Phase 6b (c)
B. The Facilitator leads the team in reviewing and revising strategies as part of the agenda for Wraparound Family Team meetings. Progress updates are recorded in the Plan of Care.
Name of Documentation and Page #’s: Wraparound Family Team Meeting 6a vi-ix.
C. The Plan of Care is in electronic form which allows the Facilitator to easily record changes to the Plan of Care. The Facilitator updates the Plan of Care with progress on strategies. Following each meeting, the Facilitator complete the meeting minutes and distribute them to Team members and Supervisor/Coaches and Program Management.
Name of Documentation and Page #’s: Plan of Care document, Implementation Phase 6a.
D. All Wraparound focus youth receive an IP CANS assessment; when a clinician is assigned as part of the Wrapround Team they complete the IP CANS and provide the results to the Team. On those cases where a clinician is assigned Facilitators complete the IP CANS. Both Clinicians and Facilitators receive training in administering the IP CANS and its usages.
Name of Documentation and Page #’s: YFC CANS Plan 2025, Plan Development Phase 6b.
E. Wraparound Family Teams utilize the information from the IP CANS to guide in the decisions and planning for the provision of the services for the family. IP CANS is a resource the Team utilizes to ensure the Needs Assessment identifies the necessary needs and strengths.
Name of Documentation and Page #’s: YFC CANS Plan 2025, Plan Development Phase 6b.
1.10 Persistence
A. Wraparound staff have weekly group supervision, where challenges with cases are discussed with Supervisor/Coaches, Program Managers if able to attend. Staff receive support from fellow staff in open discussions. Staff also have 24-hour access to supervision to debrief on challenges they may be experiencing with a case. Youth for Change works with the family until the Wraparound Family Team agrees services should end as much as possible; however, most cases referred are contracted through Child Welfare and Probation who may close the cases prior to the completion of services.
Name of Documentation and Page #’s: Training Plan 2 b-e and j, Implementation Phase 6a ix.
B. Wraparound staff can refer to the Staff Supports document to know the processes to access funding assistance for families, additional supervision/coaching or other needs and resources for support.
Name of Documentation and Page #’s: Staff Supports document 5-6.
C. Facilitators and all Wraparound staff receive Therapeutic Crisis Intervention Recertification training and Wraparound topic specific training quarterly. They participate in weekly group supervision and receive weekly or bi-weekly individual supervision/coaching to provide support in Team leadership, meeting engagement strategies and case specific challenges.
Name of Documentation and Page #’s: Training Plan 2 a-k., Therapeutic Crisis Intervention Training PP. TCI 3-day Schedule
1.11 Transitions as a part of the Fourth Phase of HFW
A. Wraparound Teams begin the discussion of case transition at the first meeting and in planning and engagement phases. The transition plan is frequently discussed so that can be implemented should the case be closed with short notice by the referring agencies, Child Welfare or Probation.
Name of Documentation and Page #’s: Transition Phase 6ai and ii, Implementation Phase 6a ix.
B. The Team celebrates families graduating from the program according to the desires of the family. Funds have been utilized to pay for graduation dinners, gift cards, and support for family trips to name some examples. After the Team has determined how they want to celebrate the family, the Facilitator submits any plan for funds requests to Program Management for approval.
Name of Documentation and Page #’s: Transition Phase 6a iv(g), Family Transition Plan template.
Expected Outcomes
2.1 Youth and Family Satisfaction
Youth for Change engages clients and caregivers regularly to illicit feedback on satisfaction of services through annual administration of client satisfaction survey, in addition to WFI EZ, and at the end of every CFT families are engaged in a meaningful process to make sure their voices were heard and needs were addressed.
Name of Documentation and Page #’s: Outcome Evaluation 6 ai-v, Client Satisfaction Survey 2023, Meeting Minutes 1.
2.2 Improved School Functioning
The team invites school partners, as applicable, to Family team meetings to gather attendance, school participation, and school progress. The facilitator documents the information in the meeting minutes and identify action items as necessary. The team works with the family to identify vocational experience and reaches out to community and natural resources to ensure this goal is being met. IP CANS measures school functioning, attendance, and behaviors and is updated minimally every 6 months.
Name of Documentation and Page #’s: Outcome Evaluation 6a i-v, Meeting Minutes 1, YFC CANS Plan 2025.
2.3 Improved Functioning in the Community
The Wraparound team identifies unmet needs with regard to justice involvement and community engagement and creates goals to improve social functioning. Wraparound staff document in progress reports after each session and review the reports with the family in the team meetings. The frequency of the activities are evaluated and documented in the team meetings. Community activities are explored with the youth and the family based on level of interest and identified growth opportunities. IP CANS measures community functioning, justice involvement, and social functioning. The IP CANS is updated minimally every 6 months and reviewed with the family.
Name of Documentation and Page #’s: Outcome Evaluation 6a i-v, Meeting Minutes 1, YFC CANS Plan 2025
2.4 Improved Interpersonal Functioning
Youth for Change Wraparound evaluates interpersonal functioning of families through administration of IP CANS (specific attention to family strengths and caregiver section), WFI-Ez, and through Family team meetings. IP CANS is updated minimally every 6 months and reviewed with the family.
Name of Documentation and Page #’s: Outcome Evaluation 6a i-v, Meeting Minutes 1, YFC CANS Plan 2025.
2.5 Increased Caregiver Confidence
Youth for Change Wraparound evaluates interpersonal functioning of families through administration of IP CANS (specific attention to family strengths and caregiver section), WFI-Ez, and through Family team meetings. Parent partners report in their progress notes caregivers needs for growth and areas of improvement with confidence in managing future programs and access to services.
Name of Documentation and Page #’s: Outcome Evaluation 6a i-v, Meeting Minutes 1, YFC CANS Plan 2025.
2.6 Stable and Least Restrictive Living Environment
Facilitators document in Family Team meeting notes if and when a new placement occurs or hospitalization. All team members are informed of new living situations and new providers and goals are created. All placement changes are discussed during weekly IPC meetings and tracked monthly with the county for fiscal management. IP CANS are updated if/when placement changes occur. WIFI EZ monitor and reflect placement changes when appropriate.
Name of Documentation and Page #’s: Outcome Evaluation 6a i-v, Meeting Minutes 1, YFC CANS Plan 2025.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
The facilitator and team track hospital visits in the meeting minutes. Safety plans are created to identify strategies to reduce the frequency of hospitalization with updates, as needed. Wraparound provides a 24hr line for clients, documenting all incoming calls. The on-call staff works with the family to stabilize and identify alternative strategies, responding in person when needed to reduce need for a hospital visit. IP CANS are updated when hospital visits occurs and reflected if hospital visits decrease.
Name of Documentation and Page #’s: Outcome Evaluation 6a i-v, Meeting Minutes 1, YFC CANS Plan 2025, Safety Plan, Incident Report, Staff Incident Reporting.
2.8 Reduction in Crisis Visits
Wraparound provides a 24hr on-call line and families are oriented to how to use this line at the beginning of the program. Facilitators and clinicians create a safety plan with the family and on-call staff have a copy. Every call is tracked and reviewed by the clinical supervisor. The number of crisis incidents are documented and reviewed quarterly to the county. Staff fill out a incident form which is tracked by leadership and clinical supervisor. The IP CANS is administered minimally every 6 months.
Name of Documentation and Page #’s: YFC CANS Plan 2025, Quarterly Report-On call tracking sheet page# 19, Incident Report, Staff Incident Reporting, Wraparound Meeting Minutes, On-call emergency phone
2.9 Positive Exit from HFW
Youth for Change uses multiple indicators to establish stabilization and adequate progress, such as: IP CANS, WIFI EZ, and Plan of Care goals. Once a family has met their goals the team provides a transition plan and works with the family to create a graduation plan. Every week the Wraparound Assistant Director provides a update to the county on families that are transitioning out of the program. Quarterly reports are prepared to track successful completions of the program.
Name of Documentation and Page #’s: Implementation phase 6a ix, Transition Phase 6a-d, Meeting Minutes 1.
Engagement
3.1 Orientation
A. Wraparound staff meet with the family at the initial meeting to complete the Intake paperwork (their rights and release of information etc.) and orient them to Wraparound principles and processes and provide them with the Youth for Change Wraparound description brochure and/ or the Youth for Change General PowerPoint. In the Engagement phase staff learn the background of the family, the culture and identify natural/community supports including possible Native American ancestry. During the orientation staff provide an explanation of the phases and principles of Wraparound using the Youth for Change Wraparound brochure and/or the General PowerPoint describing the Wraparound Program.
B. At the initial meeting with the family the intake packet is completed which includes consents, clients’ rights, notice of privacy practices, releases of information, contact information, complaint and grievance process.
C. Facilitators and/or Parent Partners discuss the roles of the Wraparound Team, begin to identify Natural/ Community supports of the family and any tribal ancestry and if so the family’s involvement with the tribe.
Name of Documentation and Page #’s: Engagement Phase 6b i, ii , Youth for Change Wraparound Program Power Point, Y4C Brochure-WRAP, Intake Checklist, Butte County YFC SB 163 Complaint Procedures, PHI in English and Spanish, Client Head Sheet.
3.2 Safety and Crisis stabilization
A. The Facilitator and Clinician develop a safety plan in the initial stages of services. The Safety Plan provides the on-call numbers, strategies for de-escalation and stabilization, resources and natural supports. The Plan is put into the clients file and is accessible to all staff for on-call purposes.
Name of Documentation and Page #’s: Engagement Phase 6b iii, Safety Plan Template.
B. Once the Plan of Care is developed, the Safety Plan can be revised and updated and provided to the family. At any time during the duration of the case, the safety plan can be updated as necessary.
Name of Documentation and Page #’s: Engagement Phase 6b iii, Plan Development Phase 6a iv(a).
C. The 24-hour crisis line number is included in the Wraparound brochure and the Safety Plan. Facilitators support the family with understanding the crisis call procedure.
Name of Documentation and Page #’s: Safety Plan Template., Y4C Brochure -WRAP, Crisis Call Guide.
3.3 Strengths, Needs, Culture and Vision Discovery
A. The Facilitator and Parent Partner learn from the family about their background, culture, strengths and needs and the vision for their family during their visits in the Engagement phase.
Name of Documentation and Page #’s: Engagement Phase 6b iv, 6c i and 6d,
B. The Strength Needs Cultural Discovery document is completed by the Facilitator within twenty-five days on the initial visit. The document is reviewed and signed by the family; copies are be provided to the Team member for their information. The document is updated with additional information obtained on the family culture, strength and need, the updated document is provided to the Team. AS new Team members are identified, they are provided with the most current document.
Name of Documentation and Page #’s: Strength Needs Cultural Discovery doc., Engagement Phase 6d, Implementation Phase 6a iv.
3.4 Engage All Team Members
A. The Facilitator records Natural/Community support information obtained during the initial engagement meetings in the Natural/Community supports section of the Plan of Care document.
Name of Documentation and Page #’s: Engagement Phase 6ci and 6d, Strength Needs Culture Discovery doc., Plan of Care doc.
B. The Facilitator contacts the identified Child’s System of Care partners, and any Natural/Community supports and notifies them of the Wraparound involvement with the family. The times, dates and location of the next meeting are provided, as well as the purpose and processes of Wraparound are explained.
Name of Documentation and Page #’s: Engagement Phase 6c iii and 6d (1) a-b.
C. As part of the agenda for each meeting a discussion regarding identifying additional Natural/Community supports and Team members occurs. Updates are recorded in the Natural/Community Inventory and Meeting Minutes summary.
Name of Documentation and Page #’s: Engagement Phase 6c iii and 6d (1) a-b, Wraparound Team Meetings 6a xi, Meeting Minutes 1.
D. Team building and therapeutic activities are recorded in progress notes and the summary section of Meeting Minutes, which summarizes the meeting. Youth activities are documented and shared with the team to report progress and any concerns noted.
Name of Documentation and Page #’s: Meeting Minutes 1, Implementation Phase 6a vii and viii.
3.5 Arrange Meeting Logistics
A. Facilitators work with the Team and particularly family members to schedule meetings according to availability to maximize participation. Meetings are held online via Teams, or in-person as determined by the preference and approval of the family. The Facilitator has the responsibility to arrange the logistics for the meeting and make sure all Team members are aware of the meeting time location and any items they would like to be a part of the agenda. Expectations are made clear during the hiring process and throughout employment that the role includes non-traditional hours. This allows for flexible schedules in the evenings and on the weekends in order to meet the family’s needs and preferences.
Name of Documentation and Page #s: Implementation Phase 6a i, Hiring Plan
B. Staff receive specific training regarding working collaboratively with families. “Family Voice-Family Choice” principles are included in initial training and through weekly group supervision and are utilized in scheduling services and meetings with youth and their families.
Name of Documentation and Page #’s: Training Plan, Wraparound Training PowerPoint slides 12, 15, 19, 21, 26
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
A. Prior to the development of the Plan of Care, the Facilitator leads the team during the Wraparound Family Team meeting in establishing Team Agreements (primarily addressing conduct during meetings), the Family Vision, a Team Mission Statement and identifying the strengths of Team members. The information is recorded in the Strengths/Needs Inventory, Team Mission and Team Agreement sections of the Plan of Care document.
Name of Documentation and Page #’s: Plan of Care, Plan Development Phase 6a i a-d.
B. The Strengths/Needs Inventory section in the Plan of Care document is updated with any additional strengths of the family that were identified by the Team. The information is added to the previously identified strengths recorded in the Strengths/Needs Inventory section of the Plan of Care document.
Name of Documentation and Page #’s: Plan of Care, Plan Development Phase 6a (a) ic.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
A. After identifying and prioritizing the underlying needs of the family, the Facilitator leads the Team in the development of a Plan of Care that is based on the identified and prioritized underlying needs of the family. The underlying needs identified in the Engagement Phase and any additional underlying needs are recorded in the Plan of Care document under the Strength/Needs Inventory section.
Name of Documentation and Page #’s: Plan Development Phase 6a ii b, Plan of Care.
B. Utilizing the prioritized needs, the Team develops specific measurable goals and outcome objectives the family has identified.
Name of Documentation and Page #’s: Plan Development Phase 6b (a)
C. Goals and Outcomes are developed in Wraparound Family Team meetings by the Team, with the voice of the family and youth being the primary consideration.
Name of Documentation and Page #’s: Plan Development Phase 6b (a)-(c).
D. During Wraparound Family Team meetings, the Team will develop strategies through the process of brainstorming to meet the desired outcomes. The strategies are documented in the Plan of Care under the specific identified needs and outcome. Progress on the strategies are updated in the Progress/Update section regarding the specific Prioritized Needs. The Facilitator also completes the Meeting Minutes document and summarizes the meeting. Meeting Minutes are shared with the family and team and are a working document.
Name of Documentation and Page #’s: Plan Development Phase 6b (b), Plan of Care doc., Meeting Minutes 1.
E. Facilitators receive initial training regarding brainstorming, identifying, prioritizing and implementing strategies through the UC Davis Wraparound Foundational training (101), Youth for Change Coach who has attended the trainer and coaching trainings from UC Davis, Youth for Change Wraparound Training PowerPoint and subsequent Youth For Change training, supervision/coaching. Youth for Change supervisors, program manager, and assistant director also use the Coaching High Fidelity Wraparound book by Jim Rast, and Brittany Rastsmith to guide training and supervision.
Name of Documentation and Page #’s: Training Plan 1 b, d, e, k, m, n and 2 b-f, Wraparound Presentation for Facilitators slides 18, 24, 25,32.
F. The development of the Outcomes, Goals, Prioritized Needs and Strategies for the Plan of Care are completed through collaboration of the family’s Team in a Wraparound Family Team meeting.
Name of Documentation and Page #’s: Plan Development Phase 6a ii and iii, Wraparound Team Meeting 5.
4.3 Develop an Individualized Child or Youth and Family Plan
A. Facilitators receive ongoing training and coaching on team engagement and planning that incorporates the voice of the whole Team and strategies to build Team cohesion and trust during weekly group supervision and either weekly or bi-weekly individual supervision/coaching.
Name of Documentation and Page #’s: Training Plan 2 b-d and k, Supervision doc.
B. The Plan of Care the Team develops is in alignment with the identified Underlying Needs, Family Vision and Culture of the family. The Plan of Care is comprehensive, with identified goals across the Child’s System of Care partners. The Plan includes various specific measurable strategies and action items that are documented and updated in Wraparound Family Team Meetings.
Name of Documentation and Page #’s: Plan of Care, Plan Development Phase 6b ii b (b)-(d).
C. Facilitators document and update the Plan of Care and provide copies to Team members at least every 90 days. Plans of Care are placed in the focus child’s electronic file on Microsoft Teams.
Name of Documentation and Page #’s: Plan of Care, Plan Development Phase 6b iv (a),
D. Plans of Care are reviewed at least quarterly by Supervisor/Coaches or Program Management to ensure it meets the standards of High Fidelity and for potential individual supervision/coaching, or group training for Continuous Quality Improvement.
Name of Documentation and Page #’s: Wraparound File Review section 3, Training Plan 2 k.
4.4 Develop a Crisis and Safety Plan
A. During the Plan of Care development, the Team develops a Safety Plan for the family. The Safety Plan expands on the initial Safety Plan developed in the Engagement phase with the family. The Safety Plan identifies potential safety concerns and strategies the Team and family have identified to address those concerns. Twenty-four-hour support contact information is included in the plan. The Safety Plan is updated as needed and given to the family, the document is put into the focus child’s file.
Name of Documentation and Page #’s: Safety Plan doc., Plan Development Phase 6a iv (a)-(b)
B. The Safety Plan is developed in a Wraparound Family Team meeting with the input of the Team. The focus of the Safety Plan is identifying resources and strategies that are sustainable utilizing Natural/ Community supports. Facilitators and Clinicians receive training on developing Safety Plans through UC Davis Foundational training, the Clinical Supervisor, Youth For Change PowerPoint for Facilitators, group supervision and individual supervision/coaching.
Name of Documentation and Page #’: Plan Development Phase 6a iv (a), Training Plan 1 e, m, n, j, 2 c, d, f and k, Wraparound Presentation for Facilitators slide 22.
C. The Clinical Supervisor, Supervisor/Coaches or Program Management review file documentation at least quarterly to ensure Safety Plans meet the High-Fidelity standards.
Name of Documentation and Page #’s: Training Plan 2k, Wraparound File Review and section 5, Supervision doc.
Implementation
5.1 Implement The Plan of Care
A. In Wraparound Family Team meetings, progress and updates on the assigned tasks and assignments are reviewed and revised as needed. The Facilitator documents progress and updates in the Plan of Care and provides a summary of the meeting in the Meeting Minutes. Successes and things that are going well are recognized and celebrated by the Team.
Name of Documentation and Page #’s: Implementation Phase 6a, Wraparound Team Meetings 6a vi-xii, Meeting Minutes 1.
B. Staff receive weekly group supervision, weekly or bi-weekly individual supervision/coaching and quarterly training focused on providing High Fidelity Wraparound services. Group supervisions models Wraparound Family Team meeting agenda of recognizing and celebrating successes. Facilitators receive Initial training on plan implementation through UC Davis Wraparound (101) training, Wraparound Supervisor who is trained through UC Davis, High Fidelity Wraparound book, and Wraparound Training PowerPoint slides 19 and 23.
Name of Documentation and Page #’s: Training Plan 1 e, m, n, j, 2 c, d, f, and k, Wraparound Training PowerPoint slides
5.2 Review and Update The Plan of Care
A. Facilitators review the Plan of Care and progress on the identified strategies with the Family Team at every Wraparound Family Team Meeting.
Name of Documentation and Page #’s: Implementation Phase 6a iii-vi, Wraparound Team Meetings 6a vi-ix.
B. Facilitators lead the Team in reviewing the plan and making any revisions to prioritized needs, strategies, as the family progresses and completes goals, achieves desired outcomes, or new needs become the priority. As changes are made to the Plan, the Facilitators records changes or any updates in the Plan of Care document and imports it into the file on Teams.
Name of Documentation and Page #’s: Implementation Phase 6a iii-vi, Wraparound Team Meetings 6a vi-ix.
C. The Meeting Minutes are provided to Team members and Program Management through e-mail or hardcopy. The minutes will record the date of the meeting, who was in attendance, appreciations, what is going well, a summary of the meeting, request for use of flex funds to support the family, and any tasks or assignments made in the meeting. Updated Plans of Care are provided to the Team Members at least every 90 days.
Name of Documentation and Page #’s: Meeting Minutes 1, Plan of Care, Implementation Phase 6a vii.
D. The Youth for Change Plan of Care document is a flexible and working document which changes based on the family’s needs, strengths, and goals. Meeting Minutes records the updates in each meeting and includes specific topics of appreciations and what is going well that can change from meeting to meeting depending on what the family experienced.
Name of Documentation and Page #’s: Meeting Minutes, Plan of Care, Wraparound Progress Note, Youth Progress Note.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
A. Team Agreements for conduct in meetings and other needs the Team identifies, are recorded in the Plan of Care document and are reviewed at each Wraparound Family Team Meeting.
Name of Documentation and Page #’s: Plan of Care, Wraparound Team Meeting 6a ii.
B. Facilitators are responsible for the Team cohesion and ability to work together to assist the family in meeting their desired objectives. In group supervision, or individual supervision/ coaching they address any challenges they may be experiencing with team cohesion and receive suggestions from other Facilitators or Supervisor/Coaches or Program Management.
Name of Documentation and Page #’s: Training Plan 2 c, d, f, h, Supervision doc., Implementation Phase 6a vii.
C. Discussions of increasing Natural/Community supports are a part of meeting agendas and an Inventory of Natural/Community supports is documented in the Plan of Care document.
Name of Documentation and Page #’s: Plan of Care, Wraparound File Review section 3 k, Training Plan 2 c, d, f, and k, Supervision doc.
D. Youth for Change Wraparound program has family events in which families are encouraged to bring natural supports to build the relationships and get to know the team. This is a fun and relaxed way for families to introduce natural supports and a way for them to enjoy each other. When new team members are identified to participate on the team, the Facilitator has the responsibility to orient them to the Wraparound processes and update them on the current plans, goals and strategies of the case. Supervisor/Coaches and/or Program Management review files at least quarterly to ensure Natural/Community supports are being identified and utilized, the information is incorporated in individual supervision/coaching as needed.
Name of Documentation and Page #’s: Wraparound Team Meetings 6a i, Implementation Phase 6a vii, Butte Wraparound Quarterly Report Pages 15 and 16.
Transition
6.1 Develop a Transition Plan
A. The discussion of transition begins early in the case planning with an emphasis on sustainability. Accessing types of support services and making changes that can be sustained overtime and after case closure. Approximately three months before the projected date of ending the case based on the identified benchmarks, progress towards achieving the goals, and other success indicators, the Facilitator begins the discussion with the Team about the plan for transition of the family out of Wraparound.
Name of Documentation and Page #’s: Family Transition Phase 6a i and ii, Implementation Phase 6a (a) ix
B. A case is determined eligible for transition as the identified needs of the family have been met or sufficient progress has been achieved based on the agreed upon benchmarks and indicators. The Facilitator completes the Wraparound Transition Plan document with the family establishing continued needs, services and supports following transitions, obtaining the signature of the Team and Program Management. The Transition Plan is incorporated into the electronic file for the youth and copies are provided to the Family and Team.
Name of Documentation and Page #’s: Family Transition Plan doc., Transition Phase 6a iv a.
C. Transition Plans are developed as a collaborative process in the Wraparound Family Team meetings, with input from the Team. The plan is specific to the identified needs and desires of the family. Facilitators are trained in this process in the initial training, shadowing seniors facilitators transition plan meetings, and through on-going group and individual supervision/coaching.
Name of Documentation and Page #’s: Transition Phase 6a ii, Training Plan 2 b-d, f and k, Wraparound Presentation for Facilitators slides 32-36.
D. Throughout the entirety of a case, the focus of the Wraparound Team is sustainability after the case closes. As the case transitions to closing, the Team ensures the resources identified in the Transition Plan are realistic and achievable after the case closes and there is clear information on how to access the resources. Adoption families are linked to Post-Adoption Services during the Wraparound process so after graduating the family knows the Post-Adoption team.
Name of Documentation and Page #’s: Family Transition Plan, Implementation Phase 6a, Transition Phase 6a ii and iv.
6.2 Develop a Post-Transition Safety Plan
A. The facilitator or clinician will update or revise the Safety Plan document and include potential crisis concerns, individual family strategies to utilize, natural and community support resources to address potential situations that may occur as part of the Transition Plan for the family.
Name of Documentation and Page #’s: Safety Plan Template, Transition Phase 6a iv (c), Family Transition Plan,
B. The Wraparound Team will discuss and update the Safety Plan for the family in a Wraparound Family Team meeting. Facilitators and Clinicians receive initial training on Transition planning through UC Davis Foundational training, the Clinical Supervisor, Relias trainings, Youth for Change PowerPoint-Facilitators and ongoing training through weekly group supervision and individual supervision/coaching.
Name of Documentation and Page #’s: Transition Phase 6a ii, Wraparound Presentation for Facilitators slides 34-37, Training Plan 2c-d, f, k.
C. The completed Transition Plan including the updated Safety Plan is provided to Program Management for review to ensure the plan meets High Fidelity Wraparound standards and signature
.
Name of Documentation and Page #’s: Transition Phase 6a iv (h), Training Plan 2c, d, g, f.
Name of Documentation and Page #’s: Safety Plan Template, Family Transition Plan, Transition Phase, Training Plan, Wraparound File Review
6.3 Create a Commencement and Celebrate Success
A. The family is asked how they would like to celebrate their graduation. The Facilitator and Parent Partner work with the family to develop a plan for the celebration. Some examples of how Youth for Change has supported families to celebrate their graduation are funding a family bonding experience, providing gift cards for a family dinner, or having a celebration party with, or without, the team.
B. Youth For Change Wraparound supports celebrations with the use of flex funds. If desired by the family, Wraparound staff who have worked with the family are invited to participate in the celebration.
Name of Documentation and Page #’s: Transition Phase 6a iv (g), Wraparound Presentation for Facilitators slide 37.
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
A. Youth for Change Wraparound seeks feedback from youth and their families through Youth for Change client surveys and the WFI Ez client surveys. Additionally, at the transition from the program, families are given the opportunity to provide written statements regarding their Wraparound experience. This information is utilized to identify areas to focus on program improvement, monitor quality of services, and highlight any successes.
Name of Documentation and Page #’s: Example Wraparound Quarterly Report pages 17, 18, 20, Outcome Evaluation 6a i-v (c)-(e), Training Plan 6a, Client Satisfaction Survey, Spanish, Client Satisfaction Survey2023.
B. Youth for Change Wraparound utilizes information from client surveys and feedback in Continuous Quality Improvement plans and Program Development to ensure High Fidelity Wraparound services are being provided. In individual cases the family voice is the primary consideration in service planning. Families are asked at the end of every meeting for any feedback to ensure their voice is heard. Families are provided with complaint procedures and the Assistant Director’s phone number at the beginning of services to ensure they know how to give feedback.
Name of Documentation and Page #’s: Butte County Complaint Procedures, Outcome Evaluation 6a i-v Outcome Evaluation 6a i-v (c)- (e) Wrapround Team Meeting 6a xii.
7.2 Community Leadership Team
A. The Assistant Director of Wraparound or designee participates in the Interagency Placement Committee which is the multi-disciplinary team that is the Community Leadership Team for Wraparound.
Name of Documentation and Page #’s: Butte County contract scope of services Page 15 section Administrative Requirements (7), Intake.
7.3 Eligibility and Equal Access
A. Youth for Change provides Wraparound services on a contracted basis through Child Welfare, Probation and Adoptions. Referrals and contracts are overseen through the Interagency Placement Committee.
Name of Documentation and Page #’s: Intake, Butte County contract scope of services Page 1 Program Overview.
B. Youth for Change Wraparound plans staffing according to the number of families contracted. Facilitators and Parent Partner caseloads are kept at no more than twelve families. Youth for Change provides 24-hour support to families in crisis. Wraparound staff members have a weekly rotating on-call assignment. After hours support, by management, is available to on-call staff on duty. The Wraparound Clinical Supervisor reviews documentation of all on-call support that was provided to families. Guidance and debriefing are provided to staff as applicable.
Name of Documentation and Page #’s: Intake, Butte County contract scope of services pg. 14 Wraparound Eligible Youth Crisis Support and pg. 15 Administrative Requirements 2, Caseload sizes, Hiring Practices pg.1, On-Call Emergency Phone.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
A. Youth for Change Wraparound funds resources to address direct service needs of families and emergency needs as they occur. Gift cards are available for staff to request for their families, cards can be for merchandise, food or gasoline. Some gift cards are available on site, while others need to be ordered. Additionally funding support may be provided by check, either for a payment, or reimbursement if paid already. Requests for funding are made by the Facilitator or Parent Partner (after approval from the family’s Team) to program management, with the specific request and amount needed for the family.
Name of Documentation and Page #’s: Wraparound Fiscal Procedures, Implementation Phase 6a v, Wraparound Staff Supports 5 and 6.
B. Youth for Change Wraparound recruits and trains all positions identified to meet High Fidelity standards. A High-Fidelity Training Plan has been developed to provide initial formal initial training and shadowing for new staff.
Name of Documentation and Page #’s: Hiring Practices, Wraparound Staff Supports, Training Plan section 1.
C. As part of the Continuous Quality Improvement plan Youth for Change Wraparound has entered into a contact to participate in WrapStat and utilize the WFI Ez survey process to collect data regarding High-Fidelity principle, client demographics, client satisfaction and case outcomes. Youth for Change uses the IP CANS as a data collection and measurement tool. Objective Arts is the CANS software Youth for Change uses.
Name of Documentation and Page #’s: Outcome Evaluation 6a i-v, High Fidelity Wraparound, Example Butte Wraparound Quarterly Report pg. 10-13, 18,
8.2 Equitable Funding Across System Partners
This does not apply to Youth for Change Wraparound.
8.3 Cost Savings are Reinvested
A. Excess funds are calculated monthly per family and reported to the county in detail and as an aggregate sum. Any use of these funds is itemized and reported monthly and quarterly to the county.
Name of Documentation and page #s. Butte County Contract Scope of Services pg. 15 Fiscal section and pg. 16 Flex Funds section, Example Butte Wraparound Quarterly Report pages 6-9, Wraparound Fiscal Procedures.
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
A. Youth for Change Wraparound provides families with access to funding to meet family needs that arise, including urgent needs.
B. With the exception of immediate urgent funding requests, requests for funding for families is discussed and agreed to by the Family Team in a Wraparound Family Team meeting . Facilitators and Parent Partners submit requests for funding and all requests are approved by management. Immediate urgent funding requests are approved through email, phone call, text within a hour of the request. Staff have all supervisors and managements contact information in order to receive approval. Requests for funds under $500.00 are approved by Wraparound supervisors. Gift cards ( Foodmax, Walmart, gas) are available on site for staff to request for their families as well as petty cash. Requests over $500.00 are approved by Program Management or Youth for Change Administration. The following question criteria is used to determine approval for funding requests:
1. Is the request supported by the Plan of Care and the family’s needs and strengths or is it an emergency request?
2. What is the plan for sustainability after Wraparound ends? Are there other supports available that could be utilized to meet the need that would be more sustainable? Does the request represent a need to be met, or a want that is not supported in the Plan of Care? Is this a reasonable use of Wraparound funds?
3. If the request for funding is denied, staff will be notified of reason for denial and that information is shared with the Team, as appropriate. The denied request can be revised and re-submitted as applicable. If the Team wants to appeal the denial decision, the request is reviewed by the Chief Financial Officer who will determine the appropriateness of the denial.
Name of Documentation and Page #’s: Wraparound Fiscal Procedures, Wraparound Staff Supports 5 and 6, Implementation Phase 6a v.
8.5 Collaborative Oversight of Flex Funds
A. Wraparound reports breakdown of expenditures monthly and quarterly in accordance with contract expectations. Youth for Change’s accounting software, FENXT by Blackbaud, allows for an extra level in the general ledger so all direct revenue and expenses are allocated directly to the individual client/family. The monthly and quarterly reports include a detailing of all revenue and costs, broken down by each family, with totals by county, and flex fund usage. The family file contains all financial requests (approved and denied) and any denials are staffed with the county.
B. All excess funds are aggregated and discussed monthly and quarterly with the county analysts. Families needs are the priority of the program and expenses can exceed revenue depending on individual family. Each month the revenue and expenses are calculated and evaluated to make sure the spending does not exceed the flex fund balance.
Name of Documentation and Page #’s: Example Butte Wraparound Quarterly Report pages 6-9, Wraparound Fiscal Procedures,
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
A. As a provider, Youth for Change High Fidelity Wraparound program funds are limited to the rate agreed to by the county. Youth for Change works hard to budget and make sure flexible funds are available for the families we serve. When eligible and appropriate, Youth for Change uses Medi-Cal EPSDT funding for their clients.
Wraparound Quarterly Report page 14, Butte County Contract Scope of Services pg. 16 Flex Funds section, Training Plan 1 l.
B. Youth for Change is bound to the rate agreement with the counties we work with. Whenever possible Youth for Change partners with other organizations to meet our client’s needs such as Cast Hope and Lassen National Park Foundation Grant.
Name of Documentation and Page #s: Cast Hope Fishing Flyer, Quarterly Report page 15.
C. Youth for Change Wraparound and Accounting department work together to ensure all families have access to the flex funds to meet their needs in accordance with allowable and appropriate expenses. Clients’ families have access to unrestricted donations in the event funding for their request is not available through county funds. This approval would come from the Chief Financial Officer, Chief Executive Officer, or Chief Operating Officer. Youth can also apply to use funds from the agencies Youth Development Fund.
Name of Documentation and Page #’s: Butte County Contract Scope of Services page 16 Flex Funds section, Wraparound Fiscal Procedures, Youth Development Fund procedure, Donation Check Request
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
A. Youth for Change strives, through various recruitment strategies, to hire staff which reflect the diverse cultural backgrounds of those we serve. We offer a bi-lingual stipend to staff to enhance our ability to offer services in a preferred language. Youth for Change Wraparound utilizes WrapStat which records client demographic information. Youth for Change collects and analyzes staff and client demographic data annually to ensure it reflects the population we serve .
Name of Documentation and Page #’s: Translation and Interpretation Services, Hiring Practice, Hiring Procedures, Wraparound staff supports, Demographics, Equal Employment Opportunity.
B. Wraparound staff have access to community services and stakeholders who can assist in meeting the cultural needs of the families, if natural supports are not available. The Youth for Change Cultural Committee connects staff with community resources and educational materials regularly. Information regarding Cultural and Ethnic resources is made available and housed in the Staff Supports electronically in Teams.
Name of Documentation and Page #’s: Translation and Interpretation Services, Wraparound Staff Supports 4, Engagement Phase 6b iv, 6ci iii and 6d 1(a).
C. Youth for Change provides language translation through staff or natural supports who speak the language, translation services are also available through a translation line.
Name of documentation and page #s: Translation and Interpretation Services, Spanish Client Survey
9.2 Tribally Responsive Workforce
A. During Initial Training Wraparound Staff complete training on the Relias online training system regarding ICWA and working with Native American tribes, this training is also part of the Annual Training for staff. Staff also can receive additional training through UC Davis ICWA trainings.
Name of documentation and page #s: Training Plan 1c and 4e.
B. Butte County has a number of local tribes and the contact information for them is provided to staff. If a family has been identified as having Native American ancestry through the Engagement Phase, the Facilitator reaches out to the Tribal Representative to invite them to participate with the family’s team and discusses the culture and tribal supports available to the family. The degree of tribal involvement is determined by the family.
Name of documentation and page #s: Engagement Phase 6b iv, and 6d 1 (a), Wraparound Staff Supports 4.
9.3 Flexible and Creative Work Environment
A. Youth for Change Wraparound provides opportunities for staff to share ideas on program improvement through regular group supervision and coaching. Data collected by surveys is shared and discussed with staff in a Staff Meeting and their input is sought regarding strengths and areas of program improvement.
Name of Documentation and Page #’s: Staff Meeting Minutes. Training Plan 2 b-e and 6a, Outcomes Evaluation 6c.
B. During monthly Staff meeting a Team Building exercise is done by a staff member who volunteered the previous month. Staff can do whatever exercise they want to do; exercises have ranged from meditation to line dancing to affirmation games. Quarterly Therapeutic Crisis Intervention re-certification trainings also are highly interactive and promote team building, not only among Wraparound staff but other Youth for Change staff. All Wraparound staff meetings and group supervision follow the Wraparound Family Team model and begin with staff appreciations, which builds unity, team cohesion and a strong sense of team community. Program Management emphasizes appreciation for the work staff do and shares the comments the survey participants shared which are almost always positive. Youth for Change has annual All Staff Day which focuses on training, team building, trauma informed care, and cohesion.
Name of documentation and page #s: Agenda YFC All Staff 2025, Staff Meeting Minutes, Wraparound Team Highlight, Commitment to Self-Care
C. Youth for Change Wraparound champions open communication. Group staffing, individual supervision/coaching, interactive Staff meetings, drop in policy for staff with supervisor/coaches and Program Management as well as 24-hour availability of Program Management or Supervisor/Coaches support open communication.
Name of Documentation and Page #’s: Training Plan 2 b-e, Supervision, 24 hour on-call clinical support.
D. From Initial Training throughout the time of a staff’s employment, High Fidelity Wraparound Principles, Practices and Values are taught and emphasized in meetings and in group and individual supervision/coaching. Youth for Change as an agency has a Mission Statement: Enhancing the Wellbeing of Children, Individuals, Families and Communities which is in line with Wraparound values and principles.
Name of documentation and page #s: High Fidelity Wraparound, Supervision, Wraparound Supervision Form.
9.4 Hiring, Performance Evaluation, and Job Descriptions
A. Youth for Change creates clear job descriptions for all positions identified in the High-Fidelity team for recruitment, hiring and job performance. All of the uniquely required roles are met through individual roles or by combining roles for instance the position of Coach is combined with the Supervisor. Positions are continually evaluated to meet the Wraparound standards as well as to meet the needs of a growing program.
B. The job descriptions include the necessary knowledge, competencies and skills to fill the specific position. The description also outlines the function and purpose of the specific position.
C. The High-Fidelity Wraparound Standards draft form was utilized as the outline to ensure all required information was included in updated job descriptions for Youth For Change Wraparound positions.
D. When a candidate is interviewed, the skills and knowledge identified in the job description is the focus of determining if the interviewee would be a good candidate to fill the position. Questions are specifically designed to identify the skills, attitudes and overall fit for the job.
E. Youth for Change conducts annual performance evaluations of staff, which includes a self-assessment of areas of performance and development of goals the staff members would like to pursue in the upcoming year, as well as a self-evaluation on the progress on the goals from the previous year. After staff have completed their portion of the evaluation, it is forwarded to Program Management who will complete their portion of the evaluation and the evaluation and send it to Human Resources for processing. Staff receive ongoing support in their working towards their goals through their individual supervision/coaching.
Name of documentation and page #s: High Fidelity Wraparound. Hiring Procedures, Clinical Supervisor, Facilitator WRAP, Family Specialist (1), MH Clinician 1. Parent Partner, Peer Mentor Job Description, Wraparound Supervisor and Coach, Wraparound Supervisor (Sutter Wrap), Annual Performance Review, Training Plan 2b-e, Safety i n the field, Values and Code of Ethics Policy.
9.5 Workforce Stability
A. Youth for Change annually reviews its compensation and benefit plans to ensure alignment with comparable nonprofit and community-based organizations and pay scales are adjusted as permitted within budget limitation.
Name of Documentation and Page #’s: Hiring Procedure, Benefits Overview, Wraparound Staff Supports 9 and 12.
B. Youth for Change continually assess workloads, through a trauma informed lens, and strives to ensure staff have a work life balance. Youth for Change Wraparound caseload size are dependent on several factors and depend on the role. Wraparound caseloads are factored in several ways, intensity of current caseload, experience of facilitator, length of time the clients have been in Wraparound, and status of the facilitator (full-time versus part-time). Caseloads for facilitators average between 8-12, parent partners 8-15, clinicians 8-15, and family specialists 8-12.
Name of Documentation and Page #’s: Caseload Sizes, Hiring Practices page 1, Wraparound Staff Supports 16.
C. Youth for Change develops career pathways by promoting from within and developing staff goals based on their skills and interests. Youth for Change advertises job positions within the agency through HR emails and posts them on the agency website. Lived experience can be considered in lieu of education for many positions and in some positions, it is required.
Name of Documentation and Page #’s: Hiring practices
D. Youth for Change supervisors completed annual performance evaluations of staff each year. Wage increases are evaluated based on job performance.
Name of documentation and Page #s: Salary Schedule and Performance Evaluations
9.6 High Fidelity Training Plan
A. Youth for Change Wraparound has developed a High-Fidelity Training Plan that includes Role Specific, Orientation, Booster Ongoing and Annual training components. Trainings are conducted by UC Davis, Relias Online, Youth for Change Wraparound Power Points and specifically trained Youth for Change staff. All Wrapround staff (including Supervisors, Program Management/ Administration) receive trainings in foundational Wrapround, ICWA and specific roles. Currently Foundational Training is conducted through UC Davis and Youth For Change Wraparound Supervisor/ Coach has completed the Training For Trainers course and can conduct he Foundational Training for new staff if a UC Davis training is not readily available.
B. Wraparound staff receive ongoing training during monthly staff meetings, weekly supervisions, UC Davis Trainings, and other trainings related to their role that are provided in the community or online. Trainings are tracked through the Professional Development Tracker and Relias and reported to the county quarterly.
C. Staff receive booster trainings through Relias, UC Davis, quarterly Therapeutic Crisis Intervention Training refreshers, and monthly staff meetings.
D. Clinical supervisors and supervisors/managers take UC Davis Wraparound trainings and same initial trainings as staff. Management attend Wraparound conferences, quarterly meetings with other Wraparound providers, and leadership trainings. Clinical supervisors meet three times a month for consultation.
E. Staff receive ICWA training through Relias upon hire and annually. Staff invite tribal representatives to Family Team meetings as requested and work with the tribe to provide supports.
Name of documentation and Page #s: Wraparound Training, Agency Training procedure, Training Plan, Non-violent practices, TCI trainings, TCI 3-day Schedule.
9.7 Community-based Training Program
A. Parent Partners are incorporated into the Wraparound introduction and share their experience with the families. Current and previous Wraparound clients have been invited to sit in on the interview process and give input on who might be a good candidates for Parent Partner, Family Specialist, Facilitator, and Peer Mentors. Previous Wraparound families are invited to family days and can interact with current Wraparound families to build connections and share their experience. In monthly staff meetings success stories are shared in order to learn from families success.
B. Families in the Wraparound Program can access UC Davis training of interest online either with a Wraparound staff member participating with them or alone depending on the client’s preference. Youth for Change also provides a Therapeutic Crisis Intervention for Caregivers training quarterly.. The training is interactive with caregivers being able to share their experiences with one another. Other community partners are welcome to join trainings that are offered, as appropriate. Stakeholder surveys are sent out yearly and responses are reviewed by the Leadership Team.
Name of documentation and Page #s: Hiring practices page 1, Quarterly Report pages 15 & 16, 20, Stakeholder Survey Results
9.8 Coaching and Supervision
A. Staff are provided with extensive training upon starting. Staff complete training through Relias, UC Davis workshops, high-fidelity videos, shadowing other staff, supervisions, and power point videos. Staff shadow each position to have a fully understanding of the program.
Name of documentation and Page #s: Training Plan section 1, Wraparound Training.
B. Staff have 24/7 access to a supervisor, program manager, or director. Staff have upper management work phone, personal phone number, and emails and can call or text them after hours.
Name of documentation and Page #s: On-Call Emergency phone, Crisis Call Guide, Supervision, , 24-hour support clinical support for on-call, Critical Incident Stress Management.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
Youth for Change Wraparound utilizes data from WFI EZ surveys, Youth for Change Client satisfaction surveys, and feedback from clients during Wraparound Family Team meetings to develop strategies for Continuous Quality Improvement. WFI Ez and WrapStat site provide demographic information, measurements of High-Fidelity indicators, Outcome and Satisfaction measurements.
Name of Documentation and Page #’s: WFI EZ Summary
Youth for Change contracts with the county.
10.2 Evaluation Metrics & Outcomes
A. Information from WFI EZ is synthesized and presented to Wraparound Staff and Youth for Change Administration. Areas that were identified as areas of improvement are identified, and strategies are developed to improve those areas.
B. Data from surveys is utilized to identify areas of improvement to meet High Fidelity Wraparound standards to better service youth and families. Continuous Quality Improvement plans are developed to address areas identified as needing improvement.
C. Youth for Change provides a Quarterly Report to County Leadership that summarizes the services provided to the families and overview of data from clients. The Assistant Director or designee meets quarterly to review the services provided to the family and bi-annually to review funding uses. At least monthly Wraparound families are discussed, and services are reviewed at the Inter-agency Placement Committee, which oversees Wraparound Services.
Name of documentation and page #s: Outcome Evaluation 6 a-e, Butte Wraparound Quarterly Report, Butte County Contract Scope of Services, Training Plan 6
Fidelity Indicators
1.1 Timely Engagement and Planning
(a) The HFW Intake Coordinator contacts the family as soon as their referral is received and the first contact occurs no later than 10 calendar days from the referral date. All outreach attempts—including phone calls, texts, emails, and coordination with referral sources—are documented in the Electronic Health Record via the Timeliness Record and included in replies to email correspondence threads with assigned HFW team, supervisors, and referral/system partners. Supervisors review and ensure pending Timeliness Records are updated and completed for all youth on the census multiple times weekly during recurring Leadership Collaboration Meetings and individual supervision with the intake coordinators to verify timely engagement. See Axiom Timeliness Record, page 1.
(b) The HFW Facilitator, Clinician, Family Specialist, Family (Parent) Partner, and Youth Advocate (when applicable) collaborate with the family to complete the Wraparound Plan of Care (“Wrap Map”) within 30 calendar days from the start of services. The Wrap Map Template guides the development of needs, strategies, and team roles. Completion dates are entered via upload of Wrap Maps into the EHR and the QI Compliance Report pulls data weekly on any outstanding/coming due HFW documents, including Initial and Implementation/Transition (Updated) Wrap Maps, for the Supervisor to ensure compliance with timelines. See HFW Training Presentation, page/slide 109.
(c) The HFW Team reviews progress towards identified needs and action plans in reference to the Wrap Map during a scheduled HFW Child and Family Team (CFT) Meeting at least every 30–45 calendar days. The HFW Facilitator ensures the meeting occurs within the required timeframe and documents the review in the CFT meeting minutes as well as in their corresponding CFT progress note in the EHR. Supervisors verify timely reviews through monitoring via the QI Compliance Report which pulls data weekly on any outstanding/coming due HFW documents, including Implementation/Transition CFT Minutes, for the Supervisor to ensure compliance with timelines. See Child and Family Teams and CFT Meetings Policy, page 2, Paragraphs 1 & 3.
(d) The HFW Facilitator updates the Wrap Map at least every 90 days—or sooner when needs change—and distributes the updated plan to all team members within three business days. Updated plans are uploaded to the child or youth’s file in the EHR, and distribution is documented in the HFW Documentation Tracking Log. Supervisors verify timely updates through monitoring via the QI Compliance Report which pulls data weekly on any outstanding/coming due HFW documents, including Implementation/Transition (Updated) Wrap Maps, for the Supervisor to ensure compliance with timelines. See HFW Documentation Tracking Log, page 1 (last column, highlighted red).
(e) Supervisors provide staff with feedback on their ability to meet timelines and strategies for consistently meeting engagement and planning timelines during weekly supervision sessions. Supervisors review the QI Compliance Report weekly to monitor HFW teams meet Timeliness Records, Wrap Map and CFT Minutes timelines, and document coaching notes in each responsible team member’s supervision record in their UKG personnel file. Aggregate timeliness data is evaluated and reviewed monthly through Program Health Reports and during quarterly Wraparound and QI Consultation meetings. See Supervision Record Template, page 1.
(f) All HFW staff receive training on timely engagement strategies during onboarding and annually thereafter. Training includes guidance on persistent outreach, culturally responsive engagement, and alternate strategies when families are difficult to reach (e.g., contacting coordinating with referral sources, sending written communication). Completion of training is documented in the Training Transcript on Relias Learning account and monitored by the Supervisor. See Intake and Assessment Flow Guide, page 1.
1.2 Led by Youth and Families
(a) The HFW Facilitator meets with the youth, family, and, when applicable, the Tribe within 10 business days of referral to learn about their values, cultural practices, priorities, and long term hopes at the collaborative intake appointment with the clinical intake coordinator through completion of the Strengths, Needs and Cultural Discovery (SNCD). These conversations guide the development of the Family Vision and Team Mission in the Wrap Map, which are drafted within 30 days of referral using the Initial Wrap Map Template and reviewed with the family to ensure accuracy. The Facilitator brings these statements to the full HFW team and revisits them during each CFT Meeting so they continue to reflect the family’s evolving goals. For American Indian and Alaska Native youth, the Facilitator ensures the Tribe is invited to all meetings, participates fully in decision making, and has an equal voice in shaping the Family Vision, Team Mission, and strategies to ensure they are culturally respectful and responsive. All information is documented in the EHR and reflected in the Wrap Map. See HFW Training Presentation, pages/slides 119-131; 136-140.
(b) The HFW Facilitator conducts structured engagement conversations during a collaborative intake appointment that occurs within 10 business days of referral to elicit the family’s cultural background, strengths, traditions, interests, and natural supports. This information is documented in the SNCD Tool and incorporated into the Wrap Map within 30 calendar days of referral to ensure strategies align with the family’s preferences and cultural identity. The Facilitator updates this information at least every 90 days during Wrap Map reviews or sooner if the family identifies new strengths or priority needs. All documentation is maintained in the youth’s EHR and reviewed by Wraparound supervisors and/or HF Coach to ensure accuracy and fidelity to HFW principles. See SNCD Tool, pages 1-2.
(c) Supervisors and/or the HFW Coach observe each Facilitator at least quarterly during CFT meetings using the Team Observation Measure (TOM 2.0) to assess fidelity to family driven practice. They also review case documentation—such as the SNCD, Wrap Map, Safety & Crisis Plans and CFT Minutes—on a monthly basis to ensure family voice is consistently reflected. Feedback is provided during weekly supervision sessions/coaching sessions, where Supervisors coach staff on strengths and growth, areas for improvement, and strategies to reinforce family led decision making. Observation dates and coaching notes are entered into the Supervision Record in Facilitator’s personnel file to monitor compliance and identify training needs across the team to manage drift from model fidelity. See Supervision Record Template, page 1.
(d) The program routinely gathers feedback from families to understand their experience of the Wraparound process. Families are asked to complete consumer perception or satisfaction surveys at least once throughout their enrollment (annually), and the program administers WFI EZs with families quarterly and TOM 2.0s during CFTs at least annually to collect standardized fidelity and satisfaction data. Supervisors and/or the HF Coach conduct periodic quality assurance phone calls to gather qualitative feedback about engagement, cultural responsiveness, strength-based approaches and team collaboration, especially if families express any ongoing concerns with the Wraparound process that the team experiences challenges with addressing or resolving quickly. Supervisors empower families to share their perspectives with the team directly whenever possible and share families’ feedback directly to the Wrapround team timely to offer coaching and supportive strategies to increase positive experiences and outcomes for families. Family Panels are conducted at least annually by the Family and Youth Partnership (FYP) Program to elicit live and direct feedback from current and previous Wraparound caregivers and youth. Current and previous families are also invited to join our recurring Shared Leadership Workgroup hosted by FYP program to continuously include caregivers’ and youths’ voices and perspectives in decisions made for Wraparound along with other agency-wide policies and procedures. Family WFI-EZ Survey and TOM 2.0 results and feedback are reviewed timely together by supervisors and HF Coach as received during weekly Wraparound and FYP Leadership Meetings (with Wraparound supervisors, HF coach and FYP leaders and Peer Partners) and High Fidelity Workgroup meetings, and themes are used to guide team and individual staff coaching and training to inform program improvements. See Shared Leadership Presentation, pages/slides 7-11.
1.3 Strength-Based
(a) The HFW Facilitator develops a strengths inventory for the youth, family, team members, and identified community supports at the Wrap Map Planning meeting during the initial Engagement phase and updates it throughout the Planning and Implementation Phases. Strengths are continually gathered through structured conversations, review of the IP‑CANS, and input from natural supports, and the inventory is posted visually and reviewed during every CFT Meeting and is documented on the CFT Minutes to ensure the team remains focused on functional strengths that can be used in planning and problem‑solving. The Facilitator updates the inventory at least every 30–45 days or sooner if new strengths emerge, and supervisors review the posted strengths during meeting observations to ensure accuracy and alignment with HFW principles. See CFT Minutes Template, pages 2 & 4.
(b) The HFW Facilitator incorporates the strengths identified in the IP‑CANS and the SNCD into the individualized strengths inventory and ensures they are clearly documented in the youth’s EHR. During early engagement, the Facilitator reviews the SNCD and IP‑CANS with the family to validate and expand on identified strengths, ensuring they are functional, meaningful, and directly tied to planning. These strengths are then integrated into the Wrap Map and revisited during each CFT to ensure they continue to guide decision‑making and strategy development. Supervisors verify the inclusion and use of IP‑CANS strengths during routine documentation reviews of Wrap Maps and monthly CFT Minutes. See Initial Wrap Map Template, page 2.
(c) Supervisors and the HFW Coach provides ongoing training and coaching to staff on delivering strengths‑based, solution‑focused services and complete DARTs quarterly to evaluate evidence for the use of strength-based and solution-focused language and interventions in the documentation of families’ HFW services. Coaching occurs during weekly supervision and/or coaching sessions, quarterly meeting observations, and through monthly review of case documentation (e.g., Wrap Maps and CFT Minutes) to ensure staff consistently identify, document, and utilize functional strengths in planning. Supervisors use supervision records to document coaching provided to reinforce strengths‑based language, redirect deficit‑focused practices, and support staff in building confidence and skill in applying strengths‑based approaches, both in practice and in documentation. Training needs identified through supervision, HF coaching sessions and documentation auditing are incorporated into staff supervision records and development plans. See HFW Training Presentation, pages/slides 23; 55-62.
(d) The program routinely gathers feedback from families about their experience with strengths‑based services through satisfaction surveys, WFI‑EZ and/or TOM 2.0 administration, and periodic quality assurance phone calls, to ensure the Wraparound process is driven by and builds upon the functional strengths of the team members, especially those of the youth, caregiver(s) or family as a whole. This feedback is reviewed during weekly Wraparound and FYP Leadership Meetings and High Fidelity Workgroup meetings and used to identify trends, celebrate effective strengths‑based practices, and address areas needing improvement. Supervisors and the HF Coach share relevant feedback and highlight findings from DARTs with staff during supervision and coaching sessions to reinforce strengths‑based approaches and guide targeted training for fidelity drift prevention. Program‑level themes inform training priorities and continuous quality improvement efforts. See TOM 2.0 Fillable Form, page 3, items c.-e.
1.4 Needs Driven
(a) The HFW Facilitator works with the youth, family, and team to identify and prioritize underlying needs before any goals, desired outcomes or strategies are developed. These needs are explored through engagement conversations, review of the IP‑CANS, and discussion of the unmet need driving current challenges. The Facilitator ensures that needs statements reflect the “why” behind behaviors or situations rather than describing deficits or services. Prioritized needs guide the development of goals and strategies in the Wrap Map, and supervisors verify alignment during documentation reviews and meeting observations. See Initial Wrap Map Template, pages 3-5.
(b) Staff receive ongoing training and coaching on identifying underlying needs, writing needs statements that reflect root causes and using needs‑ and solution-focused planning rather than behavior‑focused planning. Supervisors and the HF Coach reinforce these skills during weekly supervision and coaching sessions, quarterly meeting observations, and through review of Wrap Maps to ensure needs statements are functional, strengths‑aligned, and actionable. Supervision and Coaching discussions along with documented supervision records emphasize distinguishing between surface behaviors and the deeper needs that must be addressed for sustainable change. See HFW Training Presentation, pages/slides 69-81.
(c) The HFW Facilitator incorporates needs identified in the IP‑CANS and SNCD into the individualized needs assessment for each youth and family to help them assess and determine which life domains should be prioritized first in the Wraparound process. During early engagement, the Facilitator reviews the IP‑CANS with the family to validate and expand on identified needs, ensuring they accurately reflect the underlying reasons for current challenges. These needs are documented in the Wrap Map and revisited during each CFT Meeting to ensure they continue to guide planning and strategy development. Supervisors consistently review each family’s Wrap Map and CFT Minutes as submitted to the EHR to confirm that IP‑CANS needs are consistently integrated into planning and provide coaching to Facilitators if this area needs to be strengthened. See Initial Wrap Map Template, pages 3-5.
(d) Transition planning occurs through use of the Transition Wrap Map when the team and family agree that underlying needs have been sufficiently met and the youth and family can sustain progress with natural supports. During Transition Phase CFT Meetings, the Facilitator guides the team in reviewing each prioritized need, assessing progress (e.g., reduction in IP-CANS), and determining readiness for transition. Family Partners and/or Youth Advocates also complete Transition Readiness Scales (TRS) with the family at the start of the Wraparound process and every 90 days thereafter to support with assessing progress towards skills that prepare families for sustainability and readiness for transition. Families provide input on their confidence and capacity to maintain gains, and the team collaboratively identifies any remaining support or linkage needed for a successful transition. Supervisors confirm that transition decisions honor family voice and choice and are based on needs being met rather than time in the program. See Transition Wrap Map Template, pages 1-3.
1.5 Individualized
(a) The HFW program uses forms and documentation that allow Facilitators to create highly individualized plans of care tailored to each youth and family. Templates such as the SNCD and Wrap Maps include open‑ended fields that support creative, flexible planning rather than prescriptive service lists. Facilitators work with families to customize strategies that reflect their unique strengths, culture, values, preferences, and community resources, including Tribal input when applicable. Supervisors review Wrap Maps and CFT Minutes during regular documentation checks to ensure individualized strategies are clearly reflected. See SNCD Tool, pages 1-2.
(b) Staff receive ongoing training and coaching to provide flexible, creative, and highly individualized services. Supervisors and the HF Coach reinforce these skills during weekly supervision and coaching sessions, quarterly meeting observations, and through review of Wrap Maps and CFT Minutes to ensure staff are tailoring strategies to each family’s unique needs, strengths, and cultural identities. Coaching emphasizes avoiding “one‑size‑fits‑all” approaches and encourages staff to collaborate with families and natural supports to develop individualized solutions that reduce harm and promote long‑term stability and sustainability. See HFW Training Presentation, pages/slides 158-166.
(c) Facilitators receive ongoing and targeted training and coaching on leading HFW teams in customizing both the HFW process and the Wrap Map throughout each phase. Supervisors support Facilitators in guiding teams to develop strategies that reflect each youth and family’s needs, strengths, values, culture, and preferences, including Tribal perspectives when working with an American Indian and Alaska Native youth. Supervisors provide quarterly CFT meeting observations and review Wrap Maps and CFT Minutes during regular documentation checks to ensure individualized strategies clearly reflect each youth and family’s unique strengths, values, culture and preferences. During supervision and HF coaching, Facilitators receive feedback on how effectively they are supporting teams in generating and documenting creative, individualized strategies and ensuring the planning process remains family‑driven. All feedback and coaching provided to Facilitators is documented in their supervision record and stored in their personnel file. See Supervision Record Template, page 1.
(d) Wrap Maps and CFT Minutes are routinely reviewed for each family by Facilitators and supervisors to ensure they include individualized strengths, needs, outcomes, and strategies. During CFT Meetings, the Facilitator leads the team to assess whether strategies remain relevant, culturally aligned, and reflective of the family’s community assets and informal supports. Supervisors verify individualized planning through monthly documentation reviews and meeting observations, ensuring that strategies are not generic but uniquely tailored to the family’s circumstances through robust brainstorming. See CFT Minutes Template, pages 3-4.
(e) The program routinely gathers feedback from families about their experience receiving customized services through satisfaction surveys, WFI‑EZs and periodic quality assurance phone calls. Family WFI-EZ Survey results and feedback are reviewed timely together by supervisors and HF Coach as received during weekly Wraparound and FYP Leadership Meetings and High-Fidelity Workgroup meetings, and themes are used to identify strengths and areas for improvement in individualized planning. Supervisors share relevant feedback with staff during supervision to reinforce effective individualized practices and guide coaching where additional support is needed. See CFT Meeting Satisfaction Survey, page 1; WFI-EZ Caregiver Form, pages 2-3.
1.6 Use of Natural and Community Based Supports
(a) The HFW team develops a natural and community supports inventory with each family via the SNCD and Connection Map during the initial engagement period and updates it throughout the HFW process. This inventory and Connection Map identify extended family members, friends, mentors, cultural and/or spiritual supports, Tribal representatives when applicable, and community resources that the family identifies as meaningful. The Facilitator revisits and updates the inventory during CFT Meetings and at least every 30–45 days to ensure new supports are added and actively engaged. Supervisors review the inventory during documentation checks and meeting observations to ensure natural supports are consistently identified and integrated. See Connection Map Training, pages/slides 2-7.
(b) Staff receive ongoing training and coaching on identifying, engaging, and integrating natural supports into the HFW process, as well as on strategies to decrease reliance on formal services over time. Supervisors and the HF Coach reinforce these skills during weekly supervision and coaching sessions, quarterly meeting observations, and through review of SNCDs, Wrap Maps and CFT Minutes to ensure natural supports are meaningfully included in planning and implementation. Coaching emphasizes culturally responsive engagement, creative outreach, and supporting families in strengthening their informal networks and is discussed and documented in staff supervision records. SNCD Tool, page 1.
(c) Wrap Maps and CFT Minutes are routinely reviewed by Facilitators, supervisors and the HF Coach to ensure natural supports are included in the team and that strategies and action steps intentionally utilize community‑based and informal supports. During CFT Meetings, the Facilitator guides the team in identifying ways natural supports can contribute to goals, provide ongoing encouragement, and help sustain progress beyond formal services. Whenever family consents, natural supports are included as vital members of the CFT and invited to CFT meetings to engage them in sharing what’s working, contributing to brainstorming and participating in action items, often taking on action items whenever possible to support the family. Supervisors verify the presence and use of natural supports through documentation reviews and the use of TOM 2.0s to ensure planning is community‑based and sustainable. See TOM 2.0 Fillable Form, page 4.
(d) The program routinely gathers feedback from families about their experience with natural supports being engaged on their team through WFI‑EZ or TOM 2.0 administration, and periodic quality assurance phone calls. Fidelity tool finding and family feedback are reviewed by supervisors and HF Coach as received during weekly Wraparound and FYP Leadership Meetings and High-Fidelity Workgroup meetings, and and used to strengthen staff training, coaching, and practice expectations related to natural support engagement. Supervisors and HF Coach share relevant feedback with staff during supervision and coaching sessions to reinforce effective practices and address areas needing improvement to support families with sustainability. See WFI-EZ Caregiver Form, pages 2-3.
1.7 Culturally Respectful and Relevant
(a) The HFW Facilitator completes a SNCD with the youth and family before developing the Wrap Map. This process includes exploring the family’s cultural traditions, values, heritage, language preferences, and any Tribal connections when working with an American Indian and Alaska Native youth. The Facilitator documents this information in the youth’s EHR using the SNCD Tool, ensuring that cultural considerations directly inform goals, strategies, and team membership. Supervisors review this documentation during routine supervision and initial assessment and Wrap Map meeting observations to confirm that cultural relevance is consistently integrated into planning. See SNCD Tool, page 2.
(b) Staff receive ongoing coaching and training on eliciting and incorporating family culture into planning and service delivery. If requested and whenever possible, Wraparound supervisors support our teams with honoring requests for accommodating internal and/or external cultural matches when adding professionals to the CFT (e.g., providers with shared racial/ethnicity, gender and/or faith-based identities or relevant specialized clinical competencies/experience). Supervisors and the HF Coach reinforce culturally respectful and relevant practices during the team’s initial case conceptualization meeting following the first intake appointment and directly prior to the initial Wrap Map planning meeting, weekly supervision and coaching sessions, quarterly meeting observations and through review of Wrap Maps to ensure strategies reflect the family’s cultural identity, values, and preferences. Coaching emphasizes cultural humility, respectful inquiry, and the development of strategies that honor the family’s traditions and community connections, including Tribal involvement when applicable. See Case Conceptualization Meeting Question Prompts, page 1.
(c) The program routinely gathers feedback from families about their experience with culturally respectful and relevant services through satisfaction surveys, WFI‑EZ or TOM 2.0 administration, and periodic quality assurance phone calls. This feedback is reviewed during weekly Wraparound and FYP Leadership Meetings and High-Fidelity Workgroup meetings and used to strengthen staff training, coaching, and practice expectations related to cultural humility and responsiveness. Supervisors and HF Coach share relevant feedback with staff during supervision and coaching sessions both verbally and in writing (documented collaboratively in each staff’s supervision record), to reinforce effective culturally respectful practices and address areas needing improvement. See Supervision Record Template, page 1.
1.8 High-Quality Team Planning and Problem Solving
(a) The HFW Facilitator works with the youth, family, and team members to develop team agreements during the early stages of the HFW process. These agreements outline shared expectations for communication, participation, confidentiality, and follow‑through, and they are reviewed with all team members—including natural supports and system partners—to ensure mutual understanding. The finalized team agreements are documented in the youth’s EHR and revisited during CFT Meetings to reinforce collaboration and accountability. Supervisors and HF Coach verify the presence and use of team agreements during documentation reviews and meeting observations. See Initial Wrap Map Template, page 2.
(b) Feedback from families and HFW team members regarding their experience of team engagement and collaboration is routinely gathered through meeting observations, satisfaction surveys, WFI‑EZ or TOM 2.0 administration, and periodic quality assurance phone calls. This feedback provides insight into how effectively the team communicates, shares responsibility, and supports the youth and family. Facilitators encourage families and team members to share their perspectives during and between meetings, and supervisors review this feedback to assess team functioning and identify opportunities for improvement. See TOM 2.0 Fillable Form, page 2.
(c) Feedback collected from families and team members is used to support continuous quality improvement. Supervisors and HF Coach also elicit, review and document in staff’s supervision record any feedback received or provided during weekly supervision sessions and use it to guide coaching conversations with staff, reinforcing effective team‑based practices and addressing areas where additional support or training is needed. Supervisors and HF Coach also periodically attend case management/intensive care coordination and CFT meetings to observe team engagement and collaboration to provide in the moment and/or individualized one-on-one coaching as needed for team members participating. Program‑level themes are discussed during weekly Wraparound and FYP Leadership Meetings and High-Fidelity Workgroup to strengthen overall team collaboration, planning quality, and consistency across staff. This process ensures that feedback directly informs staff development and enhances the quality of team‑based problem solving. See Supervision Record Template, page 1.
(d) Wrap Map and CFT meeting minutes are routinely reviewed by Facilitators, HF Coach and supervisors to assess shared ownership and follow‑through on strategies and action items. During CFT Meetings, the Facilitator ensures that each action step is assigned to a specific team member—formal or natural support—and that progress is reviewed at subsequent meetings. Supervisors verify that responsibilities are clearly documented, that team members are actively contributing, and that strategies reflect collaborative problem solving. This review process helps maintain accountability and ensures that the team remains focused, energized, and aligned with the youth and family’s goals. See CFT Minutes Template, pages 3-4.
1.9 Outcomes Based Process
(a) The HFW Facilitator ensures that each Wrap Map includes specific, measurable strategies and action items with clear timeframes for completion. During CFT Meetings, the Facilitator works with the youth, family, natural supports, and formal partners to define outcomes that are directly linked to the family’s prioritized needs. Strategies are written in measurable terms so progress can be objectively monitored, and supervisors review Wrap Maps during documentation checks to confirm that all strategies and action items meet measurable standards. See Initial Wrap Map Template, page 4-6.
(b) The HFW Facilitator tracks action item completion on an ongoing basis and updates progress during each CFT Meeting or sooner if tasks are completed between meetings. The Facilitator documents progress in updated Wrap Maps and CFT meeting minutes, ensuring that team members remain accountable for their assigned responsibilities. Supervisors verify timely updates and follow through during routine documentation reviews and meeting observations to ensure consistent monitoring of progress. See CFT Minutes Template, page 1.
(c) The program’s forms and processes allow Facilitators to adjust or change strategies and action items as needed based on team feedback, progress, or emerging needs. When changes occur, the Facilitator communicates updates to all team members and ensures revisions are documented in updated Wrap Maps and/or CFT Minutes and reviewed at the next CFT Meeting. Supervisors monitor this process through documentation reviews and coaching sessions to ensure that adjustments are timely, clearly communicated, and aligned with the family’s evolving needs. See CFT Minutes Template, page 3-4.
(d) The program has a clear process for completing the IP CANS and sharing results with the HFW team. The IP CANS is completed by the HFW Intake Coordinator/Clinician (or HFW Facilitator) within the required timeframe and updated according to state guidelines. The Facilitator reviews the results with the youth, family, and team to ensure shared understanding of identified needs and strengths, and incorporates relevant findings into the Wrap Map, including documenting identified strengths and needs in the Strengths Inventory and the Needs Inventory. Supervisors and HF Coach confirm timely completion and appropriate use of the IP CANS during supervision and documentation reviews. See Initial Wrap Map Template, pages 2-3.
(e) Data from the IP CANS is used to support tracking and team decision making by helping the team understand underlying needs and measure changes over time. However, the Facilitator ensures that IP CANS data supplements—rather than replaces—ongoing tracking of needs, goal progress, and action item completion. During CFT Meetings, the team reviews both IP CANS data and progress documented in the Wrap Map to determine whether strategies are effective and whether the family is approaching readiness for transition. Supervisors and HF Coach verify that both data sources are used appropriately to guide planning and decision making. See CFT Minutes Template, pages 2-4.
1.10 Persistence
(a) HFW teams are supported to continue working with youth and families even when progress is slow, setbacks occur, or challenges arise. The HFW Facilitator leads the team in viewing setbacks as indicators that the Wrap Map needs revision rather than as failures by the youth or family, and supports the family with re-evaluating priority Life Domains and focus areas of need. The Implementation Wrap Map is reviewed and updated at least every 3 months until the CFT determines family is ready to prepare for the Transition Phase. During CFT Meetings, the team reviews unmet needs, identifies barriers, and adjusts strategies to better support the family. Services continue throughout the Implementation Phase until the team—giving priority to family voice and choice—agrees that needs have been sufficiently met and the family is ready to move into the Transition phase. Supervisors and HF Coach reinforce this expectation during supervision, coaching sessions and meeting observations to ensure persistence remains a core practice. See Implementation Wrap Map Template, pages 1-5; CFT Minutes Template, pages 1-4.
(b) The program maintains clear processes for teams to access support when facing challenges, including how to request additional coaching or supervision, how to access flexible funding, and how to obtain additional resources. Each HFW team member is encouraged to seek supervisory or coaching guidance when barriers arise during weekly supervisions, coaching sessions or via text message or phone call for more pressing needs, and supervisors and HF Coach provide timely support through coaching, case consultations, and problem‑solving assistance (e.g., attending team case management/intensive care coordination needs or CFTs to provide additional support and guidance as needed). Staff also follow established procedures for requesting flexible funds to support individualized strategies when formal resources are limited. These processes ensure that teams have the tools and support needed to persist with families through difficult periods. See Wrap Flex Funds Training Presentation, pages/slides 2-13.
(c) Facilitators receive ongoing training and coaching in post‑crisis safety planning, conflict resolution, and leading teams through effective brainstorming and plan revision. Supervisors and HF Coach reinforce these skills during weekly supervision and coaching sessions, quarterly meeting observations, and through review of Wrap Maps and CFT Minutes to ensure Facilitators are equipped to guide teams through challenges with creativity and persistence. Coaching emphasizes maintaining optimism, reframing setbacks, and supporting teams in generating new strategies that align with the family’s needs and strengths. See HFW Training Presentation, pages 149-167.
1.11 Transitions as a part of the Fourth Phase of HFW
(a) HFW teams ensure that transitions are planned thoughtfully and occur only when the youth and family’s underlying needs have been sufficiently met, rather than as a result of adverse events or administrative requirements. The HFW Facilitator begins discussing transition readiness early in the process and revisits it regularly during CFT Meetings, ensuring the family’s voice and choice guide the timing and approach. When challenges or setbacks occur, the team revises the Wrap Map rather than ending services prematurely. Supervisors and HF coach reinforce this expectation during supervision and coaching sessions and meeting observations to ensure families do not experience sudden loss of services and that transitions are always purposeful and adequately supported. See CFT Minutes Template, pages 1-3.
(b) Transitions out of HFW are celebrated in ways that reflect the youth and family’s culture, values, and preferences. The HFW Facilitator works with the family and team to plan an individualized and meaningful celebration, which may include cultural traditions, community gatherings, or recognition of progress. Administrative structures support this process by allowing access to flexible funds, accommodating staff time for community‑based activities, and ensuring staff availability to attend celebrations. These supports help families feel honored, connected, and prepared for life beyond formal services. Supervisors verify that celebrations are planned and implemented in alignment with family preferences and program expectations. See Transition Wrap Map Template, pages 1-3.
Expected Outcomes
2.1 Youth and Family Satisfaction
The team collects satisfaction data from youth, families, and Tribes (when applicable) through CFT Satisfaction surveys, WFI/TOM tools, and QA calls, and items related to satisfaction, functioning, and cultural responsiveness are reviewed to assess alignment between family experience and documented progress. Feedback is used during CQI meetings to strengthen practice. See High Fidelity Wraparound Certification Policy, Page 26; WFI-EZ Caregiver Form, Page 4.
2.2 Improved School Functioning
The Wraparound team gathers school attendance, academic performance and behavioral data from families and school partners. IP-CANS educational functioning and strengths items (e.g., Developmental/Intellectual, School Behavior, Achievement, Attendance and Educational Setting) and risk behaviors (domain items) impacting school functioning are assessed for initially during Engagement, reviewed during Implementation to monitor progress and adjust strategies to support consistency, participation and vocational development. School functioning is discussed throughout each phase, in CFT Meetings, documented in the Wrap Map/CFT Minutes and evaluated and progress in functioning is documented at time of closure in the Discharge Summary. See High Fidelity Wraparound Certification Policy, Page 26; Discharge Summary Template, page 1-2.
2.3 Improved Functioning in the Community
The Wraparound team documents community involvement, justice involvement, and engagement in pro-social activities in the community. IP-CANS community functioning and strengths (e.g., Social Functioning, Social Resources, Interpersonal and Community Life) and risk behaviors (domain items) impacting functioning in the community are reviewed to track progress from Engagement through Transition. Strategies to increase community engagement are incorporated into the Wrap Map and monitored during CFT meetings. Progress in functioning is documented at time of closure in the Discharge Summary. See High Fidelity Wraparound Certification Policy, Page 26; Discharge Summary Template, page 1-2.
2.4 Improved Interpersonal Functioning
The team assesses family and peer relationships, communication, and social connections. IP-CANS items related to family functioning and strengths, social functioning, interpersonal strengths and caregiver needs are reviewed during each phase to evaluate progress. Strategies to reduce stress and strain and strengthen positive relationships are developed collaboratively, added to the Wrap Map and in CFT Minutes and monitored during team meetings. Progress in functioning is documented at time of closure in the Discharge Summary. See High Fidelity Wraparound Certification Policy, Page 26; Discharge Summary Template, page 1-2.
2.5 Increased Caregiver Confidence
The Facilitator and/or Family Partner evaluates caregiver confidence and ability to manage future challenges through use of the Transition Readiness Scale (TRS) tool throughout the Wraparound process. IP-CANS caregiver needs and strengths items are also reviewed to track improvements during each phase. Caregivers are connected to their own services when needed as well as community resources and crisis supports, and their confidence in their abilities and connectedness to resources is reassessed throughout each phase to ensure transition readiness. Progress related to caregiver confidence is documented at time of closure in the Discharge Summary. See High Fidelity Wraparound Certification Policy, Page 26; TRS Template, Pages 1-2.
2.6 Stable and Least Restrictive Living Environment
The Facilitator documents placement stability through tracking youth’s living environment and the frequency and types of changes in the their living situation or placement environment from engagement through transition phases and collaborates with the team to address factors impacting permanency, safety and conduct. IP-CANS items related to living situation, stability, and risk items impacting stability in a family-based setting are reviewed to monitor progress throughout all phases of Wraparound. Strategies to maintain community-based living are incorporated into the Wrap Map, including family finding/seeing strategies and collaboration with our internal Wendy’s Wonderful Kids (WWK) program to collaborate with county system partners to help identify and strengthen kinship connections and placement options whenever permanency plans are not established. Any and all juvenile detentions, psychiatric hospitalizations or STRTP placement changes are tracked and documented, and each youth’s living environment at time of referral and discharge are both documented through the Discharge Summary and discharge reports. See High Fidelity Wraparound Certification Policy, Page 26; Discharge Summary Template, page 1-2.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
The Wraparound supervisor and/or team documents all behavioral health hospitalizations and emergency visits through use of Critical Incident Reports (CIRs) to track frequency of hospital visits and urgent psychiatric evaluations/safety assessments. IP-CANS behavioral/emotional needs and risk behavior domain items impacting youth’s mental/behavioral health functioning and overall safety and stability are reviewed to identify triggers, patterns and inform crisis prevention strategies. Safety and Crisis Plans are updated accordingly and regularly to ensure both proactive and reactive strategies are implemented to reduce escalated crises and/or risk of harm to self or others. See High Fidelity Wraparound Certification Policy, Page 27; Discharge Summary Template, page 1-2; CIR Template, Page 1; Hospitalization Follow-Up Report Template, page/tab 1.
2.8 Reduction in Crisis Visits
The Wraparound supervisor, team and/or on-call team documents frequency of all crisis events and the level of professional involvement through progress notes, CIRs and/or the On-Call Log. IP-CANS risk behaviors (domain) and crisis items are reviewed to monitor progress and adjust Safety and Crisis Plans and the Wrap Map throughout the Wraparound process to support implementing proactive and reactive strategies to support the family with a reduction in crisis events, use of formal interventions and strengthening natural and community supports and connections to sustainably meet the youth and family’s needs for safety and stability and reduce reliance on crisis services. Progress related to reduction in frequency and intensity of crises is documented at time of closure in the Discharge Summary. See High Fidelity Wraparound Certification Policy, Page 27; Discharge Summary Template, page 1-2.
2.9 Positive Exit from HFW
The Wraparound clinician or Facilitator documents the time and reason for exit in Discharge Summaries and progress notes and ensures transitions occur only when needs are sufficiently met. IP-CANS data, living environment and progress towards the Family Vision, treatment goals and stabilization are reviewed during Implementation and Transition phases to confirm readiness and identify any remaining needs requiring linkage to community supports. The team ensures exits from HFW are based on progress made and family voice and choice, not due to adverse events. See High Fidelity Wraparound Certification Policy, Page 27; Discharge Summary Template, page 1-2.
Engagement
3.1 Orientation
(a) The HFW Facilitator provides every youth and family with a complete explanation of the High Fidelity Wraparound process during the Engagement Phase. This includes an overview of the HFW principles and the four phases, ensuring the family understands how the process unfolds and what to expect at each stage. The Facilitator uses family‑friendly language, checks for understanding, and invites questions to ensure clarity. Documentation of the completed orientation via review and collaborative completion of the Wrap Map with the CFT is maintained in the youth’s EHR and reviewed by supervisors and HF Coach during routine supervision and coaching sessions. See Initial Wrap, page 1.
(b) As part of the orientation, the HFW Intake Coordinator/Clinician reviews all legal and ethical considerations relevant to the family’s participation in HFW. This includes confidentiality, mandated reporting, information sharing, voluntary participation, and the family’s rights within the process. The Intake Coordinator/Clinician ensures that youth, caregivers and Tribal representatives (when applicable) understand how information will be used and how decisions are made within the team. Supervisors verify that legal and ethical topics were covered through documentation review and observation, ensuring that signatures were gathered from both youth (10 and older) and legal guardians/representatives and/or parents/caregivers (for youth who are dependents or wards of the court). See SSYAF Wraparound Treatment Agreement, page 3-7.
(c) The HFW Facilitator explains the role of each team member, including the youth, caregivers, natural supports, formal system partners, and, when applicable, the Tribe for American Indian and Alaska Native youth. The Facilitator emphasizes that the family’s voice and choice guide the process and that natural supports play a central role in planning and implementation. This orientation ensures that all participants understand their responsibilities and contributions to the team. Supervisors confirm that team roles were reviewed and documented on the Initial Wrap Map and in all CFT Minutes during supervision and meeting observations. See Initial Wrap Map Template, page 2.
3.2 Safety and Crisis stabilization
(a) During the Engagement Phase, the HFW Intake Coordinator/Clinician initiates a discussion with the youth and family to identify any immediate safety or crisis concerns that may interfere with their ability to participate fully in the HFW process. If pressing concerns are identified, the Intake Coordinator/Clinician works with the family and available team members to develop an immediate crisis response plan that outlines specific steps to stabilize the situation. This plan is provided to the family in writing and documented in the youth’s EHR. Supervisors verify that initial crisis and safety concerns were addressed promptly through routine documentation review and supervision. See Axiom Safety Plan template, page 2.
(b) The immediate crisis response plan developed during Engagement is used to inform—but not replace—the comprehensive HFW Safety Plan created during the Plan Development Phase, after completion of a Functional Assessment. The Facilitator ensures that information gathered during early crisis discussions is incorporated into the updated HFW Safety Plan, including triggers, early warning signs, preferred interventions, and natural support involvement. Supervisors review both documents to ensure alignment and confirm that the crisis plan appropriately transitions into a more robust Safety Plan as the process progresses, and includes both proactive and reactive strategies. See Axiom Safety Plan Template, page 2.
(c) All families are provided with clear information on how to access 24/7 crisis response services, including the agency’s Family Support On-Call service, local crisis lines, mobile crisis teams and emergency resources. The Intake Coordinator/Clinician reviews these options with the family verbally and provides written materials to ensure they know how to obtain immediate support outside of scheduled meetings. This information is documented in the youth’s EHR, and supervisors confirm that crisis access instructions were provided during routine supervision and chart audits. See Axiom Safety Plan Template, page 1.
3.3 Strengths, Needs, Culture and Vision Discovery
(a) The HFW Facilitator meets with the youth, family, and, when applicable, the Tribe within 10 business days of referral to learn about their values, cultural practices, priorities, and long-term hopes at the collaborative intake appointment with the clinical intake coordinator through completion of the Strengths, Needs and Cultural Discovery (SNCD) during the Engagement Phase. These conversations guide the development of the Family Vision and Team Mission in the Initial Wrap Map, which are drafted within 30 days of opening, using the Initial Wrap Map Template, and reviewed with the family to ensure accuracy. For American Indian and Alaska Native youth, the Facilitator ensures the Tribe is invited to all meetings, participates fully in decision making, and has an equal voice in shaping the Family Vision, Team Mission, and strategies to ensure they are culturally respectful and responsive. All information is documented in the EHR and reflected in the Initial Wrap Map. See Initial Wrap Map Template, page 2.
(b) The HFW Facilitator conducts structured engagement conversations during a collaborative intake appointment that occurs within 10 business days of referral to elicit the family’s cultural background, strengths, traditions, interests, and natural supports. This information is documented in the SNCD Tool and incorporated into the Wrap Map within 30 calendar days of opening to ensure strategies align with the family’s preferences and cultural identity. The Facilitator updates this information at least every 90 days during Wrap Map reviews or sooner if the family identifies new strengths or priority needs and updated/most recent SNCD documents are provided to both existing and new team members as they are identified. All documentation is maintained in the youth’s EHR and reviewed by Wraparound supervisors and/or HF Coach to ensure accuracy and fidelity to HFW principles. See SNCD Tool, pages 1-2.
3.4 Engage All Team Members
(a) The HFW Facilitator completes a natural supports inventory within the SNCD with every youth and family during the Engagement Phase to identify individuals who care about the youth and can contribute meaningfully to the team. This includes extended family, friends, mentors, cultural or faith‑based supports, and, when applicable, Tribal representatives for American Indian and Alaska Native youth. The inventory is documented in the youth’s EHR and updated as new supports emerge. Supervisors and HF Coach verify completion and quality of the inventory during routine documentation reviews and supervision. See SNCD Tool, page 1.
(b) Directly following receipt of a family referral, Wraparound supervisors identify a HFW intake coordinator/clinician, Facilitator and Family (Skills) Specialist to assign to the family and send out a new referral email to the assigned internal Wraparound team and cc’ing any Children’s System of Care referral partners (e.g., from DCFAS or Probation), attorneys (for youth with court dependency or Probation) to identify these partners for the HFW team and initiate engagement with the family and system partners. Prior to and following a family’s enrollment in HFW, the Facilitator collaborates with the youth, family, and referring partners to identify any additional Children’s System of Care partners who should be included on the HFW team. This may include behavioral health providers, school personnel, probation, child welfare, regional center staff, or other formal supports involved in the youth’s life. The Facilitator reaches out to these partners to explain the HFW process, clarify expectations, and invite participation in Case Management/Intensive Care Coordination and CFT Meetings (with family’s permission when needed). Supervisors review documentation (e.g., Wrap Maps, CFT Minutes and progress notes in the EHR) to ensure appropriate system partners were identified and engaged early in the process. See New Referral Email Template, page 1.
(c) The HFW Facilitator works with the youth and family to identify potential team members—including formal supports, natural supports, and Tribes in the case of American Indian and Alaska Native youth —and discusses the role each person will play on the team during completion of the Initial Wrap Map. The Facilitator ensures that the family’s voice and choice guide team composition and that each member understands their responsibilities, such as contributing to brainstorming, implementing strategies, or providing emotional or cultural support. Supervisors confirm that team member roles were discussed and documented through supervision, documentation review and meeting observations. See Initial Wrap Map Template, page 2.
(d) The HFW Facilitator and team members ensure to engage and invite youth, family, system partners and natural supports throughout the HFW process. The HFW Facilitator intentionally engages the team in activities that build trust, strengthen collaboration, and promote a positive team culture. Engagement and team‑building activities—such as, invitations to CFTM, shared strengths exploration, team mission development, or collaborative brainstorming—are documented in the youth’s EHR through CFT meeting minutes and progress notes. Supervisors review these records to ensure that team engagement is ongoing and that the Facilitator is actively cultivating a supportive, collaborative environment. See CFT Minute Template, pages 2-4.
3.5 Arrange Meeting Logistics
(a) HFW staff demonstrate flexibility in their working hours and scheduling practices to ensure that CFT Meetings occur at times and in locations that prioritize the youth and family’s needs, preferences, and cultural considerations. The Facilitator collaborates with the family to identify meeting times that accommodate school, work, caregiving responsibilities, and any trauma‑related sensitivities regarding location or format. Staff arrange logistics such as transportation support, interpretation services, and telehealth access when needed to ensure equitable participation for all team members. Supervisors verify that meeting logistics reflect family voice and choice through documentation review and supervision. See Child and Family Team and CFT Meetings Policy, page 2.
(b) HFW staff are trained to work collaboratively with youth, families, natural supports, Tribes (when applicable) and formal system partners to schedule meetings that maximize participation and align with family preferences. The Facilitator ensures that all team members understand the importance of accessibility and inclusivity in meeting planning and actively seek input from the family regarding preferred formats, locations, and supports needed for full engagement. Documentation of scheduling efforts and accommodations is maintained in the youth’s EHR and reviewed by supervisors to ensure consistent adherence to family‑centered scheduling practices. See CFT Minutes Template, page 5.
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
(a) Before the HFW Wrap Map is fully developed, the Facilitator begins leading the team through a structured process during the Initial Wrap Map meeting to establish team agreements, identify team strengths, and create a team mission statement aligned with the family’s vision. The Facilitator guides the youth, family, natural supports, formal partners, and, when applicable, Tribal representatives in developing clear agreements about how the team will communicate, make decisions, and maintain a respectful, collaborative environment. The Facilitator also documents additional strengths identified during early team interactions, including strengths of the youth, caregivers, team members, and community resources. The team then collaborates to create a mission statement that reflects the shared purpose of the HFW process and supports the family’s long‑term vision. All team agreements, strengths, and the mission statement are documented in the EHR prior to developing the finalized Wrap Map. See Initial Wrap Map Template, page 2.
(b) The Facilitator ensures that strengths identified during the Engagement Phase are updated to reflect new strengths discovered as the team begins working together. This includes strengths of the youth and family, as well as strengths contributed by natural supports, formal partners, and community members. The Facilitator actively listens for emerging strengths during conversations, team‑building activities, and early CFT Meetings, and incorporates these into the strengths inventory. Updated strengths are documented in ongoing/updated Wrap Maps and used to guide the development of strategies and action steps during CFT meetings (as documented in the CFT Minutes). Supervisors review documentation to ensure strengths are continually identified and integrated throughout the Plan Development and Implementation Phases. See CFT Minutes Template, pages 2 & 4.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
(a) Before the HFW Wrap Map is fully developed, the Facilitator leads the youth, family, and team in identifying and prioritizing underlying needs based on information gathered during Engagement and early team discussions. The Facilitator ensures that needs reflect the root causes of challenges rather than surface‑level behaviors, and that the family’s voice and cultural context guide prioritization. All identified and prioritized needs are documented in the youth’s EHR and reviewed during supervision to ensure alignment with HFW principles. See Initial Wrap Map Template, pages 3-5.
(b) The Facilitator supports the team in developing measurable goals and desired outcomes that directly correspond to the prioritized underlying needs. These goals are written in clear, observable terms that allow the team to monitor progress over time and avoid deficit‑based or behavior‑focused goal statements. Goals reflect what success will look like for the youth and family and are grounded in their strengths, preferences, and long‑term vision. Supervisors review each new youth’s Wrap Map to ensure goals are measurable and need‑based. See Initial Wrap Map Template, pages 4-5.
(c) Goals and desired outcomes are developed collaboratively with the youth, family, natural supports, formal partners, and, when applicable, Tribal representatives. The Facilitator ensures that the family’s voice and choice drive the process and that all team members contribute to shaping goals that are meaningful, culturally relevant, and achievable. Collaboration is documented in the Initial Wrap Map, CFT meeting minutes and/or progress notes and reviewed by supervisors to confirm team‑based planning. See Initial Wrap Map Template, pages 4-5.
(d) The Facilitator leads the team in brainstorming multiple individualized strategies for each prioritized need before selecting the most appropriate ones. Brainstorming emphasizes creativity, cultural relevance, natural support involvement, and alignment with the family’s strengths. All brainstormed strategies—whether selected or not—are documented in the youth’s EHR via the Initial Wrap Map and/or CFT Minutes so the team can revisit them if adjustments are needed. Supervisors verify that brainstorming is occurring consistently through documentation review and meeting observations. See Initial Wrap Map Template, pages 4-6.
(e) Facilitators receive ongoing training and coaching on how to guide teams in identifying underlying needs, prioritizing them, brainstorming strategies, and developing action items. Supervisors and HF Coach reinforce these skills during weekly supervision and coaching sessions, quarterly meeting observations, and review of Wrap Maps and CFT Minutes to ensure Facilitators are effectively leading the team‑based planning process. See HFW Training Presentation, pages/slides 69-84; 141-148; 158-167.
(f) These steps—identifying and prioritizing needs, developing measurable goals, brainstorming strategies, and assigning action items—are used to create an individualized HFW Plan of Care in a collaborative, team‑based environment. The Facilitator ensures that the Wrap Map and CFT Minutes reflect the family’s vision, incorporates natural supports, and includes clear responsibilities and timelines for each action item. Supervisors and the HF Coach review all Wrap Maps and CFT Minutes to confirm that all required steps were followed and documented. See Initial Wrap Map Template, page 3-6.
4.3 Develop an Individualized Child or Youth and Family Plan
(a) Facilitators receive ongoing training and coaching to ensure they can effectively guide the team through a collaborative planning process that elicits multiple perspectives, builds trust, and reinforces the HFW principles. Through supervision, coaching sessions, and feedback provided from meeting observations (including regular use of the TOM 2.0), Facilitators strengthen their skills in leading inclusive discussions, managing differing viewpoints, and supporting the youth and family in articulating their vision and priorities. This training and coaching ensure that the planning process reflects a shared mission, cultural responsiveness, and a strong foundation of teamwork. See TOM 2.0 Fillable Form, pages 2-5.
(b) The Wrap Map and CFT Minutes integrate goals, outcomes, and strategies identified by all Children’s System of Care partners, including natural supports and, when applicable, Tribal representatives for an Indian child. The Facilitator ensures that the Plan reflects the full range of needs across life domains—such as safety, education, community involvement, behavioral health, and family functioning—and that each partner’s contributions are aligned with the family’s vision and team mission. This comprehensive integration supports coordinated care and reduces duplication or fragmentation of services. See Initial Wrap Map Template, pages 2-6.
(c) The Wrap Map and CFT Minute Plans are documented in the youth’s EHR and distributed to all team members to ensure shared understanding and accountability after every Plan Development and CFT meeting. The Plans includes all required elements: alignment with the family vision and team mission; needs and goals across multiple life domains; clearly documented strategies and action items with assigned responsibilities and due dates; culturally relevant supports; and a balanced mix of formal services, natural supports, and community resources. The Plans also outline a graduated approach to transitioning from formal services as the family builds confidence and stability. Supervisors review Wrap Maps and CFT Minutes to confirm they meet all criteria and reflect high‑quality team planning. See Initial Wrap Map Template, pages 2-6.
(d) Procedures are in place to routinely review Wrap Maps and CFT Minutes for continuous quality improvement. Supervisors and coaches examine these Plan documents during supervision, coaching sessions, documentation audits, and team meeting observations to assess fidelity to HFW principles, quality of goals and strategies, and the degree of collaboration reflected in the planning process. Feedback is provided to staff timely both individually and in team meetings and refresher trainings (for larger program themes/general areas of identified drift/needs for improvement) to strengthen practice, reinforce training, and ensure these Plans remain individualized, culturally responsive, and aligned with the family’s evolving needs. See Supervision Record Template, page 1.
4.4 Develop a Crisis and Safety Plan
(a) The Facilitator leads the team in developing a Functional Assessment and an individualized crisis and safety plan that identifies potential safety concerns, high‑risk situations, and crisis triggers specific to the youth and family. The plan includes both proactive strategies (for pre-crisis/baseline phase)—designed to prevent escalation—and reactive strategies (for Escalation, Outburst or Recovery Phases) that outline step‑by‑step responses if a crisis occurs. The youth and family select the strategies that feel most effective and culturally relevant to them, and the plan clearly identifies who should be contacted for support 24/7, prioritizing natural supports whenever possible. The completed crisis and safety plan is documented in the youth’s EHR, provided to the family at enrollment and throughout services as updated, and reviewed during supervision and HF coaching to ensure it meets HFW standards. See Axiom Safety Plan Template, pages 1-2.
(b) The development of the crisis and safety plan occurs in a collaborative, team‑based environment that includes the youth, family, natural supports, formal partners, and, when applicable, Tribal representatives. The Facilitator ensures that all voices are heard and that the family’s preferences guide the selection of strategies. Facilitators receive ongoing training and coaching to strengthen their skills in leading crisis planning discussions, managing differing perspectives, and ensuring that the plan reflects the family’s culture, strengths, and lived experience. Supervisors and HF Coach reinforce these skills through observation and feedback during weekly supervision and coaching meetings. See HFW Training Presentation, pages/slides 85-96.
(c) Crisis and safety plans are routinely reviewed for quality and fidelity, ensuring that strategies are individualized, culturally relevant, and include a clear progression from proactive to reactive responses. Supervisors and coaches examine plans during documentation reviews and CQI processes to confirm that natural supports are incorporated whenever possible and that the plan reflects the family’s unique needs and strengths. Feedback from these reviews is used to guide staff training and also provided individually to staff by supervisors and HF coach during weekly supervision and coaching sessions, both verbally and documented in their Supervision Record, to continuously improve crisis planning practices. See Supervision Record Template, page 1.
Implementation
5.1 Implement The Plan of Care
(a) The Facilitator leads the HFW team in consistently reviewing and implementing the strategies and action items outlined in the Wrap Map and CFT Minutes. During each CFT Meeting, the Facilitator uses structured tools—such as agendas/meeting minutes—to review action item completion, assess progress toward goals, and identify barriers that may require adjustments. The Facilitator checks in with team members between meetings through care coordination calls and meetings to support follow‑through, ensure timelines are met, and maintain momentum. When strategies are not producing the desired outcomes, the Facilitator guides the team in revising or replacing them using the HFW brainstorming process. Successes are acknowledged and celebrated as they occur to reinforce progress and strengthen team cohesion. Supervisors and HF Coach verify implementation fidelity through documentation review and meeting observations. See CFT Minutes Template, pages 1-4.
(b) Staff receive ongoing training and coaching to ensure they implement the Plan of Care in alignment with HFW principles, including family voice and choice, cultural responsiveness, and reliance on natural supports. Training emphasizes the importance of monitoring progress, adjusting strategies collaboratively, and celebrating successes to maintain engagement and motivation. Supervisors and HF Coach reinforce these skills through regular supervision, coaching, review of Wrap Maps and CFT Minutes, and observation of CFT and CM/ICC Meetings to ensure that implementation practices remain consistent with high‑fidelity HFW. See HFW Training Presentation, pages/slides 21-32; 149-157.
5.2 Review and Update The Plan of Care
(a) Reviews of strategies, progress, and action items occur during HFW team meetings, where the Facilitator leads the team through a structured discussion of what has been completed, what remains in progress, and what barriers may be impacting follow‑through. The Facilitator ensures that each meeting includes a review of the Wrap Map, using agendas/meeting minutes to track progress toward goals and outcomes. This team‑based review process ensures that all members—including natural supports, formal partners, and Tribal representatives when applicable—have a shared understanding of progress and can contribute to problem‑solving. Supervisors and HF Coach verify that reviews occur consistently through documentation audits and meeting observations. See CFT Minutes Template, pages 1-4.
(b) The Facilitator leads the team in adjusting the Wrap Map and CFT Minutes Plans as successes occur, new needs emerge, or strategies require modification. This includes updating goals, refining strategies, and assigning new action items based on the team’s assessment of progress. The Facilitator ensures that changes reflect the youth and family’s voice and choice and that updates are documented promptly in the youth’s EHR. Adjustments are made collaboratively during team meetings to maintain transparency and shared ownership of the plan. Supervisors and HF Coach review updated “Implementation” Wrap Maps and CFT Minutes to ensure changes are aligned with HFW principles and accurately documented. See Implementation Wrap Map Template, pages 1-4.
(c) The Facilitator documents and communicates all updates to the Wrap Map and CFT Minutes Plans—including completion of tasks, new assignments, team attendance, use of formal and natural supports, use of flex funds, and any changes to strategies or goals. These updates are shared with all team members, at minimum, through detailed meeting minutes that reflect decisions made and next steps. This communication ensures accountability, clarity, and continuity across the team. Supervisors and HF Coach review meeting minutes and progress notes to confirm that documentation is thorough and timely. See CFT Minutes Template, pages 1-4.
(d) All forms used in the planning and implementation process are designed to be flexible and adaptable so they can be updated and individualized as the youth, family, and team’s needs evolve. The Facilitator ensures that documentation tools—such as the Wrap Map and CFT meeting agendas/minutes—are revised as needed to reflect changes in goals, strategies, and team composition. This flexibility supports high‑quality, individualized planning and ensures that documentation remains relevant and useful throughout the HFW process. Supervisors and HF Coach confirm that forms are being individualized appropriately through routine documentation review. See CFT Minutes Template, pages 1-5.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
(a) Team agreements are actively used and revisited during HFW team meetings to maintain a foundation of trust, respect, and shared expectations. The Facilitator ensures that agreements—created during the Plan Development Phase—are visible, referenced, and reinforced throughout Implementation. When challenges arise, the Facilitator guides the team back to these agreements to support problem‑solving and preserve a collaborative environment. Supervisors and HF Coach verify the consistent use of team agreements through meeting observations and documentation review. See CFT Minutes Template, page 1.
(b) Facilitators receive ongoing training and coaching on building, engaging, and sustaining effective teams. Supervisors and HF Coach utilize the TOM 2.0 regularly to assess Facilitator’s skill level and to elicit areas for specialized coaching and support. This includes developing skills in conflict resolution, managing differing perspectives, strengthening communication, and fostering psychological safety among team members. Through supervision and coaching, Facilitators refine their ability to maintain team cohesion, support shared decision‑making, and ensure that all voices—including youth, caregivers, natural supports, and Tribes when applicable—are valued and heard. See TOM 2.0 Fillable Form, pages 2 & 5.
(c) The Facilitator monitors the use and involvement of natural supports over time to ensure they remain central to the team’s functioning and the youth and family’s long‑term stability. Supervisors and HF Coach utilize the TOM 2.0 regularly to assess for effective inclusion of natural and community supports and to elicit areas for specialized coaching and support. Supervisors and HF Coach provide feedback through coaching and documentation review to reinforce the importance of natural supports and to help Facilitators identify opportunities to strengthen or expand the family’s support network. This ongoing monitoring ensures that natural supports play an increasingly significant role as the family progresses through the HFW process. See TOM 2.0 Fillable Form, page 4.
(d) When new team members join—whether it be formal partners, natural supports, new caregivers or Tribal representatives—the Facilitator orients them to the HFW process, the family’s vision, the team mission, and the current Wrap Map. The Facilitator reviews existing strategies, action items, and team agreements, and engages the team in brief team‑building activities to integrate the new member and maintain cohesion. New team members are invited to collaborate and participate in updated Wrap Maps (which occurs every 90 days) as well as in the brainstorming and action plans developed and documented in monthly CFT Meeting Minutes. This structured onboarding process ensures continuity, shared understanding, and a smooth transition as the team evolves. Supervisors confirm that new member orientation is occurring through documentation review and meeting observations. See Implementation Wrap Map Template, pages 1-6.
Transition
6.1 Develop a Transition Plan
(a) Throughout the Implementation Phase and via review and updates to the Wrap Map and tracking through monthly CFT meetings and CFT Meeting Agenda/Minutes tracking documentation, the HFW Facilitator leads the team in determining when the youth and family are ready to begin transition by reviewing the benchmarks and indicators that have been monitored and updated throughout the HFW process. This includes assessing progress toward goals, the family’s confidence in sustaining gains, the stability of natural supports, and the team’s shared agreement that the family can move forward with less formal support. The Facilitator ensures that the youth and family’s voice and readiness guide the timing of transition. Supervisors and HF Coach verify that transition readiness is assessed consistently through documentation review and supervision. See Implementation Wrap Map Template, pages 1-4.
(b) Once the team agrees that transition is appropriate, the Facilitator leads the development of an individualized transition plan (“Transition Wrap Map”) that identifies the needs, services, and supports that will continue beyond formal HFW involvement. This plan outlines how remaining responsibilities will shift from HFW staff to natural supports, community resources, and formal partners. The Facilitator documents the Transition Wrap Map and Transition CFT Meeting Agenda/Minutes in the youth’s EHR and distributes them to all team members to ensure shared understanding and accountability. See Transition Wrap Map Template, pages 1-3.
(c) The development of the Transition Wrap Map occurs in a collaborative, team based environment that includes the youth, family, natural supports, formal partners, and, when applicable, Tribal representatives. Facilitators receive ongoing training and coaching to ensure they can guide this process effectively, support multiple perspectives, and maintain alignment with HFW principles. This collaborative approach ensures that the Transition Wrap Map reflects the family’s culture, strengths, and long term vision. See HFW Training Presentation, pages/slides 168-173.
(d) The team verifies that all services and supports identified in the transition plans (Transition Wrap Map and Transition CFT Meeting Agenda/Minutes) will remain accessible to the family after formal HFW ends. This includes confirming eligibility, availability, and contact information for ongoing supports, as well as ensuring the family knows how to access them independently. For adoptive families receiving Adoption Assistance Program (AAP) funding, the Facilitator provides information about both our internal agency and additional community post adoption services and resources that can support long term stability. Supervisors and HF Coach review transition plans to ensure continuity of care and sustainability of supports. See Transition Wrap Map Template, pages 1 & 3.
6.2 Develop a Post-Transition Safety Plan
(a) The Facilitator leads the team in updating the existing crisis and safety plan to develop a new post transition version, called the Relapse Prevention Safety Plan, to reflect the youth and family’s needs after formal HFW services conclude. The plan identifies potential crisis situations that may arise post transition and includes individualized proactive and reactive strategies chosen by the youth and family. These strategies emphasize cultural relevance and prioritize the use of natural and community supports and resources who will remain involved and available after HFW ends. The completed post transition crisis and safety plan is documented in the youth’s HER, provided to the family towards the end of the Transition Phase and reviewed during supervision and HF coaching sessions to ensure it meets HFW fidelity expectations. See Relapse Prevention Safety Plan Template, pages 1-2.
(b) The development of the post transition crisis and safety plan (Relapse Prevention Safety Plan) occurs in a collaborative, team based environment that includes the youth, family, natural supports, formal partners, and, when applicable, Tribal representatives. The Facilitator ensures that all voices are heard and that the family’s preferences guide the selection of strategies. Facilitators receive ongoing training and coaching to strengthen their skills in leading proactive and sustainable crisis and safety planning discussions, supporting multiple perspectives, and ensuring that the plan reflects the family’s culture, strengths, and long term vision. See HFW Training Presentation, pages/slides 168-171.
(c) Processes are in place to routinely review crisis and safety plans (Relapse Prevention Safety Plans) for individualized strategies, cultural relevance, and a clear progression from proactive to reactive responses. Supervisors and HF coach examine plans during documentation reviews and prior to each youth’s formal transition from HFW to ensure that natural supports are incorporated whenever possible and that the plan reflects the family’s unique needs and circumstances. Feedback from these reviews is used to guide staff training and individualized coaching, supporting continuous improvement in crisis planning practices. See Supervision Record Template, page 1.
6.3 Create a Commencement and Celebrate Success
(a) The HFW team ensures that transitions out of the Wraparound process are celebrated in ways that honor the youth and family’s culture, values, and preferences. The Facilitator works with the family to design a meaningful commencement activity—such as a gathering, ceremony, shared meal, or symbolic gesture—that reflects the family’s identity and acknowledges their accomplishments. The celebration reinforces the family’s strengths, highlights progress made during HFW, and supports a positive emotional transition as formal services conclude. Supervisors and HF Coach verify that celebrations are individualized and culturally relevant through documentation review, meeting observations and supervision and coaching sessions. See Transition Wrap Map Template, page 2 & 8.
(b) Administrative structures support the team’s ability to engage in meaningful celebrations by ensuring access to resources such as flex funds, time for community resourcing, and partnerships with community organizations. Leadership also ensure that staff have the flexibility and availability to attend celebrations, reinforcing the importance of honoring the family’s journey and strengthening the sense of closure. Supervisors confirm that staff are supported in planning and participating in commencement activities through supervision and CQI processes. See Transition Wrap Map Template, pages 1-3.
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
(a) The organization maintains clear mechanisms for youth and families to participate meaningfully in decisions regarding all levels of the HFW program and model implementation. The following are some mechanisms that utilize youth & family involvement: Listening Sessions & Family Panels: These feedback and partnership opportunities with current and previous youth & families who receive HFW are done in collaboration with our Family and Youth Partnership (FYP) department of peers with lived experience and expertise to gather insight, feedback and recommendations around the HFW implementation and continuous quality improvements. Shared Leadership Workgroup: Current and previously served youth & caregivers are invited to partner with FYP program staff and leadership to provide review and feedback on program and agency-wide policies & procedures, program practices and agency initiatives. The organization ensures that youth and family voices are not symbolic but are integrated into decision‑making structures where their lived experience directly informs program direction. Supervisors and executive leadership team review participation records and feedback gathered during listening sessions, family panels and shared leadership workgroup reviews to ensure a youth & family informed method to continuous quality improvement is embedded for the model, programs and agency. See Shared Leadership Presentation, pages/slides 7-11.
(b) Family feedback is systematically gathered and used to inform decisions related to service planning and implementation, policy and procedure development, workforce development, and quality improvement efforts. The organization uses multiple methods—such as satisfaction surveys, Family Support On-Call surveys and WFI EZ surveys, Family Panels, Shared Leadership workgroups, discharge satisfaction surveys, and real‑time feedback tools—to ensure diverse family perspectives are captured. Leadership reviews this feedback regularly and incorporates it into program adjustments, staff training priorities, and updates to policies and procedures. All Wraparound staff are trained and coached to implement Collaborative Documentation practices with families to gather and document their feedback during direct service provision in progress notes, including summarizing interventions and resources reviewed and provided to youth and families as well as a collaboratively developed plan, to elevate youth and family voice and choice and ensure transparency and shared understanding regarding documentation of services provided throughout the HFW process. Documentation demonstrates how family input has shaped program improvements and strengthened fidelity to the Wraparound model. See WFI-EZ Caregiver Form, page 2-4.
7.2 Community Leadership Team
(a) The provider designates identified leadership representatives who actively participate on the Community Leadership Team (e.g., the Interagency Youth Collaborative Workgroup) for each county that our agency provides Wraparound services in. These representatives attend CLT meetings consistently, contribute to shared decision‑making, communicate organizational perspectives, and bring information back to agency leadership and Wraparound staff. The Wraparound Leadership team ensures someone can attend every CLT meeting. Participation includes engaging in discussions about system barriers and collaborating with county system and community partners to bridge and resolve challenges impacting family’s access or outcomes, supporting cross‑agency training efforts, reviewing data trends, and ensuring that family‑centered and culturally responsive practices are upheld across the local Children’s Systems of Care. Supervisors and Executive Leaders verify participation through meeting attendance records and through saving copies of CLT meeting minutes in Agency Leadership shared drives/folders. See IYCW Meeting Notes Example, pages 1-3.
7.3 Eligibility and Equal Access
(a) The provider ensures that all youth who meet established eligibility criteria can receive HFW services and are not excluded based on the severity, complexity, or nature of their needs. Referrals are received directly from behavioral health contractors, or via self-referral for AAP-eligible families, and are provided HFW services. When applicable, families are assessed for medical necessity, only based on EPSDT requirements. See Medical Necessity Criteria Policy, page 2; EPSDT Services Policy, page 2.
(b) Staffing is intentionally planned to support appropriate caseload assignments that allow Facilitators and Support Partners to provide the intensity and frequency of services required for families with complex needs. Caseloads are structured to ensure that Wraparound staff can offer 24/7 crisis support, through providing direct crisis support during regular business hours and including On-Call Family Support for after hours, weekend and holiday crisis support needs, maintain regular contact with families, and participate in CFT meetings and community coordination activities. Leadership monitors staffing levels, turnover, and workload distribution to ensure that families receive timely, high‑quality support throughout their HFW involvement. See Wraparound Program Statement, page 3; On-Call Crisis Intervention Policy, Pages 1-2.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
(a) Contracts include funding for high‑fidelity direct services and supports that allow teams to meet the immediate, individualized needs of youth and families. This includes resources for natural support engagement, crisis response, community‑based activities, and individualized strategies identified through the Wrap Map and CFTs. Fiscal practices ensure that funds can be used flexibly and quickly to support family‑driven solutions consistent with HFW principles. For AAP funded Wraparound, AAP funding is utilized in accordance with the guidance and limitations given per CDSS guidelines. Supervisors verify appropriate use of funds through documentation review and fiscal oversight and approval processes. See AAP Wraparound Contract, pages 5-7.
(b) Contracts and budgets allocate funding for required workforce development and staffing, including all roles and functions outlined in Workforce Development Standard 9.3. This ensures that Intake Coordinators/Clinicians, Facilitators, Family (Parent) Partners, Youth Advocates (Partners), Family Specialists, clinical supervisors, HFW managers (supervisors), the HF Coach and administrative staff receive the training, coaching, and support necessary to deliver high‑fidelity services. Funding also supports manageable caseloads, ongoing professional development, and the infrastructure needed to maintain program quality and improvement, a cohesive, flexible and creative work environment, open communication amongst teams, a skilled and stable workforce and a clear sense of mission and compliance with HFW philosophy and practices. See Wraparound Program Statement, pages 6-8.
(c) Fiscal structures include funding for required data collection and data management systems that support fidelity monitoring, outcomes tracking, and Continuous Quality Improvement (CQI). This includes resources for maintaining secure data systems (e.g., Axiom EHR, WrapStat), staff training on data integrity and reporting, and the capacity to analyze and use data to strengthen program implementation. Leadership ensures that data systems are adequately funded and aligned with state and county reporting requirements. See High Fidelity Wraparound Certification Policy, page 14.
8.2 Equitable Funding Across System Partners
N/A as Stanford Sierra Youth & Families (SSYAF) is a county-contracted provider.
8.3 Cost Savings are Reinvested
N/A as Stanford Sierra Youth & Families (SSYAF) is a county-contracted provider and cost-savings are unavailable to us in all counties we provide Wraparound services.
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
(a) Flexible funds are included as part of the overall funding plan for HFW, ensuring that teams have access to resources necessary to support individualized, family‑driven strategies. The organization budgets for flex funds annually and monitors utilization to ensure availability throughout the year. Supervisors review flex fund usage to confirm alignment with HFW values and the Wrap Map and CFT Plans. See Stewardship Training Presentation, pages/slides 10-23.
(b) The organization maintains clear, accessible processes for requesting, approving, and managing flexible funds. These processes include:
1. Timely access to meet urgent needs, ensuring families receive support without unnecessary delays.
2. A defined approval process that evaluates requests using the criteria outlined in the Standard, including alignment with the team mission, cultural relevance, sustainability, and the strengthening of natural supports.
3. An appeal process for denied requests, which includes transparent communication with the team, youth, and family about the reason for denial and guidance on next steps or alternative solutions.
Supervisors, HF Coach and leadership regularly review flex fund procedures to ensure they remain equitable, efficient, and aligned with HFW principles. See AAP Wraparound Contract, pages 6-7.
8.5 Collaborative Oversight of Flex Funds
(a) Flex fund use and availability are documented and communicated transparently across funders and providers. Documentation includes the amount requested, the purpose of the request, and the HFW team’s recommendation. This information is shared through established communication channels to support accountability, identify trends, and ensure that flex funds are being used in alignment with HFW principles. Supervisors review and approve all submitted flex fund request documentation to ensure routine oversight and confirm accuracy and transparency, in adherence with County policies. See Flex Funds Request Training Guide, pages 6-21.
(b) Flex funds are pooled and held collectively to meet the needs of all families served, ensuring equitable access regardless of which provider or team is supporting the family. Collaborative oversight structures monitor the pooled fund to ensure sustainability, responsiveness to urgent needs, and adherence with county‑level fiscal policies. Wraparound and Finance Leadership review pooled fund utilization regularly to ensure that resources remain available and that families continue to receive individualized, timely support. See High Fidelity Wraparound Certification Policy, page 15.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
(a) Flex funds and program resources are supported through the braiding of available System of Care funding streams, ensuring that no single source determines availability. This braided approach allows the program to maintain a stable and flexible pool of resources that can be used to meet individualized family needs, including culturally specific supports and Tribal activities. Executive leadership and Wraparound Supervisors review fiscal planning and utilization to ensure that braided funding remains sufficient and accessible. See High Fidelity Wraparound Certification Policy, page 15.
(b) When limitations exist within a single funding source, the organization explores alternative funding options or increases reliance on other available sources to fill gaps. This ensures that families do not experience delays or denials due to funding restrictions and that the program can continue to support individualized strategies aligned with the Wrap Map and CFT Plans. Executive and Wraparound Leadership monitor funding patterns and adjusts fiscal strategies to maintain continuity of support, including partnership with our Philanthropy department to ensure we always have alternative funding options available for use to support families when Flex Funds cannot be utilized (e.g., through donated Lifeline Funds, etc.) See Stewardship Policy, page 2.
(c) The organization ensures that the requirements of any single funding source do not prevent families from accessing flexible funds to meet their needs. Staff are trained to understand funding parameters and to navigate alternative pathways when restrictions arise. Supervisors review denied requests to ensure that funding limitations are not creating inequitable barriers and that families continue to receive the individualized support required by the HFW model. See Stewardship Training Presentation, pages/slides 7-23.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
(a) The organization monitors the demographic composition of the population served and uses this information to guide recruitment and hiring strategies. Recruitment efforts intentionally target candidates who reflect the cultural, racial, and linguistic backgrounds of local communities, including outreach to culturally specific organizations, Tribal partners, and community networks. Supervisors review demographic data and hiring patterns to ensure alignment with population needs and HFW values. See Annual Report FY 24-25, pages 21-23.
(b) When the organization is unable to hire staff who match the cultural, racial, or linguistic needs of a family, alternative strategies are implemented to ensure culturally responsive support. This may include engaging natural supports, Tribal representatives, cultural brokers, or formal partners who can provide cultural insight and representation on the HFW team. These efforts ensure that families receive culturally grounded support even when staffing limitations exist. Supervisors and HF Coach verify that alternative supports are identified and integrated into team planning. See DEI Initiatives and Support Resources, page 3.
(c) When the program is unable to provide a staff member who speaks the family’s preferred language, a qualified translator or natural support person is utilized to ensure clear communication and culturally respectful engagement. Staff are trained to work effectively with interpreters and to maintain the family’s voice and choice throughout the process. Supervisors review documentation to ensure that language needs are consistently identified and addressed. See Interpreter Translation by Agency Staff Policy, page 1; Interpreter Services Policy, pages 1-3.
9.2 Tribally Responsive Workforce
(a) Staff receive training on Tribal sovereignty, traditions, values, culturally respectful engagement practices and ICWA and CFT requirements for serving American Indian and Alaska Native youth. This includes understanding the legal and cultural significance of sovereignty, the importance of honoring Tribal protocols, and the need for communication that reflects humility and respect. Staff are encouraged to attend ICWA Echo Sessions facilitated by UC Davis RCFFP, and internal training includes review and reinforcement of implementing best practices and tools from the CDSS & CTFC Tribal Engagement Guide to prepare staff to collaborate effectively with Tribal representatives and to advocate for culturally grounded supports within the HFW process. Supervisors review training participation and reinforce these expectations through ongoing coaching. See Tribal Engagement Guide, page 13-17.
(b) When serving American Indian and Alaska Native youth, HFW teams actively build partnerships with Tribal representatives and integrate Tribal perspectives into all phases of the Wraparound process. Teams encourage participation in Tribal traditions, ceremonies, and culturally rooted supports, recognizing their importance to healing, identity, and community connection. Staff work to understand the services and resources offered by the Tribe and ensure they are incorporated into the Wrap Map and CFT Plans whenever appropriate. Supervisors train staff utilizing training materials from the CDSS & CTFC Tribal Engagement Guide and verify that Tribal engagement is documented and that culturally rooted supports are meaningfully included in team planning. See Tribal Engagement Guide, pages 5-17.
9.3 Flexible and Creative Work Environment
(a) Leadership engages all staff in ongoing program quality and improvement efforts. This includes regular opportunities for staff to provide feedback, participate in CQI activities, review data, and contribute to program enhancements. In particular, staff participate in biannual Stay Interviews with their supervisors, anonymous annual Employee Engagement Surveys, post-training feedback forms and annual Clinical Supervision Surveys (for intake coordinators and clinicians specifically) to obtain feedback directly from staff about their experiences and gather patterns to support guiding leadership in improving program practices and trainings to better reduce burnout, increase retention and ensure staff are feeling engaged and supported in doing meaningful work in their roles and teams. Supervisors and HF Coach facilitate reflective supervision and coaching that encourages staff to identify strengths, challenges, and innovative solutions. Staff input is actively incorporated into program adjustments to strengthen fidelity and outcomes. See Stay Interview Template, page 1-2.
(b) Leadership promotes cohesion by creating a positive team environment where staff feel connected, supported, and aligned with shared goals. This includes hosting regular, in-person team meetings and recurring weekly team days to facilitate team celebrations, HF refresher trainings, agency and program roll outs, team‑building activities, cross‑role collaboration, and intentional practices that reinforce mutual respect and trust. Supervisors model collaborative problem‑solving and ensure that staff have opportunities to support one another in managing complex cases. See All Team Meeting PPT Template, pages/slides 1-8.
(c) The organization maintains open, transparent communication across all levels of staff. Leadership provides regular updates, invites feedback, and ensures that staff have safe avenues to express concerns, share ideas, and ask for support. Supervisors encourage honest dialogue during weekly supervision and team meetings, as well as during biannual Stay Interviews, reinforcing a culture where communication is valued and contributes to program improvement. See Supervision Record Template, page 1.
(d) Leadership ensures that all staff understand and embody the mission, principles, values, phases, and activities of High Fidelity Wraparound. This includes integrating HFW philosophy into orientation, onboarding, booster and refresher trainings, supervision, HF coaching sessions and daily practice. Staff are supported in aligning their work with HFW values, and supervisors reinforce fidelity through coaching, modeling, and reflective practice. The organization maintains a shared sense of purpose that guides decision‑making and service delivery. See HFW Training Presentation, pages/slides 5-6.
9.4 Hiring, Performance Evaluation, and Job Descriptions
(a) Each required HFW role or function is fulfilled within the program, either through dedicated positions or through thoughtfully combined roles. When roles are combined, the organization ensures that responsibilities are clearly defined, manageable, and aligned with HFW fidelity expectations. Supervisors verify that all required functions are consistently carried out and that staff understand their responsibilities within the team structure. See Wraparound Program Statement, page 6-8.
(b) Role descriptions include, at minimum, the purpose of the role, core functions, and the qualities—skills, competencies, and attributes—necessary for success. These descriptions reflect best practices and align with the examples provided in the Wraparound Standards Toolkit. Leadership ensures that role descriptions are updated regularly to reflect evolving program needs and fidelity expectations. See Facilitator I Job Description, pages 1-3.
(c) Job descriptions for all required positions are specific to HFW and reflect the attitudes, skills, knowledge, and experience most likely to identify individuals who will be successful in the role. This includes competencies related to cultural responsiveness, family‑driven practice, collaboration, crisis support, and adherence to HFW principles and phases. Supervisors use these descriptions to guide recruitment, hiring, and onboarding. See High Fidelity Wraparound Coach Job Description, pages 1-3.
(d) The hiring process includes opportunities for candidates to demonstrate the attitudes and skills essential to their role. This includes scenario‑and values-based questions, 10-minute rapport-building role‑plays, documentation samples and opportunities to reflect on lived experience and cultural humility during interviews. Leadership ensures that hiring practices identify candidates who can uphold HFW values, effectively receive feedback and coaching and engage effectively with youth and families. See Wrap Facilitator Role Interview Questions, pages 1-6.
(e) Employees receive clear expectations for their performance and ongoing feedback through regular supervision, coaching, and performance evaluations. Supervisors and HF Coach use collaborative and reflective supervision and coaching as well as fidelity‑aligned tools (e.g., TOM 2.0, WFI-EZ and DART) to evaluate and support staff growth, reinforce strengths, and address areas needing improvement. Staff are supported in developing the competencies necessary to deliver high‑quality, high‑fidelity services. See Employee Development Policy, pages 1-5.
9.5 Workforce Stability
(a) The organization matches wages to the cost of living in the geographic area where services are delivered through implementing annual Cost-of-Living Adjustments (COLAs), ensuring compensation is competitive and reflective of local economic conditions. We also offer Hiring Bonuses for all identified open positions during recruitment. These approaches support recruitment and retention, particularly for staff with lived experience who are essential to the HFW model. Leadership reviews wage structures regularly to maintain alignment with community standards. See Compensation Policy, pages 1-4.
(b) Workloads are intentionally maintained at manageable levels to support staff well‑being and ensure high‑quality service delivery. Caseload expectations reflect the intensity and frequency of HFW services, including 24/7 crisis support, team facilitation, and individualized planning. The caseload size for each role in the program is tailored to, and consistent with, the intensity of services needed by each family on the caseload. The average and maximum caseload size never exceeds the caseload dictated by county policy or contract. In situations where an Evidence Based Practice (EBP) is used, the average and maximum caseloads never exceed the caseload dictated by the EBP developer through the respective certification or other oversight process. Supervisors monitor workloads and adjust assignments as needed to prevent burnout and maintain HFW fidelity. See High Fidelity Wraparound Certification Policy, page 21.
(c) Promotion and advancement structures are clearly communicated, accessible, and designed to support staff at all levels—including those with lived experience. Career pathways do not impose unnecessary barriers such as degree requirements unrelated to job performance. Staff are encouraged to grow within the organization through leadership development, specialized training, and opportunities to take on new responsibilities, including through our Emerging Leaders Training Program for those interested in developing leadership skills and experience to seek growth opportunities within the organization. See Program Manager Job Description, pages 1-5.
(d) The organization provides wage increases or leadership opportunities that do not require a position change, allowing staff to advance professionally while remaining in roles that align with their strengths and interests. This includes opportunities such as Merit-Based Increases (MBIs), pay equity salary adjustments, stipends and bonuses (including a Service to Families (STF) productivity Incentives, On-Call Service stipend, Cultural Brokerage Stipend, Language Proficiency Stipend and Bonus, Commitment Bonuses, Recruitment Bonus, Trainer Pay Differentials and Additional Duties Stipends), mentoring, training facilitation, project leadership, or specialized practice roles. These strategies reinforce staff satisfaction and long‑term commitment to the program. See Compensation Policy, pages 1-10.
9.6 High Fidelity Training Plan
(a) All staff receive an initial 2-day HFW training by utilizing internal curriculum that aligns with the Statewide standardized Foundational HFW curriculum and Wraparound 101:Foundations of Fidelity Training Checklist. This foundational training ensures that every team member begins their work with a shared understanding of HFW values, principles, phases, activities, and fidelity expectations. Supervisors, HFW Coach and our Agency Training Department verify completion of initial training and reinforce learning through early coaching and supervision. See HFW Training Presentation, pages 5-6.
(b) All staff receive ongoing training in both general Wraparound practice and their specific role. Ongoing learning occurs through formal internal and external trainings (through UC Davis RCFFP), bi-monthly all-team meetings, monthly role specific development meetings, coaching, peer shadowing, and reflective supervision and coaching. Our Wraparound staff are also offered the opportunity and encouraged to attend the biannual Partnerships for Well-Being Institute, which leadership budgets for every other year to support with fostering learning, connection and inspiration for our team. These opportunities deepen staff skills, reinforce fidelity, and support continuous professional growth, and topics and content for booster trainings are guided through incorporation of feedback from families, data from fidelity measurement tools and through supervisor and coach observation to support with reducing model drift and reinforcing areas needing improvement. Supervisors and HFW Coach track attendance, participation and integrate training content into supervision and coaching conversations. See Role Specific Development Meetings Policy, page 1.
(c) All staff receive annual booster trainings in general Wraparound practice and in their specific roles, called “Wrap-A-Thons,” which are held 1-2x per year and cover various trainings and workshop topics focused on refreshing core competencies, addressing emerging needs, and strengthening fidelity to the model. Leadership ensures that booster trainings are scheduled consistently and that staff have protected time to participate. See Wrap-A-Thon Agenda October 2025, page 1.
(d) HFW Supervisors/Managers and clinical supervisors receive general Wraparound training (both internally and externally through UC Davis RCFFP), as well as initial, ongoing, and booster trainings tailored to their leadership and supervisory responsibilities, including supervisory-specific training in use of Wraparound fidelity tools, managing flex funds and leadership development (through use of Korn Ferry curriculum). These trainings focus on coaching, fidelity monitoring, reflective supervision, crisis support, and leading high‑performing teams. Wraparound supervisors also participate in weekly Leadership training led by program directors to support with enhancing leadership development in areas such as field supervision and evaluation, needs-based coaching and feedback, and managing transitions, staff turnover, team dynamics and conflict resolution. Clinical Supervisors, also receive trainings specific to leading case consultations in alignment with Wraparound principles and values, incorporating fidelity tool data into clinical guidance and feedback, high fidelity clinical documentation and navigation of confidentiality, legal and ethical responsibilities and information sharing for clinicians in the CFT and coordinating and collaborating with system partners. Supervisors document participation and integrate leadership training into their supervisory practice. See Wraparound Supervisor Training Agenda, page 11.
(e) All staff receive ICWA and Tribal sovereignty training, ensuring culturally respectful and legally compliant practice when serving American Indian and Alaska Native youth and families through external participation in annual County BHS Cultural Competency Training series, the RCFFP and CTFC offered ECHO: ICWA and Tribal Engagement training series and review and utilization of tools provided in their CFT Tribal Engagement Guide. The program also maintains mechanisms to identify and provide both internal and external trainings that support populations with specific and unique needs, such as LGBTQIA+ youth, commercially sexually exploited children, adoptive families, youth with developmental disabilities, or families with limited English proficiency. Supervisors ensure that staff training needs are identified and addressed through individualized development plans and tracked on their Relias training account. See Tribal Engagement Guide, page 2; RISE Training, pages/slides 37-55.
9.7 Community-based Training Program
(a) Youth, families, and peer partners (both Family/Parent Partners and Youth Advocates) with current or prior Wraparound experience are incorporated into the delivery of required Wraparound trainings by participating as co‑trainers, panel speakers, or facilitators during each scheduled training session. Wraparound training materials are also shared with and reviewed by current or prior caregivers and youth who participate in the Shared Leadership Workgroup and by Wraparound peer team members from our Family and Youth Partnership program to ensure that their perspectives and lived HFW experience are directly incorporated and honored in the content, formatting and language utilized to strengthen the impact and fidelity alignment of our HFW trainings for staff. See Shared Leadership Presentation, page/slide 10.
(b) Community partners are invited to attend Wraparound trainings and are offered standalone Wraparound overview trainings at least quarterly to strengthen their participation on HFW teams and their role within the system of care. This is completed both independently by our HFW Coach and Wraparound supervisors for inclusion in our internal organization’s HFW trainings to help build direct partnerships with county and community system partners, as well as in larger collaboration with our County and Managed Care Behavioral Health contractors, where we provide both on-site and/or virtual trainings to community/system partners in each county where we provide Wraparound services to foster collaboration, shared understanding and alignment to the HFW process and standards, increased access, linkage and appropriate referrals for families and increase comprehensive and effective and partnership between all members and roles of CFTs within the system of care. See Wraparound Presentation for Community Partners, pages/slides 2-15.
9.8 Coaching and Supervision
(a) All staff are provided with an initial apprenticeship that includes training on HFW values, principles, phases, activities, and the effective use of flex funds during their first 30 days of employment. This training is co-led by HF Wraparound Coach, Supervisors, and Wraparound staff from various HFW and peer roles and the HF Wraparound coach also provides supplementary one-on-one trainings, coaching and shadowing opportunities during the initial apprenticeship to support the staff through a parallel “Do For, Do With, Cheer On” process as they begin directly working with families. See High Fidelity Wraparound Certification Policy, page 24; Stewardship Training Presentation, pages/slides 10-21.
(b) Staff have access to supervision or coaching 24/7 through an on‑call supervisor rotation schedule maintained by program leadership to support flexible scheduling and crisis response needs. All Wraparound staff have access to an On-Call supervisor outside of regular business hours, including evenings, weekends and all observed holidays to receive on-demand coaching, emergency flex fund use and approval support and crisis response interventions, linkage and planning needs. See On-Call Crisis Intervention Policy, pages 3-4.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
N/A as SSYAF is a county-contracted provider.
10.2 Evaluation Metrics & Outcomes
(a) Data is utilized to improve practice with youth and families by providing staff with timely feedback from reports relevant to their service provision and by using data trends to identify staff training needs. The program systematically gathers family feedback and fidelity tool/observational data through satisfaction surveys, WFI‑EZ and TOM 2.0 tools, quality assurance calls, Family Panels, Shared Leadership Workgroups, and collaborative documentation practices. Supervisors and the HF Coach review this information weekly during Wraparound and FYP Leadership Meetings and High‑Fidelity Workgroup meetings to identify trends in engagement, cultural responsiveness, strengths‑based practice, individualized planning, natural support engagement, and team collaboration. Relevant findings are shared with staff during supervision and coaching sessions—both verbally and in writing—to reinforce effective practices and address areas needing improvement. Supervisors also conduct periodic observations of engagement and planning meetings, CFTs and case management meetings to provide real‑time coaching during each phase of Wraparound. This continuous feedback loop ensures staff receive timely, actionable guidance that strengthens direct practice with youth and families and enhances the overall quality of the Wraparound experience. See WFI-EZ Caregiver Form, pages 2-4; TOM 2.0 Fillable Form, pages 2-3; Supervision Record Template, page 1.
(b) Data is utilized to identify and address program needs by reviewing program‑level reports monthly and implementing adjustments to improve overall program effectiveness. Feedback from families and team members is reviewed regularly by supervisors, the HF Coach, and program directors to identify program‑level strengths and areas for improvement. Themes emerging from WFI‑EZ, TOM 2.0 and DART results, satisfaction surveys, quality assurance calls, Family Panels, Shared Leadership Workgroups, and discharge surveys inform training priorities, coaching strategies, and quality improvement initiatives. Leadership uses these data to refine policies, procedures, and service delivery expectations, ensuring the program remains aligned with Wraparound fidelity and responsive to family needs. Program‑level trends are discussed during weekly leadership and High‑Fidelity Workgroup meetings to guide continuous improvement efforts, strengthen consistency across staff, and enhance the effectiveness of individualized planning, cultural responsiveness, natural support engagement, and team‑based collaboration. See WFI-EZ Caregiver Form, pages 2-4; TOM 2.0 Fillable Form, pages 2-3.
(c) Data is utilized to identify and communicate system barriers to the Community Leadership Team through quarterly data summaries and barrier reports provided by program leadership during agenda item requests and through attendance at regular CLT meetings during agency updates, system changes and/or future meeting planning and requests portions of the collaboration meetings. The program uses family and team feedback, fidelity tool results, and observations from supervisors and the HF Coach to identify system‑level barriers affecting Wraparound implementation. Themes related to access, collaboration challenges, service gaps, or structural obstacles are elevated during High‑Fidelity Workgroup meetings and communicated to the Community Leadership Team through established feedback channels such as Shared Leadership Workgroups and Family Panels. Leadership uses these insights to advocate for system improvements, adjust cross‑agency processes, and strengthen supports that impact the broader Wraparound system. This structured approach ensures that system barriers identified through direct family experience and staff practice are communicated effectively and used to drive collaborative problem‑solving at the system level. See IYCW Meeting Notes Example, pages 1-3.
Fidelity Indicators
1.1 Timely Engagement and Planning
(a) The HFW Facilitator contacts the family and referring part within 24-72 hours from the date of referral (or self-referral from AAP (Adoption Assistance Program). The HFW Facilitator schedules the First meeting with the family within 5-14 days of the date of referral, attempting contact at least every two days. Please see Training- Wraparound Guidelines pg.5 ,
Please see All Policies No Wrong Door For Mental Health Services pg. 49. ( pg. 3 of Policy)
(b) The HFW Facilitator completes the Wraparound Plan of Care (POC) also referred to as the Individualized Child and Family Plan (ICFP) within 30 days from the date of referral. The POC is completed collaboratively with the Child and Family Team and is considered complete when it contains all required signatures and dates. Please see Wraparound Orange County Timeline pg. 2, Wraparound Guidelines pgs.5, 6
(c) The HFW Facilitator completes subsequent POCs every 3 months and more often if necessary. Addendums are completed as needed and are filed in the youth’s chart. Addendums do not change the timelines of the due dates and a copy of the POC is given to the referring party and the family. Please see Wraparound Orange County Timeline pgs. 1,2
(d) The HFW Facilitator facilitates a Child and Family Team meeting, at least monthly and more often if needed, in which the Plan of Care is reviewed and copies are distributed to the referring party and the family. Please see Wraparound Document Timeliness and Resource Guide pg. 6
(e) The Tracking Tool is utilized to monitor compliance and provide feedback in Supervision meetings for the purpose of meeting engagement timelines and tasks. The data is used to improve timelines and processes. Please see OC Wrap Tracking Tool and Fac Tracking Tool. Please see the Wraparound OC Basic Timeline which outlines the process from referral to Plan of Care. Please see Wraparound Guidelines pg. 5,6 for timelines from time of referral to assessment and includes who completes tasks. Please see SCCS Progress Report APR pg. 1 for Process indicators for timely POC compliance
(f) Staff is provided with several trainings, guides, and reference materials to be educated about timely engagement strategies and planning processes. All new staff are oriented to High Fidelity Wrap timelines and engagement practices during their initial orientation training. Trainings are provided by internal trainers and county trainers. Please see All PowerPoint Trainings Engagement and Team Preparations pg. 4, Engagement in CFTs training pgs.4,24
Please see additional supporting documents; OC and SB Wrap Training Plans, SB (There are variations across counties and SCCS has two County Wrap Contracts and one non County Contract).
1.2 Led by Youth and Families
(a) The Wraparound Team elicits families’ perspectives and cultural factors including tribal involvement throughout the course of treatment beginning with the completion of the Plan of Care and 7- Domain Assessment. Please see Individualized Child and Family Plan (ICFP). Blank POC Template pg. 1, 2. (There are variations across counties in which form is utilized) . Please see All Polices Indian and Native Alaskan Child Policy pg.36 (pgs. 1,2) Please see Wraparound CFT Policy pg. 88 ( pg. 1 ).
All PowerPoint Trainings file 2 Strengths Based Wrap pgs. 73 (pg. 76)
(b) The family values, culture, expertise, interests and skills are gathered starting at the initial meeting and documented on the Clinical Assessment by the Clinician and Supporting Treatment Team Members. The Clinical Assessment is completed within 30 days and updated throughout treatment when clinically necessary which may include when significant life or diagnostic changes occur. No more than 3 years will lapse before the Clinical Assessment is updated. Family strengths, values, culture, interests and skills are also gathered during the process with the Parent Partner writing the Strength Summary/Family Story.
Please see All Policies Assessment & Treatment Policy pg. 1 (pg. 2) and Clinical Assessment pgs. 17 , 19, 38,
All PowerPoint trainings New Fac Training file 1 pg. 409 ( pg. 421)
(c) Supervisors join CFTs and other meetings with the Youth and Family monthly to observe, support and train staff with developing skills and interventions to support implementation of Wrap services. Supervisors also provide weekly supervision in the form of groups and individual 1:1. Please see Supervision of Administrative Staff and Paraprofessionals pgs. 1,2, Clinical Staff Weekly Supervision Check In pg. 1, All Policies Progress Note policy pg. 65 (pgs. 4,5)
d), The agency satisfaction survey is provided to the client and family every 6 months and at discharge. The results are entered into the SCCS data base which generates a report on level of satisfaction, effectiveness, endorsement and quality. The results are shared with all Supervisors and Providers as soon as the data is entered. Please see All Polices Client Satisfaction Survey Policy and Survey pg. 8 (pgs1,2,3). The family satisfaction survey is completed after the conclusion of the case. A representative from Family Support Network (FSN) calls the family and completes the survey. The results are compiled and then sent to the director. who shares the feedback during staff meetings. All feedback/constructive criticism is discussed and addressed. The Wraparound Fidelity Index (WFI) is sent out every 3 months to youth (if 11 years or older) and the caregiver, by the facilitator, care coordinator, youth partner and parent partner after the family has been open for 4-6 months. Please see SCCS WFI Fidelity Analysis Results Survey Comments . (There are various survey processes due to having multiple County contracted requirements for feedback gathering).
1.3 Strength-Based
(a) Gathering strengths begins at the initial meeting and occurs throughout treatment. A Strengths List is completed within 30 days after the DOA and includes all members of the treatment team including, client, family members, Wrap staff and referring worker. Staff are encouraged to be creative with this list Strengths and culture are also gathered through the use of the CANS which is completed within 30 days of referral date (date of entry) typically during the initial assessment and every 3 months after that. The CANS is done collaboratively with the client and family during the assessment by the Facilitator. Please see Wraparound Guidelines pgs. 13, 14, All Policies Assessment and Treatment Policy pg. 1 (pg. 2), Strengths Summary Procedure pg. 1,2
(b) The individualized strengths inventory developed by the CFT (Child Family Wrap Team, Child, Family, Natural Supports, and Community Partners) informs the client’s personalized care and is identified in the IP CANS. The Facilitator regularly presents the narrative summary and treatment progress report at CFT meetings to ensure child, family, referring worker, and other treatment team members are aware and updated on progress. Please see Strength Summary Procedure pgs. 1,2, Blank POC Template, PWOM Data Master tab 1, Please see pg. 7 Training Outcomes Forms for Narrative Summary.
(c) In addition to new hire training strength based services is emphasized in all monthly trainings, weekly supervisions and day to day case consultations with supervisors. Please see All PowerPoint Trainings file 1 New Fac Training pg. 429, All PowerPoint Trainings file 2 pg. 65 (pages 69,74) Training-Wraparound Guidelines pgs. 13, 14 (a, d)
(d) The WFI-EZ is the survey used to measure the degree to which HFW care coordination is implemented with adherence to it’s principles and practice model. The measure also includes items related to satisfaction with Wraparound and included questions about experiences, satisfaction, and outcomes. The results are shared in a quarterly report and reviewed by the Wraparound Team to improve quality of care and services. Please see SCCS Family Satisfaction Survey, SCCS WFI Fidelity Analysis Results Survey Comments and WFI Consent. A confidential Satisfaction Survey is also completed at the 6 month mark of treatment and at discharge. This Satisfaction Survey is completed by the Caregiver and results are available and shared with the HFW Treatment Team to improve quality of services and satisfaction.
All Polices Client Satisfaction Survey Policy and Survey pg. 8 (pgs1,2,3). The PWOM is administered upon discharge and every six months thereafter up to twenty four months. The Post Wraparound outcome measure provides longitudinal data long after child and family discharges from the program. These are conducted by telephone interviews by the Wrap Fidelity Trainer and results are presented to the management team. The Team Observational tool is completed by the HFW Trainer or Supervisor when monitoring and reviewing the HFW fidelity during the CFT meetings. Each Facilitator is monitored at minimum 1x per year. Please see Team Observation Tool pg. 1
1.4 Needs Driven
(a) The Supervisor facilitates a Team Pre-Planning Meeting before the first face to face meeting with the client and family focused on family/client strengths, potential team members, target behavior(s)/safety concerns and potential needs. The first face to face meeting with the family begins with listening for and identifying strengths, needs, safety concerns, and possible team members. A Clinical Assessment is completed in one or two sessions by the HFW Facilitator in order to gather information on underlying needs, symptoms, impairments, strengths, history and diagnosis. The IP CANS is completed within 30 days of the Date of Entry, typically during the initial assessment and every 3 months after that. The CANS is done collaboratively with the client and family to identify strengths and needs. The PWOM is also completed during this assessment period to gather information about problematic behaviors, community/natural supports and service needs. Please see CANS OC, PWOM Data Master and Call Questions
(b) All staff obtain new hire training on Wraparound Principals and how to identify and prioritize needs throughout treatment. Training includes how to document to the client and family needs and how to facilitate strength based conversations around service needs, behaviors and deficits. Training is ongoing during weekly supervisions.
Please see All PowerPoint Trainings Purpose Driven CFTs and Collaterals pg.5, Individualized Child and Family Plan pg. 3, Introduction to Wraparound pgs. 207, 237,238,239
Please see: Cracked Egg-Needs Egg- CFT Handout pgs. 5,6
(c) The initial Child & Family Team Meeting is where additional information is gathered to prioritize the family’s needs and create a vision statement. Team Action forms are tools utilized to identify, review and update needs throughout treatment. These tools include needs, tasks/actions with specific dates of completion. Meeting Agendas are also utilized at each CFT which includes needs/concerns and strengths/successes which are reviewed and updated by the team with feedback gathered from the child, family and each team member. CFT’s are held regularly dependent on Wraparound phase and client need. Please see CFT Agenda Format pg. 1, CFT Meeting Summary and Action Plan pg. 2
(d) Discharge Planning is a process that starts from the onset of treatment as natural and community supports are identified and built upon and is assessed throughout the Wraparound phases. Once it is identified that client has met their goals and all needs have been addressed to the client and family’s satisfaction the discharge process is initiated by the treatment team and reviewed within a CFT meeting. Discharges from HFW are planned with the collaboration of the entire treatment team, client and family and are individualized to the needs of the client and family which consists of; preparation of community resources, linkage to services, warm hand offs, and the completion of discharge and or transfer documentation.
Please see Wraparound Guidelines pg. 18,19,20 , All Policies Discharge Policy pg. 29 (pgs. 1,2)
Please see After Care Plan and Wraparound Discharge Summary
1.5 Individualized
(a) The Plan of Care is developed using the Wraparound Principals through a collaborative team-brainstorming process which allows for creativity and flexibility. The forms used to document this process can easily be customized, updated and shared with all team members, client and the family. Please see Blank POC, pg. 1 Individualized Child and Family Plan pg. 1
(b) Staff receive a combination of weekly supervisions, quarterly and annual trainings and have a variety of opportunities to learn through shadowing, formal training through the County and the SCCS internal HR training team. Trainings emphasize skillful ways to create individualized treatment interventions that meet the needs of the client and family. Please see All PowerPoint Training Wrap Tools- Out of the Box Interventions pg. 3, Innovations in Providing Wraparound Services pgs. 2, 3,5, Introduction to Wraparound pg. 13.
(c) HFW Supervisors/ HFW Trainer participate and shadow CFT meetings on a monthly basis and provides feedback on the CFT meeting minutes which is reviewed by the treatment team and utilized to communicate modifications in treatment and provide treatment planning support and suggestions. . Please see Meeting minutes pg. 2 Plan Participation in CFT meetings. The Facilitator meets weekly with the Supervisor to work on reviewing needs, progress and outcomes and team consults are done when clinically appropriate to review resources, challenges, referrals, needs and natural supports. Facilitators receive specific training for their roles. Training March 2025 Agendas and PowerPoints, Wraparound Training Tracker pg. 1. Please see SCCS Team Consult Form and CFT Forum Agenda Form pgs.1, 2.
Please see All PowerPoint Trainings Billing Prior to Completion of Assessment pgs. 7,8,
(d) Initial Plan of Care Provider Presentations are for the purpose of sharing and brainstorming where teams are in the process of exploring resources and strategies with the intake team. The Director and Supervisors are present at the POC presentation and provide a concise summary. Please see Plan of Care Provider Presentations, Wraparound Guidelines pg. 11, 12, 13
(e) The WFI-EZ is the survey used to measure the degree to which HFW care coordination is implemented with adherence to it’s principles and practice model. The measure also includes items related to satisfaction with Wraparound and included questions about experiences, satisfaction, and outcomes. The results are shared in a quarterly report and reviewed by the Wraparound Team to improve quality of care and services. Please see SCCS Family Satisfaction Survey, SCCS WFI Fidelity Analysis Results Survey Comments. A confidential Satisfaction Survey is also completed at the 6 month mark of treatment and at discharge and more often when needed. This Satisfaction Survey is completed by the Caregiver and results are available and shared with the HFW Treatment Team to improve quality of services and satisfaction. The Quality Assurance Team supports with the survey entry into the internal data base. Please see All Policies Performance and Quality Improvement pg. 58 (pgs. 1,2)
1.6 Use of Natural and Community Based Supports
(a) The Engagement Phase starts on day 1 with building a team that includes natural supports and a strengths list of informal supports both for client and caregiver. Identifying and engaging natural supports is everyone’s role on the team including; Facilitator, Family Specialist, Parent Partners, Clinician, Supervisors and other HFW Team members. A connectedness Map and Family Resource Tree is completed within 30 days of Date of Admission (DOA). It is created with the client and family by brainstorming local community resources, strengths and an informal support person. These supports and resources are utilized when creating the crisis/safety plan. A Client Resource Evaluation is also completed during the the initial assessment to gather additional resource needs. Please see; Training Tool Client Resource Evaluation. Community resources and natural supports are reviewed during CFTs and updated regularly with the goal of increasing these supports throughout treatment. Please see Connectedness Map and Helpline Meeting pgs. 1,2,3 Includes Family Resource Tree, All PowerPoint trainings Resource POD pg. 5
Individualized, Child and Family Plan pg. 2, 14
(b) Staff receive training on Natural Supports as part of their on boarding and new hire training. Training on resourcing, developing natural supports and completing connectedness maps are also provided during weekly supervisions. Please see Natural Support (NH) 1.0 (Training), Financial- Customized Resource Bank, Pass the baton training slide 6, Commencement Template 2, Resource Tracking Form, WFI Fidelity Analysis, Resource Tracking Tool, The Family Search and Engagement Specialist actively searches for natural supports in the beginning of treatment and is offered to every family. Please see Family Search and Engagement Request Form pg. 1
(c) The Wraparound Plan of Care is developed by the youth and family with the assistance of the team, according to what they perceive their needs to be. The Plan of Care (POC) reflects activities and interventions that draw on sources of natural supports. Interventions and supports are unique to each person and the Initial Plan of Care is developed with the treatment team, client and family during the implementation phase which begins approximately 30 days after the referral is assigned. The Team recognizes and celebrates successes and integrates community resources. The initial Plan of Care Presentations are verbally shared and brainstormed with the Intake Team, Director and Supervisor in order to provide a concise summary that includes; status of coordination, status of engagement, stabilization plan, safety, challenges and initial identified needs. Please see Plan of Care Provider Presentations. Subsequent Plan of Care are due every 3 months and a copy is provided to the referring party and the family. Please see Blank POC template pgs. 1, 2 ,Care Plan Progress Note Review Procedure pg. 1, Individualized Child and Family Plan, Team Observation Tool pg. 1.
(d) The WFI-EZ is the survey used to measure the degree to which HFW care coordination is implemented with adherence to its principles and practice model. The measure also includes items related to satisfaction with Wraparound and included questions about experiences, natural supports engagement, satisfaction, and outcomes. The results are shared in a quarterly report and reviewed by the Wraparound Team to improve quality of care and services. Please see SCCS Family Satisfaction Survey, SCCS WFI Fidelity Analysis Results Survey Comments
1.7 Culturally Respectful and Relevant
(a) The Facilitator creates the Plan of Care with the family and treatment team and during this time needs and culture is explored and addressed. These cultural considerations are documented on the Plan of Care. The Domain Cards are used by the Family Specialist, Facilitators and Parent Partner to use as visual prompters during all phases of Wrap as needed. Please see Blank POC template and Individualized Child and Family Plan. Please see
All PowerPoint trainings Domain Cards pg. 1
(b) Staff are kept abreast of trends and new methodologies in cultural sensitivities and competencies (knowledge, skills, awareness and attitude) by attending ongoing trainings throughout the year. Trainings are focused on equity, diversity and interdependence. Bilingual staff are tested for their level of language proficiency as they are hired. Cultural discourse and considerations are interwoven into all aspects of care (e.g., in-service, supervision, case consultations, policies). All staff receive a new hire training and monthly brief training at All Staff meetings on appropriate cultural etiquette for using interpretation services to ensure linguistically appropriate services.
Please see Introduction to Wraparound Training pg. 273. Staff trainings are recorded and a copy is kept in their HR file. Please see OC Wrap Cultural Training Relias, (OC Wrap Annual YP, PP, CC, Clinician Trainings), All Polices Indian and Native Alaskan Child pg. 36 (pgs. 1,2), All Polices Cultural Competency Policy pg. 27 ( pg. 2)
(c) The Family Support Network staff/HSS Research, Outcomes, & Quality Support administers the WFI which is a confidential phone interview with the family “caregiver survey” and the Facilitator is done approximately 4 to 6 months into the program. Please see the WFI Quarterly Report, WFI Annual Report FY 22-23
1.8 High-Quality Team Planning and Problem Solving
(a) Every family is assigned a Clinician and Peer Partner. The entire team signs the Plan of Care which is the team agreement and a copy is saved in the youth’s chart.
Please see All PowerPoint Trainings file 1 Engagement and Team Preparation pg 193 (pg. 201). Training Wraparound guidelines pg. 14 (Please click on CFT meeting Format)
(b)The WFI-EZ is the survey used to measure the degree to which HFW care coordination is implemented with adherence to its principles and practice model. The measure includes items related to the satisfaction of needs and individual treatment planning. Please see All PowerPoint Trainings file 2 WFI Training PowerPoint pg. 84 (pgs. 87, 88,89)
(c) The results are shared in a quarterly report with the Director and Supervisor and reviewed by the Wraparound Team to improve quality of care and services. Please see SCCS Family Satisfaction Survey, SCCS WFI Fidelity Analysis Results Survey Comments and WFI Consent. Supervisor engage in monthly shadowing of team meetings and provides case consultations along with weekly supervision to to provide guidance and feedback on processes to improve services. Please see SCCS Team Consult Form and CFT Forum pgs. 1,2
(d) HFW Supervisors participate and shadow CFT meetings on a monthly basis and provide feedback on the CFT meeting minutes which is reviewed by the treatment team and utilized to communicate modifications in treatment, provide suggestions and model collaborative problem solving. Please see CFT – White – Flag Meeting minutes pgs. 1,2,3, CFT, All PowerPoint trainings file 1 Engagement in CFTs pg. 225 (pgs 232,234), CFT Survey pg. 1
1.9 Outcomes Based Process
(a) The HFW plan of care includes an estimated date of completion and date completed for all activities, services, needs and supports. Status update presentations are also dated on the form. Please see Pg. 1 of Individuated Child and Family Plan. Please see pg. 2 of the Blank POC (Form templates varies by County)
(b) The action items are on the plan of care and are completed within 30 days with the collaboration of the treatment team and reviewed during weekly CFTs or more often when necessary. Please see pg. 4 Individualized Child and Family Plan
(c) Changes are communicated to all team members and presented in CFTs. Copies of the forms are provided to client and caregiver. Initial and all updated to the plan are filed in the electronic health record.. My evolv is used as the electronic health record. Please see QA and Audit Process 2024 pg. 7, 8,9
(d) The IP-CANS is completed by the Facilitator within 30 days of DOE and every 3 months after that. It is done collaboratively with the client and family. The Facilitator informs the Supervisor once it is submitted and the Supervisor reviews the scores accuracy prior to data entry. A copy is scanned in the client’s chart. Please see Wraparound Guidelines pg.14, Training Outcomes Forms pg. 2
(e) Several CANS reports are utilized to monitor and track outcomes Please see PSC35- Eng, Outcomes, Training- Outcome Forms
Objective Arts Refresher Training- CANS is completed by a Managing Clinician, if a Managing Clinician is not assigned it will be completed by a Licensed or Registered Supervisor, Wraparound Document Timeliness pg. 12, Wraparound Olympics pg. 10, All Policies Assessment & Treatment policy pg. 1 (pg. 4, 5,6,7)
1.10 Persistence
(a) Supervisors are always available for consultations to brainstorm and discuss set backs and challenges with all treatment team members including, Supervisors and Directors not affiliated with the team. A monthly site support visit with the child welfare, probation and mental health service agencies occur in order to brain storm and address system barriers and identify ideas to support progress. The Plan of Care is utilized as a guide to ensure the Child and Family Team are addressing accurate needs that reflect family voice and choice. When progress is limited it is an indicator for the team to review the Plan of Care and make necessary updates. Please see SCCSTeam Consult, Wraparound Guidelines pg. 15, 16 (No Shows)
(b) All HFW staff are provided ongoing and regularly scheduled supervision as well as open access to all Supervisors and Directors. There is a licensed supervisor on call 24 hours a day. Supervision of Administrative Staff and Paraprofessionals pg. 1, 2, Wraparound Guidelines pg. 16 (Flex Funds), Flex Categories and Funds Guidelines pgs. 5,6
(c) All staff receive crisis management training as part of their new hire training plan as well as ongoing crisis trainings throughout the year. Facilitators engage in ongoing training including conflict resolution, leadership, safety planning and skill building specific to their role. Facilitators also attend a professional growth training six times per year.
Please see All PowerPoint trainings file 1 Facilitation Training pg.6, New Fac Training pg. 409 (. 440), Wraparound Comm Training Oct and Engaging caregivers when met with resistance, Wraparound Principals Olympics pg. 9,
1.11 Transitions as a part of the Fourth Phase of HFW
(a). The fourth phase of HFW is the Transition Phase which is introduced to the client and family in the beginning of treatment. The team prepares the client and family for the transition phase by creating a Family Vision through a collaborative process of creating clear and specific goals, objectives and a picture of the future after services end. Please see Have a Vision, Vision Assistance Link tool and Have a Vision Notes. Adequate transitions occur through a process that starts with the Wrap treatment team members meeting for consultation to discuss all transfers led by the facilitator. When a client has been identified as being ready for graduation, the Facilitator will complete the Family After Care Plan and the Wraparound Discharge Summary 3-4 weeks prior to the planned discharge/graduation date. Please see After Care Plan and Wraparound Discharge Summary, Wraparound Guidelines pgs. 19,20,21
(b) The family’s natural supports are in place by the time the client is ready to graduate HFW through the treatment process. Community linkage and resources that may consist of referrals will be in place. A “warm handoff” between Wrap Team and the new provider will occur prior to graduation facilitated by the Facilitator. Once it has been determined that the client is ready to graduate/transition, the Facilitator will coordinate a graduation celebration with the entire treatment team, family and those that the client and family invite to participate in the celebration. Accommodations are made and coordinated to allow all those that would like to attend the graduation are available to meet at the designated time and date that the client and family determine. The Facilitator will complete a Flex Fund Request and Graduation Breakdown Form as well as a Gift Card Acknowledgement Form to provide a gift card and food that will be used to celebrate client’s achievement. A certificate is also presented to the client. Please see Graduation Breakdown- Flex Fund Request -Graduation Cert. Please see additional supporting documents for transition and graduation planning; Commencement template, All PowerPoint Trainings file 2 Pass the Baton Training pg1 (pages 6,15)
Expected Outcomes
2.1 Youth and Family Satisfaction
Family Satisfaction Surveys are administered within 30 days of a family commencing Wraparound services. Family Support Network, a contracted agency with Orange County, contacts families by phone to ask a series of 7 questions. Results are distributed to the Wraparound agencies, including SCCS. SCCS management reviews Family Satisfaction Survey results with Wraparound staff to inform quality improvement strategies. In the case of an Indian child, the family may include their tribe in the survey process. Family Satisfaction survey scores are included in the monthly Progress Report as an outcome indicator. The SCCS Confidential Satisfaction Survey is completed by the youth or caregiver within 6 months of services and at the end of treatment. The results are entered in an internal database which all supervisors have access and results are shared with the team during regular team meetings.
Please see: SCCS Family Satisfaction Survey pgs.1,2,3,,5, This document contains the survey questions and the All staff Agenda.
Please see All Polices SCCS Client Satisfaction Survey Policy and Survey pg. 8( pgs. 1,2,3,4,5.) This document contains the policy, survey questions and example of the program’s survey Results
Wraparound Document Timeliness and Resource Guide pg. 14, and PWOM Data Master and Call Questions pg. 1
2.2 Improved School Functioning
School functioning data is gathered first through the SSA consent and then the CANS assessment throughout the course of Wraparound Services. School Attendance data is gathered by the Facilitator at the first face to face meeting with the youth/family and assessed again at time of Commencement. SCCS is in the process of generating reports through our Tableau system to evaluate CANS data over time. School functioning data is monitored by the Wrap team for SB Wrap programs through the Treatment Progress Report that is generated and accessible through San Bernardino Objective Arts. The Treatment Progress Report is shared with the Social Worker and the team during CFT meetings. OCCTAC has been in partnership with SCCS for over 20 years and provides valuable touring services for the youth served in our programs. Youth receive basic academic and achievement tests, learning strategies, organizational skills, time management and academic tutoring while collaborating with the HFW team.
Please see: Improved School functioning pg. 1,2,3, (includes face to face data, family acceptance verification, OCCTAC, SSA Consent and Course description)
Please see All Polices Assessment & Treatment policy pg. 1 (pg. 7) CANS- OC, Commencement Template 2, pg. 1, Training Outcomes Forms pg. 6
2.3 Improved Functioning in the Community
The IP CANS is used to assess and monitor youth’s functioning in the community. Engagement in community activities is also assessed through the IP CANS by the Facilitator. A narrative report from Objective Arts for SB County is printed and shared during team meetings and must be shared with the youth and caregiver at least quarterly. A treatment progress report from Objective Arts is also shared with the Case Worker and Probation Officer. This report contains several areas of Life Domain Functioning including community functioning. The Facilitator has the option to share a CANS score sheet, narrative report or treatment plan report and hide items if necessary. Supervisors utilize these reports to assist with monitoring the clinical presentation and progress of treatment. Upon completion of Wrap services, the Wraparound Team ensures that families are successfully connected to ongoing services as well as provided with community resources that may need to be accessed in the future. The Care Coordinator also provides the family with a Crisis Safety Plan that only includes the family and natural and formal supports that will remain in place after Wraparound services have closed.
SCCS is in the process of generating reports through our Tableau system to evaluate CANS data over time.
Please see , Outcomes Policy, pg. 1, Training Outcomes Forms pg. 8,9), Commencement template (includes Sample, Progress Summary, Community Resource Outings) pgs. 1, 2, 3, 4,
2.4 Improved Interpersonal Functioning
The IP CANS is used to assess and monitor youth’s interpersonal functioning as part of the assessment process and throughout treatment as part of the life domain areas. This information is gathered by the Facilitator and is done collaboratively with the youth and family. The treatment progress, narrative report, and score sheet are all utilized to share this data with the team, youth and family during CFT meetings. The Plan of Care is also updated and completed by the Facilitator to monitor progress in this area.
The PSC 35 is completed during the assessment, at the 6 month mark and at discharge to gather information about interpersonal functioning and improvement throughout treatment. The Facilitator completes the progress summary at the end of each 90 day POC cycle.
Please see: Assessment and Treatment Policy pg. 1, Training Outcomes Forms pg. 7, 8,9
2.5 Increased Caregiver Confidence
Wraparound Team Members track all provided resources in the Resource Tracking Form within the Electronic Health Record. Staff partake in monthly “Community Outings” organized by our Wrap Fidelity Trainer. These “Community Outings” provide staff an opportunity to physically visit community resources and connections so as to better match and provide resources to caregivers and families.
Please see Resource Tracking Form pg. 1, All Policies Referrals to Resources pg.71, SCCS Family Satisfaction Survey, pg. 1 Safety Plan English Pgs. 1,2, Commencement template pg. 1, 2
2.6 Stable and Least Restrictive Living Environment
The Facilitator completes the KET anytime there is a change in administrative information, discharge, or change of placement category as a method to record and evaluate the frequency and types of placement changes. The DCR and KET forms are reviewed by the Supervisor throughout treatment. A white flag meeting is held by the Facilitator anytime placement is at risk e.g., anytime the caregiver is considering a 7 or 14 day notice of removal, bench warrant. SB- DCR- KET- Child. Respite care is also offered to families to support placement stabilization in the least restrictive environment. There is a set procedure the HFW team follows to initiate services including completing a request form and completing an invoice. Facilitators complete an Active COR Report anytime a client is placed out of the home during their enrollment in Wraparound. The COR Report is reviewed monthly with WRIT during POC Presentations. The QI Group home tracking log is updated by the Supervisor once a client is moved to an STRTP and coordination with the County occurs to ensure the least restrictive living environment is arranged. Please see SCCS- Progress Report- APR 25 (tab 2) QI Group Home includes Active COR Report Sample and Respite Care Procedure)
Please see CFT – White Flag- Meeting Minutes, Outcomes Forms Training pg. 11
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
All special incidents including psychiatric inpatient hospitalizations are documented in the EHR by completing the Incident module and completing and submitting a Special Incident Report to overseeing agency/county. This data is reviewed quarterly with the Management Team, Quality Assurance, Compliance and the CEO to evaluate trends and collaborate on solutions to increase safety and overall quality of services provided . Please see the SIR- July 2024-July 2025 (data), SIR Tip sheet and Unusual Occurrence Policy pg. 2, Special Incident Report Training pg. 3, 5 , SIR Data February to April 2025 pg. 5
2.8 Reduction in Crisis Visits
Crisis and Special Incident events are recorded in the Electronic Health Care Record (Myevolv) as they occur by the staff involved in the incident within 24 hours. Most crisis situations are able to be handled by the Wraparound team and there are policies in place as well as training on how to manage most crisis. All staff are trained how to enter this data within the E H R as well as how to complete the required County SIR forms. The Management team including Quality Assurance, Compliance and the CEO meet quarterly to review the programs special incidents and a formal report is provided to the Wraparound Program. All staff are trained on how to use the standardized Safety T Risk Assessment tool. This assessment is conducted prior to determining if external crisis support is needed. Natural supports are incorporated into the youth’s safety plan by identifying who in their life can participate in supportive interventions when needed. The Aftercare plan is completed upon commencement of wraparound services by the Facilitator and it is a safety plan that relies on learned skills the youth and family can use after services have ended.
Please see SIR tip sheet and unusual Occurrence Policy pg. 5,(Includes Special Incident Report Training ), 2.8 SIR Data February to April 2025, Performance and Quality Improvement Policy pg. 2,3, SIR training pg. 3, SIR tip sheet pgs. 1, 2,, Aftercare Plan pg. 1
2.9 Positive Exit from HFW
The Wraparound Team engages the CFT in the Transition Phase of Wraparound prior to commencing services. Family strengths and progress are celebrated with CFT and collaborative plans for safety and sustained progress and self-sufficiency are established prior to exit from services. Family exits from Wraparound are tracked in the Commencement document as well as through Family Satisfaction Surveys. The Graduation Report records reasons why families exit from Wraparound and reports are evaluated by leadership. A discharge summary is completed that summarizes the youths treatment progress and reason for closure. An additional discharge summary is completed for Medi- cal beneficiaries. All staff receive training on the discharge process.
Please see 2.3 Commencement Template pg.1, ( includes graduation report Discharge and Transfer training tab 2) PWOM Data Master and Call Questions tab 1,5, PWOM , Wraparound Document Timeliness pg. 10, Wraparound Discharge Summary pg. 1
Engagement
3.1 Orientation
(a) The Facilitator and Parent Partner contact caregiver upon receiving referral to introduce themselves, begin explaining the Wraparound process and schedule the first CFTM. At the first face to face meeting with the family, the HFW process is thoroughly explained and families are provided with the Wraparound Handbook. We plan to utilize the Wraparound Informational video from UC Davis to help support understanding of the Wraparound process. A link will be provided to each youth and family. An Introduction to Wraparound video is currently shown to families in the beginning of treatment explaining the Wrap phases and process.
Please see All PowerPoint trainings file 1 Engagement and Team Preparation pg. 193 (203). Please see Wraparound Handbook pg. 2, 3, CFT Brochure for both the youth and family is also provided to orient to the CFT meeting process. Please see CFT Brochure pg. 1
(b) Legal and ethical considerations as well as how to handle complaints are explained in the Family Handbook. A participation Agreement is signed to ensure clear collaboration and communication among all treatment providers. Please see Participation Agreement pg. 1, Wraparound Handbook pgs. 3,4
(c) The Family Handbook is provided to all youth and family at the beginning of treatment which outlines all roles of the treatment team. Please see Family Handbook Jan 2020 pg. 6, Please see All PowerPoint trainings file 1 Engagement in CFTS pg225 (pgs. 243,244,245,246,247,2,48,249,250
3.2 Safety and Crisis stabilization
(a) Facilitator contacts the referring party prior to the first meeting with the youth and family to begin gathering immediate crisis and safety needs. Safety concerns are reviewed with the family and additional crisis and/or safety needs are gathered with the family. An immediate crisis plan is created as a CFT and practiced with the family when immediate crisis needs are identified. The youth and family always receives a copy of all crisis plans. All staff receive training on how to develop and complete safety and crisis plans.
Please see All PowerPoint trainings file 1 Engagement in CFTS pg. 225(pg. 235), Engagement and Team Preparation pg 193 (pgs. 221,222,223, Developing a Safety plan pg 160 (pgs. 164,165), First Contact with Referring Party Example pg. 1
(b) The crisis plan is completed prior to the development of a safety plan and is used to inform the treatment team of immediate concerns. . Please see Safety Planning for Undocumented Families- Conversations- Teen Safety Plan pg 3, Safety Plan Wraparound pg. 1, 2, All Polices Safety Plan Policy pg. 74 ( pg. 1)
(c) All families and youth are provided with a copy of the SCCS on call crisis numbers and contact information during the first meeting along with information about how to access alternative resources for emergency events. Please see; On Call Crisis During Non Business Hours pg. 2, Safety Plan Wraparound pg. 1, 2
3.3 Strengths, Needs, Culture and Vision Discovery
(a) The youth and family develop a family vision with the Facilitator by discussing family strengths, resources, supports and goals and utilizing techniques such as the family collage, family mural, family vision board, or the family time capsule. A copy is provided to the youth and family and is filed in the youth’s chart. Please see: All PowerPoint trainings file 1 Family Vision pgs. 282,283,284,285, Engagement and Team Preparation pg. 207 (Tree of Life) Have a vision pg. 16, Blank POC Template pg. 1,
(b) The Parent Partner completes a Strength Summary that describes each family member’s strengths within the context of their unique family story. The strengths that are gathered are also included in each Plan of Care which is updated every 90 days. The Strengths list includes all members of the treatment team including, clients, family members, wrap staff and referring worker and is completed within 30 days of initial meeting. Staff utilize examples, a template and are trained on the strengths summary procedure. Please see: Wraparound Guidelines pg. 13. Strengths Summary Procedure pgs. 1, 2.
3.4 Engage All Team Members
(a) All staff are trained on how to help the youth and family identify natural supports. Natural supports worksheets (connectedness map and family resources tree)
are used in the engagement phase by the Facilitator and copies are placed in the youth’s chart. Additional supports are identified throughout treatment. Please see All PowerPoint Trainings file 1 Engagement and Team Preparation pgs. 218, 219 for examples of the worksheets used and training provided. Please see All PowerPoint trainings file 1 Engagement in CFTS pg. 236
(b) CFT meetings involve all members of the team including referring worker, FS, PP, assigned therapist/TBS coach, supervisor, MHS supervisor, referring worker’s supervisor, and FFA worker if applicable. The meetings meet WRAP Fidelity and follow the CFT Meeting Format. At the beginning of the meeting confidentiality is explained, and verbal consent is obtained from all attendees and document in the minutes. For the 90 Day review CFTs, an Outlook invite including the Invite E-mail for the 90 Day Review is sent to the Social Worker and SSSP prior to the CFT. Please see All PowerPoint trainings Engagement in CFTS pg. 237, CFT Individualized Child Care Plan pg. 1, All Polices Wraparound CFT Policy pg. 88 (pg1)
(c) Natural and formal supports are invited to CFT meetings. All team members and supports are a part of creating the plan of care. When supports are not able to attend meetings barriers preventing attendance is discussed. Please see All PowerPoint Trainings file 1 Natural Supports pg. 385, 386
(d) HFW Team usually opens each CFT Meeting with an “Ice Breaker” activity to engage the family. All CFT meetings, treatment sessions and engagement activities are documented in the E H R. All progress notes are signed by the writer and most notes go through a quality assurance review. Please see CFT Meeting minutes pgs. 1,2,3,4 and Wraparound Family Team Building pg. 2, All Polices Progress Note Policy pg. 65 ( pg. 4)
3.5 Arrange Meeting Logistics
(a) During the interview, candidates are asked if they are able to work a flexible schedule, usually to accommodate before and after school/work hours. The Wraparound team implements service and support strategies that take place in the most inclusive, most responsive, most accessible, and least restrictive setting possible. Staff work varied schedules with some staff on call during non- business hours. The Wraparound Fidelity Trainer completes the WFO to monitor adherence to the Wrap principles including asking a question about logistics and scheduling to accommodate youth and family preference and needs. Please see: Wraparound Principals Olympics pg.5 and WFO pg. 1, FAC Interview Questions pg. 2, All Policies Safety in the Community pg. 73 ( pg. 1)
(b) All HFW staff receive training on how to collaboratively coordinate and schedule meetings with treatment members, families and supports during their initial Wrap 101 training and internal SCCS training. Staff also receive training on how to maintain safety while providing services in the community. Please see All PowerPoint Trainings file 2 Purpose Driven CFTS and Collaterals pg. 22,23
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
(a) The Facilitator engages the family and child team in multiple meetings to collaboratively create the Wraparound Plan of Care. The mission statement is included in all meeting minute agendas. The Facilitator completes the meeting minutes and provides a copy to all team members and the family. – please see 4.1 From Referral to Care Plan Signing pg. 1 , Individualized Child and Family Plan p. 1
(b) The plan is reviewed at every CFT and is an item listed on the CFT Agenda Format. Please see , CFT- White Flag- Meeting minutes pg. 1
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
(a) The Child and Family Team identify goals maximizing family strengths to reach the goal, prioritize and agree on family needs in considering all 12 life domains. The HFW Team utilizes a tool, “The Needs Egg”, to brainstorm and identify underlying needs and behaviors before the plan of care is developed. This process is documented in the youths chart. Please see Needs Egg- Cracked Egg-CFT Handout pg. 1.
(b) The youth, family, and Team creates the “Child and Family Team Goal Statement/Vision Statement” on the ICFP/POC. This is a living document and this statement can change. This statement drives the purpose. The HFW Team utilizes SMART goals which are specific, measurable, achievable, relevant and time-bound to address identified needs and desirable outcomes. Please see Goal setting pg. 29. This training is provided to all HFW Team members to support the appropriate prioritization of needs and goals that are youth specific. Please see SMART- RAAAR Tool, pgs. 1-6. Please see Individualized Child and Family Plan pg. 1
(c) Every family is assigned a Clinician and Peer Partner. The goals are created collaboratively and use client preferred language. Outcomes are also monitored and addressed collaboratively through the CFT. The team ties the goals and strategies of the wraparound plan to observable and measurable indicators of success, monitors progress in terms of these indicators, and revises the plan accordingly. The CFT meeting minutes document/CFT Agenda document is used to document goals and any new needs that present. The family and referring worker details any court and legal considerations and monitors progress. Relationships with natural supports and community are cultivated and strengthened to enhance youth and family success and help to meet needs. Please see CFT- White Flag- Meeting Minutes pg. 1, 3 /CFT Agenda Format , , Individualized Child and Family Plan pg1 , 2. Please see Wraparound Principals Olympics pg. 17
(d) Team members work cooperatively and share responsibility for developing, implementing, monitoring, and evaluating a single wraparound plan. The plan reflects a blending of team members’ perspectives, mandates, and resources. The plan guides and coordinates each team member’s work towards meeting the team’s goals. Please see Individualized Child and Family Plan pg. 1, Needs Egg- Cracked Egg, CFT Handout, CFT Meeting Format pg. 5
(e) Facilitators are trained upon first hire and receive ongoing trainings through weekly team meetings, monthly seminars/ forums, professional growth meetings and HR clinical and annual training. All staff receive HFW training by the HFW Trainer who has completed the train the trainer curriculum through UC Davis or the coordinated training through Orange County Training Committee. All training PowerPoints file 1 New Fac training pg. 409, Facilitation Training pg. 259. Please see Introduction to Wraparound Training pg. 13 , OC and SB Wrap training Plans pg. 31, Wraparound Training Tracker pg. 1
(f) The steps involved in creating the initial plan of care include determining ground rules, describing and documenting to strengths, creating a team mission statement, prioritizing need/goals through the use of the IP CANS , determining outcomes and indictors for each goal and, selecting strategies the team will utilize and assigning action steps. The Facilitator coordinates the meeting to develop the plan of care by ensuring all team members and supports can be present in a location that is convenient to the youth and family. The plan of care is developed with the participation of the entire team that will be working with the youth and family as well as supports and referring workers. Please the Individualized Child and Family Plan, , CFT- White Flag- meeting minutes pgs. 1, 3, Wraparound Guidelines Training pg. 5, 27,28 (Wraparound Phase List)
4.3 Develop an Individualized Child or Youth and Family Plan
(a) Facilitators are trained upon first hire and receive ongoing trainings through weekly team meetings, monthly seminars, growth development meetings, and HR clinical and annual training. All staff receive HFW training by the HFW Trainer who has completed the train the trainer curriculum through UC Davis. Please see Wraparound Phase List, All PowerPoint trainings file 1, Innovations in Providing Wraparound pg.12,13,14,15, Wraparound Principals Olympics pgs. 2,4, All PowerPoint Trainings file 1 Facilitator Training pg. 260, 264,265
(b) All Children’s’ System of Care partners including court and legal care members are included in the Plan of Care. The family and referring worker details any court and legal considerations and monitors progress through the Plan of Care. The youth, family, and Team creates the “Child and Family Team Goal Statement” on the ICFP. This is a living document and this statement can change. This statement drives the purpose. Please see Individualized Child and Family Plan pgs. 1, 2
(c) The Plan of Care is signed by all participants of the CFT. All participants including the youth and family receive a signed copy and all updated copies to the plan. All Plan of Care documents are filed in youth’s chart. Please see signature page (CFT Agreement) of the Individualized Child and Family Plan pg. 15, Wraparound Guidelines pg. 13
(d) Plans of Care are reviewed at every CFT meeting and updated as clinically appropriate but no later than 90 days. This process is supported by the Supervisor and the HFW Trainer to ensure all Plan of Care goals remain relevant and the process is tracked for timeliness. QA compliance tracking for CFTM’s is based on the Phase & Progress report (Tickler Report). This report will provide a list of cases that did not have a CFTM and is sent monthly to the Supervisor and is reviewed to provide guidance to the treatment team. Please see Fac Tracker (Ticker Report) , The Facilitator periodically presents Plan of Care Presentations to the Supervisor for the purpose of receiving guidance and feedback on creating quality plans. The HFW Supervisor attends CFT meetings to monitor and provide coaching on effective planning by sharing in the brain storming processes and offering suggestions. Plan of Care Provider Presentations,, Wraparound Document Timeliness and Resource Guide pg.6
4.4 Develop a Crisis and Safety Plan
(a) The safety plan is part of the Plan of Care for some programs and a separate document for other HFW programs, it includes the contact information of the 24 hour on call Supervisor and alternative crisis resources, and is completed within the CFT meeting. It is completed within one month of the referral date and subsequent plans are due every three months. The safety plan is reviewed by the family and treatment team. A copy of the safety plan is given to the referring party and the family. The plan is updated whenever circumstances change or when new safety issues are identified and all copies are placed n the youths chart. Please see Safety Plan Wraparound, All Policies Safety Plan Safety Plan (Policy) pg. 74 (pg. 1), Wraparound Documentation Timeliness and Resource Guide pg. 7
(b) The development of the safety plan begins during the initial Child and Family Team meeting with the collaboration of the treatment team and the , family, youth and natural supports and continues on through the comprehensive assessment. It is done as early in treatment as possible and completed within 30 days. The Facilitator asks about areas of concern and determines both proactive and reactive interventions to address the issue with the family and documents the gathered information on the plan.
Please see All PowerPoint Training file 1 Developing a Safety Plan pg.164,165
(c) The Facilitator guides the team in a process to think in a creative and open-ended manner about strategies for meeting the safety needs of the client. The safety plan is signed by the youth and family and is reviewed by the Supervisor to ensure all potential and high risk behaviors are addressed. Staff receive a variety of safety related trainings starting with initial HFW training and annually that cover safety planning strategies for teens, recognizing risks, proactive and reactive interventions and safety planning documentation. The teams role play the safety plan within the context of a CFT meeting. Please see Safety Planning for Undocumented Families- Conversations- Teen Safety Plan pg. 1,2,3,4 , Safety Plan Wraparound pg.1
Wraparound Guidelines pg. 13, All Polices Safety Plan, pg.74 , In-Home Safety Contract pg. 1, ASC Safety Plan Approvals
Implementation
5.1 Implement The Plan of Care
(a) The Facilitator implements the Plan of Care by engaging in actions steps for each strategy, tracking progress on action steps, evaluating success of strategies and celebrating success and considers new strategies as necessary. A poster board is utilized during the team meeting to assist with everyone following along with the planned agenda. The content of the meeting minutes is a copy of what is written on the poster board to ensure transparency and full collaboration from the team. The task assignments are giving during the CFT meeting and distributed to the team by the Facilitator.
Please see White Flag Meeting Minutes, Wraparound Guidelines pg. 14, CFT Agenda Format , CFT Meeting Summary and Action Plan pg. 1,, CFT – White Flag-meeting minutes pgs. 1,2
(b) Facilitators are trained upon first hire and receive ongoing trainings through weekly team meetings, monthly seminars/ forums, professional growth meetings and HR clinical and annual training. All staff receive HFW training by the HFW Trainer who has completed the train the trainer curriculum through UC Davis or the coordinated training through Orange County Training Committee. Please see Wraparound Training Comm. October, OC Wrap Training Plan 2025 pgs. 1 through 12, CFT Agenda Format pg. 1
5.2 Review and Update The Plan of Care
(a) The HFW team revises strategies, progress and action items during the CFT meeting. Opportunities to improve the process is built into every CFT meeting so that action items remain relevant to the family’s progress and needs.
CFT – White Flag- Meeting Minutes- pg. 1,, CFT Meeting Summary and Action Plan pg. 1, Sample Progress Notes of CFTs, CFT Agenda Format pg. 1, Individualized Child and Family Plan pg. 1, 2
(b) The Plan of Care is reviewed at every CFT meeting and updated at minimum every 90 days. Please see Wraparound Guidelines pg. 14, Wraparound Document Timeliness and Referral pg. 6
(c) The Facilitator provides a copy of the CFT meeting minutes to every member of the team. The Facilitator documents to the review of flex funds, plan updates and ensures formal and natural supports are included in the process. These interventions are documented in the Facilitators progress notes Please see Documenting CFT in OCIMS and Template pgs. 1, 2, CFT Agenda Format pg. 1
(d) Forms are able to be updated and changed according to the youths and families individual needs by use of the POC addendum. A Plan of Care can also be updated at any time by the Facilitator as determined by the team in CFT meetings. Please see Wraparound Document Timeliness and Referral pg. 6, OCIMS USER Guide Plan of Care pg. 1
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
(a) Facilitators create team agreements and ground rules collaboratively with the Child and Family Team. These agreements are included in the CFT Agenda and updated as needed. Please see CFT Agenda Format pg. 1
(b) Facilitators are trained upon first hire and receive ongoing trainings through weekly team meetings, monthly seminars/ forums, professional growth meetings and HR clinical and annual training. All staff receive HFW training by the HFW Trainer who has completed the train the trainer curriculum through UC Davis or the coordinated training through Orange County Training Committee. Please see All Training PowerPoints file1: Purpose driven CFT’s and Collaterals (training), (Youth Behavioral Checklist), Strengths Based Wrap, Facilitation training. Needed Communication Skills for Facilitators , Wraparound Training Comm. October, OC Wrap Training Plan, Facilitator training pg. 15, Building Trust Within the Treatment Team pg. 46, Wraparound Family Team Building pgs. 1,2
(c) Facilitator gathers information about the family’s natural supports at initial CFT meeting. The supervisor provides coaching and guidance to increase engagement with natural supports throughout services. Facilitator gathers natural support information at time of commencement and are monitored through data entered into the County System. Please see Initial Face to Face Data. Natural supports are integrated into the Plan of Care and safety plan. Please see CFT Agenda Format pg. 1, All Training PowerPoints file 1 Natural Supports 1.0 pg. 385 and Training Email Natural Supports pg. 1
(d) Ice Breakers are used to engage all team members and supports. A poster board is utilized during the team meeting to assist with everyone following along with the planned agenda. The team reviews what is working and acknowledgments during each CFT meeting. The content of the meeting minutes is a copy of what is written on the poster board to ensure transparency and full collaboration from the team. Case Consultations between team members also occur regularly to update all new staff to cases or whenever communication and collaboration is necessary. Please see Ice Breaker Example and All PowerPoint Trainings Engagement and Team Preparation pg. 195, All PowerPoint Trainings Working together pg. 108 (pgs. 121, 122)
Transition
6.1 Develop a Transition Plan
(a) The facilitator builds consensus with the Child and Family Team around entering the phase of Transition. The Facilitator monitors and reviews progress towards benchmarks and indicators and explains the Transition phase of wraparound. There are court and legal considerations that get monitored by the team when preparing for the transition phase. Please see Individualized Child and Family Plan pg. 1,2
(b) Once the CFT has agreed to move into the Transition phase, the Facilitator creates the Transition Plan of Care. The Transition Plan of Care typically includes less intervention from the Wrap team and more active intervention from the Child, family and natural supports. The Plan of Care is labeled Transition once entering this phase. Please see CFT- White Flag- Meeting Minutes pg. 3, Agenda Format pg. 1, Myevolv Form Location pg. 7
(c) The facilitators receive new hire training and ongoing training during weekly supervisions, and all staff meetings on transition planning skills. Please see All PowerPoint Trainings file 2 Pass the Baton Training pgs. 118,119,120, All PowerPoint trainings file 2 New Fac Training pgs. 438,439
(d) The Plan of Care includes services and referrals the youth and family will continue to engage in post wraparound. The facilitator completes the individualized transition plan which includes natural supports and community resources, proactive intervention plan to manage anticipated crisis, with community emergency phone numbers that can be accessed after wraparound services end. During the Transition phase, and throughout services, the Parent Partner supports caregiver in successful linkage and engagement to services that will continue after Wraparound services close. Formal supports that will remain in place following wrap services are invited to participate in CFT Meetings to ensure coordinated continuity of care. The facilitator provides a copy of this transition plan during the CFT to all team members and a copy is placed in the youth’s chart. For adopted youth, the family is linked to Adoption Wrap services. Please see Myevolv Form Location pg. 5, After Care Plan, CFT- White Flag- Meeting Minutes, CFT Agenda Format pg. 1 Training Wraparound Guidelines pg. 28, All Polices Discharge pg 29 (pg 2,) All Policies Ethical Referral pg 31 (pg. 1), All Polices Referrals to Resources pg. 71 (pg. 1, 2)
6.2 Develop a Post-Transition Safety Plan
(a) Upon introduction to wraparound services, the HFW Team discusses strengths, needs, and support with the intention of building self-sufficiency, self-determination, and thus, to work “ourselves out of a job.” The Transition Phase is a point of discussion in every CFT meeting. During transition the Child and Family Team works collaboratively to update the safety plan with interventions that rely on the youth, family, natural supports and formal supports that will remain in place after wraparound ends. Please see After Care Plan pg. 1, Wraparound Guidelines pg. 13
(b) Throughout the course of Wraparound all safety plans including the transition plan are developed in collaboration with the Child and Family Team. The facilitator leads this process and is provided with ongoing training. Please see: All Training PowerPoints file 1 Developing a Safety Plan pgs. 164,165,167, New Fac Training pg.32, 2025Training Schedule, 2025, pg 1,
(c) All safety plans take into consideration the youth and family’s culture, natural supports, tribal involvement and ability to execute the proactive and reactive interventions and are reviewed and approved by the case supervisor. Feedback is given if any changes are needed. Plans are provided in the youth and caregivers preferred language. Please see All Polices Safety Plan Policy, pg. 74 (pgs. 1,2), Wraparound Guidelines pg. 13,
All PowerPoint Training file 1 Natural Support (NH) pgs. 405,406,407
6.3 Create a Commencement and Celebrate Success
(a) Graduation planning occurs no later than one month from scheduled graduation but termination is discussed at the beginning of treatment. After care planning, planning the graduation acknowledgment and linkage to support are all tasks that are completed during this transition phase. An invitation list with natural supports, wraparound team members and other services providers is created with a location of preference chosen by the youth and family to arrange a collaborative celebration. Speeches from team members or family members during the graduation are also planned to allow an opportunity for positive acknowledgements of achievements made. The youth is then presented with a certificate of completion and gift card of $25 signed by the team. Graduations are individualized and if the family and or youth decides not to have a celebration with formal supports then, flex funds are provided to the family for private celebrations.
Please see: All PowerPoint Trainings Graduation and Transitions pg. 6, Pass the Baton Training Power Point
Please see: Pass the Baton Transition Tool pgs. 1,2,3, Graduation Breakdown- Flex Fund Request- Cert, Wraparound Discharge Summary
(b) All staff receive training on how to utilize flex funds and flex funds are readily available to be used for celebration purposes.
Please see 6.3 Flex Fund Categories and Guidelines (includes request form expenditure request checklist), Wraparound OC Commencement Tip Sheet, pg. 1,2, Wraparound Guidelines pg. 20, 6.3 , All PowerPoint Training Flex Fund Training Wraparound pg. 290
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
(a) Families are encouraged to participate in HFW implementation and decisions by eliciting their feedback about opportunities to improve the process and evaluation of the CFT meeting through the CFT meeting agenda, There are two sections of the CFT meeting agenda where families are asked direct feedback. These questions include, Are there any barriers that the team should be aware of and any barriers to receiving services/ concerns about services? This feedback is reviewed with the HFW team as soon as received and considered when changing processes, treatment and considering needed training. SCCS plans to implement routine focus groups with Parents and Youth to be held no less than annually. Please see CFT- White Flag- meeting minutes pg. 2, Parents Helping Parents Events are provided through the year and are facilitated by Parent Partners. This event is provided to support parents and provide education and resources. Feedback is elicited and gathered through interactive dialogue and Q&A immediately following the events. Please see Parents Helping Parents Event pgs. 3,4 (Includes. staff assignments and feedback).
(b) The Family Satisfaction Survey feedback is reviewed to improve staff training, staff development and improvements within the program. The HFW Trainer conducts the PWOM to gather additional data and feedback 3 months, and 1 year post discharge. Please see SCCS Family Satisfaction Survey pgs. 1, 2,3 (Includes All Staff Agenda), PWOM Consent Form Wraparound Principals Olympics pg. 1
7.2 Community Leadership Team
The Program Director and Program Manager when the Director can not attend is the identified person to attend and participate in the Community Leadership Team.
7.3 Eligibility and Equal Access
(a) Referrals come from San Bernardino ASC and Orange County WRIT who has already determined the eligibility for Wraparound services. We always accept the referrals and make sure the youth and family receive the services they are referred for and do not exclude by the nature of their needs. Please see All Polices No Wrong Door for Mental Health Services pg. 47 (pg. 1, 2)
(b) Staffing minimums are maintained and reported back to the County on a weekly basis to ensure adequate capacity. Please see OCW Weekly Openings, On Call Crisis During Non-Business Hours, On Call Schedules
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
(a) HFW Contracts reflect rates that support the immediate individualized needs of the youth and family. Please see Language from the Wraparound Contract pgs. 1 through 6, 8.1 Funding pg. 1 (Funding from Contract),, All Policies (Contracts and Agreements) pg 24 (pgs. 1,2,3), Management and Accounting Policy & Procedure Manual, , 8.1 Funding pgs, 12,13,14 (Cost Allocation Plan, Financial Customized Resource Bank)
(b) Paylocity and the workforce and development system is used for the management of the HFW staffing. Tracking for HFW expenses including staffing is tracked and monitored through the accounting team using the tracking of expenses excel spreadsheet. Please see 8.1 Funding pgs. 4,5 (Sample for tracking of expenses for programs), pg. 8(AAP Program Funds),
Please see All Policies Job Description Policy pg. 38( pg. 1), Staff Function Policy pg. 1
(c) My Evolv a product of Net Smart is used for the data management system for clients. NetSuite is used to manage the cost of services. Systems and Software. Please see All Policies Systems and Software PG. 85 (Pgs. 1,2,3),
8.1 Funding pgs. 12, 13 (CAP SCCS 2025-2026), Management and Accounting Policy & Procedure Manual , SCCS Long Term Strategic Plan and Process pg. 7, 8,
8.2 Equitable Funding Across System Partners
County only
8.3 Cost Savings are Reinvested
County only
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
(a) There is a defined written approval process for flex funds that include guidelines that outline how the items/services/good must tie into the Wraparound Plan of Care, ensuring referring party’s agreement, requests for emergency and same day requests, required documentation and accounting of expenses . Language from the Wraparound Contract pgs. 1 through 6, 8.1 Funding pg. 1, 9 (Expenditure Form Instructions)
(b) The flex fund guidelines and trainings that are provided to all staff outline timely access to families, a defined approval process and how to appeal denied requests. The Program Director will communicate to the treatment team and youth and family an explanation of denial and will assist with identifying alternative ways to support the need. Please see Flex Funds Categories and Guidelines pgs. 1,2,3, 4, All PowerPoint Trainings file 1 Flex Fund Training pg. 287 (pg. 301), Flexible Fund Policies and Procedures Wraparound pgs. 1,2,3, Wraparound Document Timeliness and Referral pg. 8
8.5 Collaborative Oversight of Flex Funds
(a) Flex fund reports are pulled from OCIMS monthly by the QA Manager and reconciled with the SCCS accounting team. A monthly meeting is held to review flex fund usage across the programs to ensure flex funds reflect the needs of the family/plan of care, are within appropriate budget limits and are equally available to all youth and families. Please see Program Expense 01.31.26, Flex Fund Guidelines, OCW FF Expenditure Accounting Checklist, Flex Fund Expenditure Form, OCIMS USER Guide 2018 Individual Service Report, Flex Fund Request, Financial Budget, Financial Customized Resource Bank
(b) There is three hundred dollars of flex funds per client readily available to be used at any given time for needs identified by the Child and Family Team. Please see Flex Fund Categories and Guidelines pg. 1,2, All Policies Flexible Fund Policies and Procedures Wraparound pg. 33 pg. 1,2,3
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
(a) Flex funds are equally available to all youth and families regardless of funding source. Please see Flex Funds Categories and Guidelines,
(b) In addition to flex funds all staff explore alternative community resources and other funding sources to support the needs of youth and families. If flex funds exceeds what is budged over three hundred dollars additional approval is approved by the Program Director.
Please see and Financial Customized Resource Bank. pg. 1
All PowerPoint Trainings Flex Fund Training Wrap New Hire pg. 13,14
(c) Flex Funds are utilized to support the stabilization of placement and to meet individualized goals that families would otherwise not be able to meet due to financial constraints and lack of resource. There are no single funding requirement for families to access flexible funds or emergency funds. We complete a budget with families before usage of flex funds and complete a Customized Resource Bank for larger ticket needs (e.g., rent). Their is specific language written in the Wraparound Contract that specifies use of Emergency Fund, ” The fund established and maintained by the Contractor in the amount of $300 per enrollee to ensure that monies re available 24 hours a day/seven days a week to meet the emergency needs of the child and family for children enrolled in Wraparound Services.
Please see 8.1 Funding pg. 1, 6.3 Flex Fund Categories and Guidelines pg. 5
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
(a) The demographic information of the staff and youth are both monitored by the Management and HR Team through the use of KPI reports in order to ensure recruitment of new staff meets the needs of the service population. Please see Client Diagnosis and Client Demographics pg. 5, Data insights Demographics Ethnicity2025 pg. 1, All Polices Cultural Competency pg. 27 (pg. 2), Interpreter Services in Wraparound 3.0 pg. 9
(b) When unable to utilize formal translation services or professional interpreters natural supports are utilized to support communication and linguistic needs. All staff receive training on how to utilize and engage natural supports to better service youth and the family, Please see All PowerPoint trainings file 1 Natural Supports 1.0 pg. 389, and Interpreter Services in Wraparound 2.0 pg358 (pgs. 361,362)
(c) Professional Interpreters are apart of the HFW team however, when a bilingual staff is unavailable to meet the linguistic needs of the youth and family interpretation services are requested and utilized through Interpretation Services of CTS. Please see All PowerPoint trainings file 1 Interpreter Services in Wraparound 2.0, pg. 358 Interpreter Services in Wraparound 3.0, pg. 365
Please see All Policies Language Proficiency Assessment pg. 45 (pgs. 1,2) Training Wraparound Guidelines pg. 5
9.2 Tribally Responsive Workforce
(a) All HFW staff receive training on Indian and Native Alaskan children and policy during on boarding and is part of their new hire training plan. Please see All Policies Indian and Alaskan Native Children pg. 36, OC Wrap Cultural Trainings. pg. 1,
(b) Tribal involvement and cultural preferences is inquired about during the completion of the seven domain clinical assessment with the youth and family and once identified, spiritual practices, tribal supports, traditions and customs are explored and encouraged to be applied to treatment with the agreement of the youth and family. Please see Tribal Involvement Assessment Question
9.3 Flexible and Creative Work Environment
(a) The leadership team oversees the structure and process of evaluation, monitoring, and management to prevent drift and ensure high fidelity. While Directors, Program Managers, and Supervisors are responsible for HFW program quality and improvement, efforts are shared amongst all roles and integrated in all practices. Management provides a variety of opportunities for staff to provide feedback around Wraparound program quality and improvement. Client Satisfaction Surveys, WFI data, and outcome progress reports are reviewed and discussed at all-staff meetings with time allocated to open discussions for brainstorming new and creative strategies to improve service delivery, quality of care and internal processes. Please see WFI Training PowerPoint pgs. 3, 4,5, 2026 COP Tracking Outcomes pg. 1, BBS Assessment Shadow Tracker tabs. 1, 2
(b) In addition to monthly trainings and weekly supervision meetings (Director with Program Manager, Program Managers with Supervisors, Supervisors with Direct Care Staff), ongoing case consultations are held to develop and maintain team cohesion and positive teaming. The Wrap Programs function as families within our larger agency family. The Child and Family Team model is practiced within the work place, along with Wraparound Values. Staff strengths are identified and recognized on a regular basis, Collaboration is a key component of all decision making management provides opportunities for team bonding through various team building gatherings, trainings, Pod Meetings pg. 1. Please see All PowerPoint trainings file 1 Building Trust Within Treatment Teams pg. 44, Wraparound Principals Olympics pg. 4, All PowerPoint Trainings file 2
Working Together pg. 108
(c) Open communication surrounding all HFW families, in particular complex cases, is crucial. Shared experience about engaging families, effective interventions, awareness of what works and pitfalls, and appropriate clinically-informed discussions are some examples of how our HFW team practice and ensure open communication. Open communication is encouraged and valued. Staff have opportunity to share differing points of view, new ideas, constructive feedback with each other and management. Any staff may request a case consultation that includes the internal wrap team as well as a wrap supervisor who is not involved on the case being discussed. Staff meetings includes time dedicated to acknowledging what is working as well as questions/needs from the HFW staff. All Facilitators receive training and handouts on communication skills. Please see Clinical Staff Weekly Supervision Check In pg. 1, pgs. 1,2 and All Policies Staff Competency pgs. 82(pgs. 1,2)
All PowerPoint trainings Building Trust Within Treatment Teams pg. 44, All Polices CFT Policy pg. 88
(d) The HFW philosophy is woven into the culture of the Wraparound Departments. The principles are our foundation for all client-related decision making, but also guide our internal team collaboration and culture. New team members are warmly welcomed to the team and assigned a designated buddy who is also in the same role. Monthly awards are given to staff who adhere closely to the “Whatever It Takes” philosophy of Wraparound. The WIT Award is based on nominations from staff members. Management awards monthly recognition for Employee of the Month. The annual Heart of Wraparound Award is the most special recognition, nominated by the team and management for an individual who embodies the 10 Principles of Wraparound. Please see Heart of Wraparound and WIT Award Nomination pgs. 1,2, Training Email, Natural Support and Summer Jam pg.5,6, Introductions to New Staff pg. 1
9.4 Hiring, Performance Evaluation, and Job Descriptions
(a) In creating each position’s job description the UC Davis Wraparound standards job description examples and tool kit were referenced to ensure all positions include the required responsibilities. All job descriptions include defined roles and responsibilities. SCCS has the following positions and job descriptions as part of the HFW team. Please see All Job Descriptions with Job Specific Performance
HFW Clinical Supervisor
HFW Facilitator
HFW Family Specialist
HFW Fidelity Coach
HFW Parent Partner
HFW Youth Partner
HFW Program Supervisor
(b) Each of the above HFW positions has their own job descriptions that include specific functions, competencies and pay scales. Please see Job Description Policy pg. 1, HFW Paraprofessional Core Competencies pg. 1, All Job Descriptions Supervisor Core Competency Performance pg. 33
(c) The HFW Director and Supervisor uses a Interview questionnaire that includes a list of interview questions that inquires about specific skills, experience and competencies. Please see FAC Interview Questions pgs. 1,2
(d) During the interview candidates are asked to engage in a written activity that demonstrates their clinical writing skills, asked about how they would handle a crisis, and are presented with real life scenarios of how to respond to high risk situations working with families and youth. Please see FAC Interview Questions pgs. 1,2 , All Policies Staff Competency pg. 82
(e) The Supervisor completes a weekly journal in paylocity (human resource information system) in order to perform a check in on key performance areas. For clinical positions weekly individual and group supervisions are provided and a supervision note is filed in paylocity. These supervision notes are documented and pulled into the annual performance evaluations. Clinical Positions also receive annual clinical evaluations from their Clinical Supervisor. All positions including Supervisors and Directors receive an annual performance review on their role’s specific competencies Please see HFW Paraprofessional Core Competencies Performance pg. 1
All Policies Clinical Supervision Revised pg. 13 (pg. 18), All Polices Performance Review Policy pg. 63, Weekly Supervision Check in and Notes pg. 3
9.5 Workforce Stability
(a) HR uses HRIS system with a specific compensation module that allows our HR team to match wages with the cost of living based on location. Salary.com is the tool that is used by the HR department. Please see Market Pay Insights (Salary.com) pg. 1. The HR team periodically reviews ( no less than annually) the organizational goals, labor market conditions, cost of living changes and work force retention outcomes and updates the policy as needed. Please see All Policies Compensation Policy pg. 20,21,22
(b) All staff are trained how to keep their scheduling calendars updated for supervisors to monitor weekly. The Supervisor has the Facilitator submit an updated provider census which is called the SCOOPS. This document is reviewed weekly to manage distribution of cases and maintain appropriate case load size. This document also gets shared with ASC for oversight for the SB County Program. Please see Fac Tracker (SCOOPS Blank form). The Fac Tracking tool is also updated weekly and shared with the Supervisor to manage workloads. Please see Fac Tracker pg. 1. All staff have access to a ’My clients’ Widget in the EHR, which list their full case assignment. This gets updated with every new client assigned or closed out of the program once an enrollment is closed.
(c) Wage ranges for each position is published with the position that is posted in public job boards and online. The tiers are based on previous professional experience and lived life experience. During the interview process wages are also communicated verbally and posted internally. Please see Job Descriptions with Tiers pg. 3,4,5,6,7
(d) The tier structure does not require a position change and each tier explains what additional experience is necessary to move up. Please see All Job Description with Job Specific Performance, Job Description Policy with Tiers pg. 3,4,5,6,7
Please see: All Polices Compensation Policy pgs. 20,21, Strategic Process and Plan pg. 5, 6
9.6 High Fidelity Training Plan
(a) All staff receive comprehensive initial HFW training through an internal curriculum by the HFW Trainer. These trainings are tracked and monitored by the HFW Trainer and Supervisors ensuring al staff complete the full series of trainings. The HFW Trainer is responsible for keeping all trainings updated and in compliance with HFW standards. Please see New Hire Training Tracker and Curriculum pg. 1 and Introduction to Wraparound. All staff that complete and review the IP CANS are trained and certified through the Praed Foundation.
(b) HFW is a Team-Based service that draws on the knowledge, skills, and lived experience from each team member. Thus, each member must be aware of their specific role, unique responsibilities, and “function” within the child and family team. This allows them to fully and successfully contribute to the HFW process. Understanding individual roles not only allows each member to best engage families with clarity, it also eliminates undue conflict and frustration and supports boundary-setting. Ongoing trainings throughout the year are provided by the Supervisors during one on one weekly meetings with staff, during quarterly all staff meetings and through the HR training team. The HR training team tracks completion of trainings through Relias and paylocity.
Please see Wraparound Training Comm October 2025 pg. 6, Please see OC and SB Wrap Training Plans 2026
(c) Trainings provided to each member of the HFW Team occurs not only upon hire but also annually and monthly. Ongoing trainings cover wraparound-specific topics that are catered to position-specific audience members. General topics that support the successful service provision to children and families are also provided to each member. These trainings are provided by Supervisors, the HFW Trainer and the HR training Team. Every month a training flyer is sent out by the HR Training Team announcing trainings offered and staff are allowed to self assign as well as request booster trainings for any previous trainings received. The Wraparound training log demonstrates monthly training topics to provide to all Wraparound staff as well as role-specific topics. Understanding Wraparound Roles Training is provided to all staff on an annual basis.
Please see SCCS Trainings March 2026. Please see Wraparound Training Log and Understanding Wraparound Roles
(d) Clinical Supervisors and HFW Supervisors/Managers are a crucial part of the HFW Team. They complete all general Wraparound training as well as receive initial, ongoing, and booster trainings that are specific to their leadership/supervisory role. This allows them to be active and “hands-on” with each direct care staff. From shadowing and observations, to coaching and monitoring strengths/needs and progress, leadership must have a firm grasp on the in’s and out’s of HFW. This includes but not limited to HFW concepts (principles, phases, etc.), practices and processes, tools and interventions, and general culture and attitude of “doing whatever it takes” with strength-based lens. Supervisors are offered the opportunity to attend a one time Middle Management Academy training offered externally to develop management skills. All Supervisors are offered and invited to attend monthly Supervisor Consultation groups facilitated by the HR training team. Supervisors are also provided with monthly booster trainings in Clinical Supervision skills, ethics and boundaries. Wraparound management meets on a weekly basis to collaborate on best practices, consultation and service implementation of the HFW model. HFW Supervisors will attend UC Davis Leadership training opportunities and share out the information to the SCCS Wraparound leadership team.
Please see SCCS Trainings March 2026 pg 6, Please see OC and SB Training Plans 2026 pg. 43, 44, 45,46
Please see Fac tracker (SBW- SF Program Supervisor Tasks), New Hire Training Tracker(Supervisor Master Training Agenda), Please see Wraparound Training Comm October 2025 pg. 6 this is a schedule that shows supervisor professional growth trainings on a by monthly basis.
(e) All HFW staff receive training on Indian and Native Alaskan children and policies during on boarding and is part of their new hire training plan. Please see OC Wrap Cultural Trainings Relias pg. 1 All Polices Indian and Alaskan Native Children pg. 36
9.7 Community-based Training Program
(a) Our HFW Parent Partners may be former or current recipients of wraparound services, primary caregivers of a child/youth involved in congregate care, CFS/Dept of Probation; and/or primary caregivers of children/youth with complex needs. All Parent Partners leverage their own lived experience to educate, support, and train direct care staff, caregivers, and community partners. Through a personal and unique perspective, PP offer their knowledge, skills, and experience to enhance trainings for direct care staff and community. Please see Parents Helping Parents Event pg. 1,23,4. We plan to have our current Parent Partners who have previously participated in Wraparound services share their story and experience during our “Intro to Wraparound” Training. When available, we will also have our Family Specialist share their story of being wrapped as a youth as part of our “Intro to Wraparound” Training. We plan to invite youth and families who have successfully graduated from SCCS Wraparound services to share their experience during our monthly booster trainings. Please see Parent and Parent and Youth Story Agenda 2025.
(b) Trainings are provided to CFS and Department of Probation employees to support partnerships between and within systems of care. This allows for aware, engaged, and effective formal supports (referring workers, etc.) who recognize the value of their role in a CFT. Trainings are also provided to community partners such as California Connect, churches, resource parents, and universities/schools. Please see All PowerPoint Trainings file 2 Respite Presentation pg42 (pg45), Working Together pg. 108, Wrap 101 DBH Psych Fellows, pg. 131 (133).
Please see Program Services and Overview pg. 8 and 9.,
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9.8 Coaching and Supervision
(a) Our robust HFW new hire training curriculum provides didactic trainings as well as an apprenticeship program that allows “learn by doing.” The intentional structure and pacing of our HFW training program allows for gradual increase in participation and responsibility, supports success, and minimizes burn out. In addition to receiving didactic trainings, new direct care staff participates in role playing, receives ongoing support in supervision meetings, work in the community and field shadowing mentors, and observing more experienced team members in CFT Meetings and various services (one-on-ones, collaterals, documentation, etc.). Eventually, they are assigned to be a part of a CFT and observed, monitored, and supported by the Wrap Fidelity Trainer, Leads, and Supervisors. The support and learning is ongoing.
Please see All PowerPoint trainings Flex fund training Wrap New Hire pg. 3. Introductions to New Staff pg. 1., Training Email Natural Supports pgs. 3,4 (Shadowing Email Team Spirit Committee), New Hire Training Tracker and Curriculum (Shadows completed). The training tracker is used to monitor staff shadowing experience.
(b) All HFW staff have access to 24/7 supervisory support and coaching by way of their primary supervisor, other program supervisors, program managers, on-call supervisor, and Director. An On call schedule is posted on a shared drive for all staff to access. Please see On Call Schedules pgs. 1,2
Please see additional supporting documentation Supervision of Administrative Staff and Paraprofessionals pg. 1
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
County only
The Program Director will be the contact person to coordinate and gather information from the County representative designated to communicate the quality improvement plan to it’s contracted providers.
10.2 Evaluation Metrics & Outcomes
(a) The PQI measurements of the program are reviewed weekly by the Leadership team, The Program Director meets with the CEO and other members of management to review census, program data and identify areas for improvement. Please see SCCS Long Term Strategic Plan and Process pg. 9, 13, 14 . The HFW program uses a logic model to measure fidelity, performance and outcomes.
The identified needs from this logic model informs topics of discussion for monthly staff trainings and weekly team meetings.
The Quality Assurance and Billing team provides management with reports on progress notes, lapse in services, pending documents, internal audits and trends to ensure quality assurance in documentation and quality of care standards are met. Data is also shared by SCCS internal data team that is provided through Tableau reports that are updated daily. These reports contain information about client demographics, services, diagnoses and other pertinent treatment indicators. Data is shared with staff during weekly meetings and supervisions and then formally during quarterly All Staff Meetings. Please see All Polices Performance and Quality Improvement pg. 58
(b) The Post Wraparound Outcome Measure (PWOM) was created by SCCS HFW Team to measure youth and family outcomes after graduation. This longitudinal data further informs program strengths and training needs.
A program logic model is used to identify needs, inputs, activities outputs and outcomes for the program and is reviewed and updated annually to assess program goals. Please see Logic Model Wraparound and All Policies Outcomes pg. 53, PWOM Data Master pg. 1
(c) Data that is collected is reported and shared with our county contractors through uploads into their County systems. The Program Director and Managers attend weekly CFS/DBH Help line meetings to communicate system barriers. Once a Community Leadership Team is identified the Director will be the point of contact for communicating data with the team. Please see Consecutiveness Map and Helpline Meeting pg. 1
Fidelity Indicators
1.1 Timely Engagement and Planning
1.1a
First contact with families is made as soon as possible, but no later than 10 calendar days after referral. Per Core Training, Day 2. This is also trained to in the Orange County Intervention Management System (OCIMS) Training Day 1. This is also documented in Page 1 of Wraparound document timeline and resource guide along with New CC Training. The Direct Services Amended contract requires that providers be in line with all licensing standards and laws noted on page 2 of Amendment, Section 5 and page 10 Section 5.1.
1.1b
Wraparound Teams complete a Wraparound Plan of Care within 30 calendar days from start of all services. All Wraparound contracted providers are expected to have Plans of Care completed and clearly documented in our Orange County Management Intervention System (OCIMS). This is also documented in Wraparound CORE Training Day 3. Please refer to Wraparound CORE training. This is also noted in the Wraparound Document Timeline and Resource Guide, page 6-7, and Day 1 and 2 of OCIMS Training. Please refer to those training documents. This expectation is also noted in the Direct Services Contract Attachment A, page 23, Sections 5.4.2, 5.4.4, 5.9; page 29, Section 6.8 and is more clearly outlined as 30 days in the Direct Services Contract Amendment Page 13, section 22 (6.8). This is also trained to in the New Care Coordinator Training. Please refer to the Training Matrix.
1.1c
HFW teams are expected to review the Plan of Care (POC) within the HFW team meeting at least every 30-45 calendar days. This expectation is clearly documented in CORE Training Day 2 and 3. Please refer to the CORE Training Power point and agenda. This is also trained to at the OCIMS Training Day 2. Please refer to the OCIMS training power point and agenda. The Direct Services Amended Contract, page 13, Section 6.8.8 clearly defines this requirement. This is also trained to in the New CC Training. Please refer to the Training Matrix.
1.1d
Wraparound teams are expected to update the plan of care, distribute to all team members, and document the updated plan in the child or youth’s file at least every 90 days and more often as needed. This expectation is clearly documented in the Direct Services Amended Contract, page 14, section 6.9. This is also explained to contracted Wraparound Provider’s staff in the Wraparound Document Timeline and Resource Guide page 7, is trained to in OCIMS Training Day 2, and Wraparound CORE Training, Day 2 and 3, along with New Care Coordinator Training. Please refer to Power Points listed for each and description of Trainings matrix along with training agendas. The OC SSA Quality Assurance Staff Specialist also sends out Monthly Progress Reports to each contracted provider to demonstrate their monthly compliance with meeting this requirement.
1.1e
Staff and their supervisors are provided with feedback on their ability to meet timelines for Continued Quality Improvement. This is completed at monthly Site Support visits where the WRIT (Wraparound Review and Intake Team) composed of Child Welfare Supervisors (Liaisons), Behavioral Health – Health Care Agency Wraparound Liaison, Probation Supervising Probation Officer, and Family Support Network Executive Director, meet monthly to provide each respective contracted provider with monthly feedback. WRIT attends monthly Site Support visits and provides feedback on their ability to meet timelines, address any barriers, identify any gaps, and make themselves available to provide support. Monthly Progress reports are also sent out by the OC SSA Quality Assurance Staff Specialist. A tickler report is also sent out when there is missing information observed in the OCIMS reports, phase and progress reports. Information is also shared at monthly contract meetings attended by Wraparound OC SSA Senior Manager and HCA Service Chief and OC SSA Contract staff. Utilization Reviews/Site Reviews are also conducted a minimum of once per year to review compliance and feedback is provided to contracted providers regularly. The expectation that contracted providers also have individual supervision with the various role types is an expectation that is well documented in each contract. There are numerous opportunities to review progress and ensure minimum standards are being met. Please also refer to Direct Services Contract Agreement, Attachment A, page 19, section 2.90 for a description of WRIT and also meeting matrix for a description of activities related to WRIT. Please also refer to Direct Services Contract Agreement, Attachment A, page 60, section 17.7.1.15; page 65, section 17.7.4; page 68, section 17.7.6; 69, section 17.7.6.16 for a description of requirements for individual supervision.
1.1f
Staff are trained to timely engagement strategies that include encouraging alternate strategies when contact with the family is difficult. This is typically addressed in Wraparound CORE Training, Day 2. This is also addressed in monthly Site Support meetings where WRIT provides feedback to contracted providers. Wraparound Review and Intake Team (WRIT): A group that includes a parent representative and representatives from SSA/CFS, HCA/Behavioral Health Services, Probation, and Orange County Department of Education. WRIT reviews eligibility for Wrap OC and provides consultation to Wrap OC Provider Agencies through the Family Review Process. WRIT also identifies strategies during Reviews of Commencements whereby WRIT reviews each commencement submitted. If a contracted provider submits a commencement request, rather than simply approve it, WRIT reviews each commencement to ensure that all efforts were made to engage the family. If a Wraparound team attempts to indicate a family is not interested, the contracted provider, Wraparound staff, need to meet with a WRIT/Child Welfare Supervisor to explain and detail their engagement efforts. Technical Assistance meetings as needed are scheduled. Please refer to Direct Services Contract, Attachment A, page 17, section 2.79; page 19, section 2.93; page 24, section 5.5; page 33, section 6.20; and page 52, section 13.1.5. This is also assessed and discussed at Monthly POC presentations for each provider which is led by WRIT team. Please refer to Meeting Matrix for a description of WRIT meetings and POC Presentations. Topics regarding engagement, alternative strategies and commencement are also introduced at New Care Coordinator Training as well. Please refer to Training Matrix for a description of meetings for New CC Coordinator Training. Please refer to page 81, section 19 for quality assurance and quality control expectations for each contracted provider. Commencements are reviewed and assessed for commencement only after all efforts have been made and an agreement is reached that all efforts have truly been exhausted. Commencements for families not interested are not readily approved without thorough discussion and alternatives explored thoroughly.
1.2 Led by Youth and Families
1.2a
Teams elicit and incorporate families’ perspectives, including Tribes in the case of an Indian child (including development and documentation of the Family Vision and Team Mission statements). Please refer to Direct Services Contract, Amendment, page 12 5.4.2. While the current POC does not include a Mission Statement, it does include a Vision statement. OC SSA plans to incorporate a Mission statement into the POC in addition to the current vision statement. Currently the database that OC SSA utilizes (Orange County Intervention Management System) can only accept the Vision statement as the OCIMS database cannot easily and readily be upgraded without completing a major enhancement. For the time being, the mission and vison will be included in one section, in order to comply with the standards. Given competing priorities with the expected rollout of CARES, OCIT expects to be able to begin a major enhancement to make changes to OCIMS to accommodate the new POC changes in April 2027. As a result, OC SSA intends to use the same POC with the Mission being added to the Vision section for now until OC SSA can update OCIMS to mirror the updated draft POC. Please see attached POC currently being utilized and Draft POC with Mission statement included. The parents are required to sign the POC and also required to sign their willingness to participate in Wrapround.
1.2b
At consultation when gathering information on family; needs and strengths gathering is completed when developing the POC. This is reviewed at monthly POC presentations when Providers join WRIT to present their cases. Wraparound Review and Intake Team (WRIT): a group that includes a parent representative and representatives from SSA/CFS, HCA/Behavioral Health Services, Probation, and Orange County Department of Education. WRIT reviews eligibility for Wrap OC and provides consultation to Wrap OC Provider Agencies through the Family Review Process. Supervisors and WRIT team also review POC selected cases. Teams also complete this during monthly CFTs. Staff are expected to document POCs in OCIMS database and this are trained in OCIMS training on this requirement. This is also reviewed in Utilization Reviews/Site Reviews conducted twice per year and at Technical Assistance Meetings. Please refer to Meeting Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services contract, Attachment A, page 6, section 2.24, 2.25; page 20, section 3.1.4, page 29, section 6.8, page 4, section 2.11; page 10, section 2.40; page 11, section 2.46; page 14, section 2.65. Please also refer to Wraparound referral form which clearly documents information gathering.
1.2c
Supervisors routinely observe HFW team meetings and review documentation to gather and provide feedback to staff to reinforce practice expectations, build skills, and increase confidence. Supervisors attend CFT meetings regularly. Please refer to Direct Services Contract, Attachment A page 4, section 2.11.2. Supervisors also participate along with WRIT Technical Assistance meetings. Please refer to Direct Services Contract, Attachment A, page 17, section 2.79; page 69, section 17.7.6 for a description of the duties related to a Wraparound Supervisor. Trainings are provided to all Wraparound Supervisors through the various trainings. Please refer to Trainings Matrix for a comprehensive list of required trainings for Supervisors and staff they supervise. Feedback is also shared with Supervisors in order that they share with their staff through monthly Site Support Meetings, and monthly POC presentations.
1.2d
Family Satisfaction Surveys are completed at commencement and are conducted by OC SSA contracted agency, Family Support Network. The WFI is completed at the 4-month mark. Please see Support Services Contract Attachment A, page 1, section 1.1.5; page 17, section 2.86; page 18, section 3.1.4; page 20, section 3.2.5; page 23, section 7.2; page 34, section, 14.11.1.2, 14.11.1.4, and 15.4.5.1. Family Satisfaction Surveys and WFI is also identified and noted in the Direct Services Contract Attachment A, Page 18, section 2.86, page 20, Page 21, section 3.2.4, pages 23-26, page 34 and page 39; page 60; page 63 sections 17.7.3.4, 17.7.1.17; page 76, section 17.7.7.30; page 80, section 18.2.8.7. This is also trained to in CORE training, OCIMS training, regulalry brought up at monthly Site Support Meetings.
1.3 Strength-Based
1.3a
All the Wraparound team works on the family story which includes the strengths and needs. OC Wrap currently includes family members, New POC will included all team members. The Parent Partner uploads CFTM note into OCIMS. This is also covered in OCIMS training and CORE training in day 2. This can also be observed in Site Review tool page 1. Please also refer to the Direct Services Contract, attachment A, page 11, section 2.44; page 12, section 2.51; page 14, section 2.64; 2.65; page 23, section 5.4.1; 5.4.2; page 24, section 5.6; page 25, section 5.6.6; page 59, section 17.7.1.3; page 70, section 17.6.22; page 78, section 18.2.5.
1.3b
The identification of individualized strengths include and are not limited to, the strengths identified in the IP-CANS. Staff are trained to not solely base needs on these identified in CANS, rather include the family’s needs which evolve over time and need to be assessed continuously throughout. This is trained to in CORE training, MediCal training, Care Coordinator training PP training and YP training. Please refer to Training Matrix. Please also refer to Direct Services contract, attachment A, page 11, section 2.51; page 14, section 2.64; 2.65; page 16, section 2.72; page 20, section 3.1.4; page 23, section 5.4.1; 5.4.2 and 5.6; page 25, section 5.6.6; page 32, section 6.17.4; page 38, section 9.2; page 59, section 17.7.1.3; and page 69, section 17.7.6.8. This can also be identified in amendment of Direct services Contract page 9, section 16; page 10, section 18.
1.3c
The entire Wraparound Training Committee is continually working on and identifying training for staff. The Training Committee meets monthly to identify training needs for subsequent months. Training Committee is composed of the WRIT team (Child Welfare, Probation and Health Care Agency staff) along with Program Directors for each contracted Wraparound provider (Olive Crest, South Coast Children’s Services, and New Alternatives). The Training Committee works collaboratively to identify trainings to be delivered based on various factors including training survey responses from all the previous trainings completed, a review of processes, review of Family Satisfaction Surveys and WFI results, and an identification of what training may be needed based on any issues as they arise such as new staff, an issue or barrier/trend that may be observed. All trainings delivered are developed with input from all agencies including Child Welfare, Health Care Agency and Probation along with participants from the contracted Wraparound providers. New topics are identified and collaboratively agreed to by the Training committee. Core Training, monthly Institute trainings, Professional development trainings specific to Supervisors, CCs, YPs and PPs along with POC meetings and monthly Site Support meetings are developed with input from the entire Wraparound OC team. Please refer to the Wraparound Meeting Matrix , OCIMS Training agenda and Power Point, Technical Assistance, Facilitation Training, NEW CC Training, Critical Thinking Training, and Wraparound Overview Training. Updates are also made collaboratively and trainings teams are represented equally across all contracted providers, Child Welfare, HCA and Probation. Please also refer to Direct services Contract Attachment A, Contract page 52; page 65; 68; and pages 76-81.
1.3d
Family Satisfaction Surveys are completed at commencement and are conducted by OC SSA contracted agency, Family Support Network. WFI is completed at the 4-month mark. Please see Support Services Contract Attachment A, page 1 1.1.5, page 17, section 2.86, page 18 3.1.4, page 20 3.2.5, page 34 14.11.1.2, 14.11.1.4, 15.4.5.1. Family Satisfaction Survey and WFI is also identified and noted in the Direct Services Contract Attachment A, page 18, section 2.86; page 20; page 21, section 3.2.4; pages 23-26; page 34; page 39; page 60; page 63, section 17.7.3.4; 17.7.1.17; page 76, section 17.7.7; page 80, section 18.2.8.7. Feedback is provided to Program Directors regarding responses in order to assist with Quality Assurance and providers are expected to share trends with staff in order to collaborate and identify quality assurance issues/barriers. Trends are also shared at monthly Site Support visits. Feedback is provided routinely through these various forums in order to work towards continuous quality improvement. Please see listing of Meeting Matrix.
1.4 Needs Driven
1.4a
Underlying needs are identified and prioritized before goals and strategies are established for the youth and family. When Child Welfare Liaisons complete referral consultations, they gather information to assess the needs of the family and share these needs with contracted providers. Upon the Wraparound team’s initial contact with the family, they conduct their own assessment of the family’s needs and upon their first face to face meeting they continue to assess. Upon the Wraparound team’s completion of the needs and strengths and during the CFTMs and development of the POCs, the team continues to gather information and conduct their assessment of the needs and strengths. Continuous reassessments throughout monthly CFTMs are completed. This is trained to in Day 2 and 3 of Wraparound CORE training. This is also addresses in internal trainings by the contracted provider, in CANS training by behavioral health, which is also delivered after CORE training in order to teach and reinforce the use of IP-CANS. Please refer to Day 2 and 3 of CORE training. Also, please refer to Direct Services Contract Amendment, page 10 item 18, section 2.96, Direct Services Contract page 4, section 2.11; page 7, section 2.30.1; page 10, section 2.40; page 12, section 2.51; page 14, section 2.65; section 2.77; page 20, section 3.1.2; page 21, section 3.1.4; page 22, section 5.3; page 23, section 5.4.2; page 24, section 5.6; pager 24, section 5.6.3; page 25, section 5.8; 5.9; page 26, section 5.11.1, page 32, section 6.17.3; 6.17.4, page 44, section 10.1.4; page 59, section 17.7.1.7; 17.7.1.8.
1.4b
Staff receive ongoing training and coaching in identifying needs statements that are reflective of the underlying reasons why problematic situations or behaviors are occurring and utilizing needs focused planning over problematic behavior focused planning. This is typically addressed at monthly Site Support visits to agencies where the WRIT team visits and engages in dialogue with the agencies to address cases, issues, and often address how to resolve problematic situations. Please see list of trainings and meetings. This also addressed in OCIMS Training Day 2, CORE training Day 3, Staff Supervision by providers at their respective agencies. POC training is currently being developed and will be completed in Professional Growth trainings and will be provided ongoing. Please refer to Direct Services contract Attachment A, Page 60, sections 17.7.1 to 17.7.15. Wraparound teams are provided with supervision, direction, support, and/or emergency crisis management to Parent Partners and Youth Partners, twenty-four (24) hours a day, seven (7) days a week, including holidays, utilizing an on-call system after business hours, page 65, section 17.7.4.4.
1.4c
The Wraparound team collaborates with the family to identify individualized needs and ongoing reassessment in CFTs and in the development of IP-CANS. This is also effectively addressed in monthly POC presentations where feedback is given to individual providers/teams. This is also covered in OCIMS training and CORE training in Days 2 and 3. Please refer to the training and meeting matrix. The Wraparound team works on the family story which includes the strengths and needs. The PP uploads CFTM note into OCIMS. Covered in OCIMS training and CORE training in Day 2. Site review tool page 1. Please also refer to Direct Services Contract, attachment A, page 4, section 2.11; page 9, section 2.38; page 10, section 2.40; page 11, section 2.46.1; page 12, section 2.51; page 13, section 2.55; page 14, sections 2.64 and 2.65 which is agreed upon and signed by the Family Team; page 16, section 2.73; page 20, section 3.1.2; page 21, section 3.1.4; page 22, section 5.3; page 23, section 5.4.1 and 5.4.2; page 24, section 5.6; page 25, section 5.8; page 26, section 5.11; page 31, section 6.14; page 31, section 6.17.2; page 32, section 6.17.4; page 38, section 9.2; page 39, section 9.3.1.9; page 44, section 10.1.8.1; page 58, section 17.7.1.3; page 59, section 17.7.1.7; 17.7.1.8; section 61, section 17.7.2.1; 17.7.2.5; page 62, section 17.7.3.1; page 69, section 17.7.6.8; page 70, section 17.7.6.22; page 72, section 17.7.7; page 72, section 17.7.7.4; page 73, section 17.7.7.12.
1.4d
Transition is planned according to team and family agreements that the family’s needs have been sufficiently met. This is addressed at monthly Site Support visits, reviewed by OC SSA Quality Assurance Staff Specialist and reviewed in Progress reports sent out monthly, monthly ticklers, when missing information is identified in OCIMS reports, during phase and progress reports, and is trained to in CORE Training (Day 1 ), and OCIMS training (Day 2) & (Day 3). Please refer to Training Matrix and Meeting Matrix. This is also noted as an expectation in the Direct Services Contract, page 24m, section 5.4.4; pave 32, section 6.17.6; page 73, section 17.7.7.14.
1.5 Individualized
1.5a
Forms/documentation allow for significant flexibility in creating individualized plans for each child/youth and family. Wraparound Teams document this in Action Forms, POCs, the Progress Summary, Family Story, CFT Agendas, CANS and this is all trained to in Wraparound CORE training (Day 3) and Safety Plan Training. This is also trained to in Flex Funds ISR in OCIMS training. Please refer to Direct Services contract Attachment A, page 11, section 2.46.1; page 12 2.51; page 18/19, section 2.87; page 20, section 3.1.2; page 21, section 3.1.4; page 23, section 5.3; page 40, section 9.3.1.13; page 45, section 10.1.8.1; page 59, section 17.7.1.2; page 79, section 18.2.8.2. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas.
1.5b
Staff receive ongoing training and coaching in providing flexible and creative and highly individualized services and strategies. These efforts are observed in the various trainings such as in our OCIMS training, monthly POC Presentations, monthly Site Support visits, Professional Growth Trainings for YP, PP, CC and Supervisors, monthly Institute Trainings for all role types, New YP/PP/CC & supervisor trainings, CORE trainings, Flex Funds Trainings, Facilitation trainings, Critical Thinking Trainings, SIR Trainings; Utilization Reviews/Site Reviews and Technical Assistance meetings. Please refer to matrix of Trainings and Meetings lists. Please also refer to Direct Services contract Attachment A, page 10, section 2.46; page 11, section 2.46.1, page 12, section 2.51 and 2.52; page 18/19, section 2.87; page 14, section 2.65; page 20, section 3.1.2; page 21, section 3.1.4 and 3.13; page 23, section 5.3; page 40, section 9.3.1.13; page 45, section 10.1.8.1; page 59, section 17.7.1.2; page 79, section 18.2.8.2. While the current contract identifies “interventions” we will be utilizing the term “strategies” synonymously as we move forward and plan to transition to strategies. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas.
1.5c
Care Coordinators (Facilitators) receive ongoing training and coaching in leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences. These efforts are accomplished in the various trainings such as in our OCIMS training, monthly POC Presentations, monthly Site Support visits, Professional Growth Trainings CC and Supervisors, monthly Institute Trainings for all role types, New CC & Supervisor Trainings, CORE Trainings, Flex Funds Trainings, Facilitation trainings, Critical Thinking Trainings, SIR Trainings; Utilization Reviews/Site Reviews and Technical Assistance meetings. Please refer to matrix of Trainings and Meetings lists. Please also refer to Direct Services contract Attachment A, page 10, section 2.46; page 11, section 2.46.1, page 12, section 2.51 and 2.52; page 18/19, section 2.87; page 14, section 2.65; page 20, section 3.1.2; page 21, section 3.1.4 and 3.13; page 23, section 5.3; page 40, section 9.3.1.13; page 45, section 10.1.8.1; page 59, section 17.7.1.2; page 79, section 18.2.8.2. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas.
1.5d
HFW plans of care are routinely reviewed and assessed for use of individualized strengths, needs, outcomes, and strategies and for the presence of strategies that capitalize on the assets of the family’s community and informal networks. This is accomplished at monthly POC Presentations attended by WRIT and providers, monthly Site Support meetings, Utilization Reviews/Site Reviews and Technical Assistance meetings. This is also achieved during at Quality Assurance & OCIMS Coordinator and liaison’s spot checks, Wrap Agency supervision. Please refer to Meeting Matrix and Training Matrix. Please refer to Direct Services Contract, attachment A page 14, section 2.65; page 3, section 2.11, page 10, section 2.40; page 11, section 2.44; page 25, section 5.7; Page 15, section 2.69; page 11, section 2.44; page 81, section 19.2; page 59, section 17.7.1.5 -1.8.; page 23, section 5.4.2 through page 26. Wraparound Review and Intake Team (WRIT): A group that includes a parent representative and representatives from SSA/CFS, HCA/Behavioral Health Services, Probation, and Orange County Department of Education. WRIT reviews eligibility for Wrap OC and provides consultation to Wrap OC Provider Agencies through the Family Review Process.
1.5e
Family feedback regarding their experience of receiving customized services is routinely elicited (e.g., through Family Satisfaction surveys, use of the WFI and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes. This is accomplished at monthly POC Presentations attended by WRIT and contracted Wraparound providers/teams, monthly Site Support meetings, Utilization Reviews/Site Reviews and Technical Assistance meetings. This is also achieved during Quality Assurance & OCIMS Coordinator and liaison’s spot checks, and Wraparound Agency supervision. Please review to list of meetings and trainings matrices. The family’s satisfaction is achieved through review of Family Satisfaction Survey responses that are completed at commencement and are conducted by OC SSA contracted agency, Family Support Network. WFI is completed at the 4-month mark. Please see Support Services Contract Attachment A, page 1 1.1.5, page 17, section 2.86, page 18 3.1.4, page 20 3.2.5, page 34 14.11.1.2, 14.11.1.4, 15.4.5.1. Family Satisfaction Survey and WFI is also identified and noted in the Direct Services Contract Attachment A, page 18, section 2.86; page 20; page 21, section 3.2.4; pages 23-26; page 34; page 39; page 60; page 63, section 17.7.3.4; 17.7.1.17; page 76, section 17.7.7; page 80, section 18.2.8.7. Feedback is provided to Program Directors regarding responses in order to assist with Quality Assurance and providers are expected to share trends with staff in order to collaborate and ensure quality assurance. Please see listing of Meeting Matrix.
1.6 Use of Natural and Community Based Supports
1.6a
A natural and community supports inventory is developed and updated for every family during POC development, at monthly POC Presentations, and monthly Site Support meetings. This is also achieved through the following trainings: Core Training (Day 2), OCIMS training, and a Natural Supports Training that has been developed and attached. Please refer to Meeting Matrix and Direct Services Contract, Attachment A pg. 59, section 17.7.1.5 and 1.6.
1.6b
Staff receive ongoing training and coaching identification, engagement, and integration of natural supports in the HFW process and in decreasing reliance on formal supports. This accomplished through OCIMS training, monthly POC Presentations, monthly Site Support meetings, Professional Growth Trainings for all role types (YP, PP, CC, and Supervisor), monthly Institute Trainings, CORE trainings, Flex Funds Training, Utilization Reviews/Site Review, trainings and TA’s. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to the Direct Services Contract, Attachment A, page 76- 80, entire section 18.
1.6c
HFW plans of care are routinely reviewed and assessed for the inclusion of natural supports in the plans and for use of community and natural supports in the assigning of strategies and action items. This is accomplished in monthly consults, monthly POC Presentations, monthly Site Support meetings, Utilization Reviews/Site Reviews, and TA meetings. QA & OCIMS Coordinators and liaison’s spot check cases as well. This is also achieved through Wrap Agency supervision. Results of WFI are also shared regularly with providers. Please refer to Meeting Matrix and Trainings Matrix. Please also refer to Direct services contract, Attachment A, 17.7.1.2; page 73, 17.7.7.14; page 74, 17.7.16. At assignment of referrals, WRIT identifies natural supports the team can start engaging the family with. WRIT also assesses for natural supports at commencements and provides feedback prior to approving commencements to each team.
1.6d
Family feedback regarding their experience of having natural supports engaged on their team is routinely elicited (e.g., through satisfaction surveys and use of the WFI). It is also used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes. Other forums that are also used include QA monthly Progress Reports, CORE (day 4 training). Please refer to CORE power points and corresponding agendas. Please also refer to Direct Services Contract, Attachment A, page 18, section 2.86, page 60; section 17.7.1.17; page 63, section 17.7.3.4; page 75, section 17.7.7.30; page 80; section 18.2.8.7. You may also refer to Support Services contract page 1, section 1.1.5; page 17, section 2.86; page 19, section 3.1.4; page 20, section 3.2.5; page 23, section 7.2; page 25, section 9.1.1.7; page 26, section 9.1.2.5; page 34, sections 14.11.1.2; 14.11.1.4; page 39, section 15.4.5.11.
1.7 Culturally Respectful and Relevant
1.7a
A strengths, needs, culture discovery is completed before the HFW plan of care is developed and is clearly documented in the child or youth’s case file. This is accomplished during the Strength’s Chat, Needs Gathering, CANS completion, and when OC SSA Liaison’s conduct WRAP Consults. This is also trained to in POC training, CORE training (day 2 & 3), OCIMS training (day 3) which addresses documentation requirements. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to the Wraparound referral. Please also refer to Direct Services Contract, Attachment A page 12, section 2.51; page 14, section 2.64 and 2.65; page 21, section 3.1.4; page 23, section 5.4.1 and 5.4.2; page 24, all of section 5.6 and section 5.7.
1.7b
Staff receive ongoing coaching and training in the elicitation and use of family and culture in planning and service delivery and in providing culturally respectful and relevant strategies. This is accomplished via OCIMS training, monthly POC Presentations, monthly Site Support visits, Professional Growth Trainings for all role types (CC, YP, PP, and Supervisor), monthly Institute Trainings, New YP/PP/CC & Supervisor trainings, CORE trainings, Flex Funds Trainings, Facilitation trainings, Utilization Reviews/Site Reviews and Technical Assistance mtgs. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also see Direct Services Contract- page 22, section 5.3; page 26, section 5.13, page 27, section 5.17.1 page 57, section 17.1; page 6, section 2.24; page 6, section 2.24 and 2.25; page 13, section 2.56.
1.7c
Feedback from families regarding their experience of culturally relevant and respectful services and strategies is routinely elicited (e.g., through satisfaction surveys, use of the WFI quality assurance phone calls and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes. Other forums that are also used include QA monthly Progress Reports, CORE (day 4 training). Please refer to Training matrix, example of monthly progress report. Please refer to the Trainings Matrix and Meetings Matrix along with CORE power points and corresponding agendas. Please refer to Direct Services Contract, Attachment A – page 18, section 2.86; page 60, section 17.7.1.17; page 63, section 17.7.3.4; page 75, section 17.7.7.30; page 80, section 18.2.8.7. You may also refer to Support Services contract page 1, section 1.1.5; page 17, section 2.86; page 19, section 3.1.4; page 20, section 3.2.5; page 23, section 7.2; page 25, section 9.1.1.7; page 26, section 9.1.2.5; page 34, section 14.11.1.2 and 14.11.1.4; page 39, section 15.4.5.11.
1.8 High-Quality Team Planning and Problem Solving
1.8a
Team agreements are created for each HFW team and documented in the Orange County Intervention Management System (OCIMS) database for each case. This is observed in the CFT Agenda, Meeting Notes, POC, ECFT Agenda, and trained to in Facilitation Training, OCIMS training, and CORE training. Please refer to Training Matrix which includes OCIMS training requirements and POC documents. Please also refer to OCIMS power points and agenda. Please also refer to Direct Services Contract, Attachment A, page 2, section 2; page 14, section 2.65; page 23, all sections in 5.4; page 244, section 24; page 25, section 5.7; page 44, section 10.1.3; page 47, section 12.2, to 12.4 (all of section 12.4); page 60, section 17.7.1.17; page 64, section 17.7.3.16; page 67, all of section 17.7.5; page 72, section 17.7.7.7; page 75, section 17.7.7.27; page 78, section 18.2.3.1; page 79, section 18.2.8.
1.8b
Feedback from families and HFW team members regarding their experience of team engagement and collaboration is routinely elicited (e.g., through meeting observation, satisfaction surveys, and use of the WFI. WFI results are shared routinely with contracted providers so they can directly observe trends. Family Satisfaction Surveys are completed regularly and in the 4th month of an open Wraparound case. The Wraparound Quality Assurance Staff Specialist sends out Monthly reports and feedback is shared with contracted provider agencies, including direct quotes so that providers can observe progress made and areas for improvement. This is also trained to in OCIMS Day 3 training which can be observed in the OCIMS power point and corresponding agenda. This is also trained to in Wraparound CORE training, Day 4 and can be observed in the CORE power point and corresponding agenda. Please also refer to Direct Services Contract Agreement, Attachment A, page 18, section 2.86; page 60, section 17.7.1.17; page 63, section 17.7.3.4; page 76, section 17.7.7.30; page 80, section 18.2.8.7. Please also refer to Support Services Contract Agreement, Attachment A, page 1, section 1.1.5; page 17, section 2.86; page 19, section 3.1.4; page 20, section 3.2.5; page 23, section 7.2; page 25, section 9.1.2.4; section 9.1.1.7; page 26, section 9.1.2.5; page 33, 14.11.1.2; page 33, section, 14.11.1.4; page 34, section 14.11.1.2; and section 14.11.1.3; page 39, section 15.4.5.11;
1.8c
This feedback is used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes. WFI results, Family Satisfaction Surveys and Monthly reports are shared regularly with contracted Wraparound provider agencies, including direct quotes. Providers are expected to address any barriers or issues in their staff meetings, individual supervision meetings. These concepts are trained to in OCIMS Day 1-3 training, CORE, Day 1-4 training, Professional Growth Trainings, Facilitation, Critical Thinking Training . Results are also reviewed during monthly-Site Support Visits, Technical Assistance Meetings, and POC Presentation Meetings. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 15, section 2.69; page 2, section 2; page 11, section 2.44; page 52, section 13.1.4; page 61, section 17.7.1.20; page 65, section 17.7.4.7
1.8d
HFW plans of care and meeting minutes are routinely reviewed and assessed for shared ownership and follow through on strategies and action items. This is accomplished through the development and review of CFTM Agenda Notes (Wraparound Provider Supervisors review and QA Staff Specialists reviews for thorough completion and documentation), Technical Assistance Notes, POC Presentation Meetings, Site Support Visits, and is trained to in CORE training Day 3. Please refer to Training matrix, Meeting Matrix. For review of expectations for Wraparound Supervisors, please also refer to Direct Services Contract Agreement, Attachment A, page, 4, section 2.9 to 2.11; page 14, section 2.65 and 2.65.1page 47, section 12.4; section; page 68, section 17.7.6
1.9 Outcomes Based Process
1.9a
The HFW plan of care includes specific, measurable strategies and action items with timeframes. This is trained to at the OCIMS Day 2, training, Wraparound CORE training, Day 3, Professional Growth Trainings, and Critical Thinking Trainings. This is also regularly addressed at monthly Site Support Visits, Technical Assistance Meetings, POC Presentation Meetings, and reviewed in Team Action Forms. Please refer to Training Matrix, Meeting Matrix, OCIMS power point and agenda, and CORE training power point and agenda. Please also refer to Direct Services Contract Agreement, Attachment A, page14, section 2.65; page 20 section 3; page 21, section 3.3;
1.9b
Action item completion is tracked by Care Coordinators and updated at HFW team meetings, or more often as needed. This is accomplished through the development of Team Action Forms, POCs, monthly CFT, ECFTMs, and addressed at monthly Site Support meetings and in Safety Plans. Please refer to Meeting Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 4, section 2.9; page 14, section 2.65; page 15, section 2.71; page 20,section 3.1.5; page 23, section 5.4 and 5.5; page 24, section 5.6; page 29, section 6.8, 6.9 to 6.20.
1.9c
Forms and processes allow strategies and action items to be adjusted or changed as needed and processes are in place to communicate this to all team members. Monthly CFTMs and EFCTMs that are documented allow for updates or changes as needed. TA meetings, monthly POC meetings, monthly Site Support meetings, yearly Utilization Reviews/Site Reviews and feedback received from that process are reviewed and discussed in multilayer meetings with all levels. Feedback from all these meetings is requested and suggestions on how to amend forms and documents are made throughout the whole process. Wraparound OC has a very collaborative process from the very top Wraparound administrative levels to case carrying staff. As a result, the same process are afforded youth and families. It is a very open and flexible process which allows for feedback and pivoting. If a gap is identified in a process, an opportunity is quickly identified in order to address a gap or process. This is in reference to youth and families and team as well as to all partners and processes within Wraparound OC. Please refer to Meeting Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 15, 2.71, page 20, 3.1.5, page 23, 5.4.1 to 5.4.7
1.9d
There is a process in place for who will complete the IP-CANS and how the IP-CANS will be shared amongst all team members. The Care Coordinator completes the CANS and the Wraparound Supervisor ensures completion of the CANS and ensures a copy was provided to the youth and families and referring party (Social worker, probation officer, etc). The Wrapround Clinician reviews for accuracy as well. Please refer to Direct Services Contract Agreement, Attachment A, page 68, section 17.7.6.8. Please also refer to Amended Direct Services Contract Agreement, Attachment A, page 9, section 2.65.
1.9e
Data from the IP-CANS is used to support tracking and team decision-making, but does not replace using tracking of needs, goal completion, and action item completion to plan for transition. This is accomplished in monthly CFTMs, ECFTMs, and the development of POCs. This is also trained to in Core Training Day 3, POC training, OCIMS training Day 2, MediCal Eligibility Training Day 2. Please see Training Matrix and Meeting Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 68, 17.7.6.8
1.10 Persistence
1.10a
Teams are supported to keep working with a youth and family even when faced with setbacks or limited progress until the HFW team agrees that services should end. This is accomplished through monthly review of CFTMs, EFTMs and is addressed at monthly Site Support meetings with each provider, monthly POC meetings. This is also trained to in CORE training Day 1-4, OCIMS Day 3, New CC, YP and PP training and in Technical Assistance calls. On a consistent and monthly basis, Wrapround Child Welfare Liaisons and QA Staff Specialist provide feedback with opportunities to review cases for commencement by providing feedback to encourage teams to continue working with families. The WRIT team meets to review engagement efforts and when deemed appropriate, declines to approve closing a case until it is clear all efforts have been completely and thoroughly vetted and engaged in, in order to collaborate with the family. Please refer to Meeting Matrix and Training Matrix. Please also refer to OCIMS and CORE power point and agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 5, section, 16; page 24, section 5.4.4.
1.10b
There are clearly defined processes for teams to access help when facing challenges including how to request additional coaching or supervision, how to access/request flexible funding, and how to access additional support. This is accomplished through Technical Assistance meetings, monthly Site Support meetings, OCIMS Training, CORE Training Days 1-4, Institute Trainings, Flex Fund Training, Supervision at each training and Supervision. Please refer to the Matrix of all the trainings and Meetings Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 9, section 2.34; page 11, section 2.46; 20, section, 2.93; page 21, section 3.3.2; page 27, 5.16.3; page 32, section 6.17.4; page 38, all of section 9; page 44, section 10.1.4
1.10c
Care Coordinators (Facilitators) receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision. This is accomplished through the various trainings put in place for Care Coordinators and all role types. This is alco accomplished CFT training, Facilitation Training, monthly Site Support, POC meetings, at Wraparound CORE trainings Day 1-4, Technical Assistance calls and providing feedback to encourage to continue working with families, OCIMS Day 3, Professional Growth trainings for CC, YP and PP trainings, and Institute Trainings. Please refer to the Matrix of all the trainings and Meetings Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 69, section 17.7.6.10; 17.7.6.12; 17.7.6.16 to 17.7.6.34; page 73, 17.7.7.15; pages 75 to 80
1.11 Transitions as a part of the Fourth Phase of HFW
1.11a
HFW teams provide transitions and families do not experience sudden loss of services due to adverse events or due to administrative requirements. The Wraparound OC team works diligently to ensure that families are afforded transitions and at no time are cases closed/commenced for administrative reasons or due to caseload sizes. This is a accomplished through developing regular and frequently updated POCs and is trained to in Wraparound Core training 1-4, at monthly Site Support meetings, New POC training, POC monthly Presentations, New CC and New YP, OCIMS days 2 and 3. Please refer to the Matrix of all the trainings and Meetings Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 23, section 5.4; 5.5; page 32, section 6.17.6; page 39, 41.2, page 3, 2.5
1.11b
Transitions out HFW are celebrated according to the youth and family’s culture, values, and preferences and administrative structures are supportive of engaging in celebration including access to flex funds, accommodating staff time for community resourcing, developing community partnerships, and ensuring staff are available to attend celebrations. This is accomplished through POCs, assessed and encouraged at monthly Site Support Meetings and POC Presentations. This is also trained to in Wraparound Core training, day 1-4, New CC and New YP, OCIMS days 2 and 3, Flex fund training, New POC training. Please refer to the Matrix of trainings and Meetings Matrix. Please also refer to CORE and OCIMS power points and respective agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 5, section 2.16; page 9, section 2.34; page 11, section 2.46; page 38, section 9 to 9.5.3. Transitions out of HFW are strongly supported and encouraged.
Expected Outcomes
2.1 Youth and Family Satisfaction
Policies and procedures are in place to record and evaluate youth and family satisfaction with their HFW experience. This is addressed in Wraparound Core Training Day 4, Overview Training, and OCIMS Training Day 3. Please see Training Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 15, section 2.72, page 16. 3.2.4; page 18, section 2.86; page 21, section 3.2.4. Please also refer to Support Services Contract Agreement, Attachment A, page 14, section 2.72; page 19, section 3.1.4; page 20, section 3.2.4; page 23, section 7; page 26, section 9.1.2.4;
2.2 Improved School Functioning
Youth experience improved educational and vocational functioning as a result of their involvement in HFW. They have more consistent attendance, are participating at or above grade level or according to their educational plan, and/or are developing needed vocational experience. Our PNP contract is in place in order to refer youth that are in need of tutoring. Attendance and performance in school is assessed. This also accomplished at initial referral by the Wraparound Child Welfare Liaisons who assess for any educational deficiencies and again when Teams meet for a face to face with the family. This is accomplished at the CFT’s, POCs, CFTMs. Improved educational and vocational functioning is assessed in commencements, Utilization Reviews/Site Reviews. Please refer to the Matrix of all the trainings and Meetings Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 7, section 2.30 and 2.31; page 13, section 2.56; page 18, section 2.82 to 2.83; page 19, section 2.90; page 26, section 5.13; page 27, section 5.19; page 53, section 14.1, page 59, section 17.7.1.5; page 60, section 17.7.1.13; page 63, section 17.7.3.7; page 73, section 17.7.7.8 and 17.7.7.12; page 25, 25.4.1; page 20, 3 to 3.4; page 6, section 3. Please also refer to the Provider Network Program Tutoring Services contract, Attachment A, page 6, section 3. Lastly, please refer to the Wraparound referral form.
2.3 Improved Functioning in the Community
Youth experience improved functioning in the community as a result of their involvement in HFW. Policies and procedures are in place to record and evaluate the level of justice involvement and engagement with community activities. This is achieved through the development of individualized POCs. This is also trained to at Wraparound Core training, days 1-4, New POC training, New CC and New YP trainings, OCIMS days 1 and 3 training, Professional Growth Trainings, and Institute Trainings. This is also addressed at monthly Site Support meetings and monthly POC Presentations. This is ultimately reassessed at commencement when WRIT reviews proposed commencements and critically assesses to ensure that the youth have been encouraged and supported to engage in community activities and events to ensure they have built up natural supports, in their community. Please refer to the Matrix of the trainings and Meetings Matrix. Please also refer to Core and OCIMS Power points and agendas. Please also refer to Direct Services Contract Agreement, Attachment A, pages 75 to 79.
2.4 Improved Interpersonal Functioning
Youth and their families experience improved interpersonal functioning as a result of their involvement in HFW. There is less stress and strain at home attributed to them and they are able to develop or maintain positive family relationships and friendships. These concepts are identified in the CFTMs and trained to in Wraparound CORE training, Day 2 & 3, YP and PP professional Growth Training, and monthly Institute Trainings for all role types. The WFI survey and Family Satisfaction survey captures youth and families assessment of the impact of collaboration with HFW team on their functioning. This is also assessed through CANS and again at Commencement when the WRIT team assesses for progress made. Please refer to the Matrix of all the trainings and Meetings Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 24, section 5.6 & 5.12 and page, 21, sections 3.2 -3.3; page 18, section 2.86; Please also refer to Support Services Contract Agreement, Attachment A, page 1, section 1.1.5; page 17, section 2.86; page 19, section 3.1.4; page 20, section 3.2.5; page 23, section 7.2; page 24 5.6 & 5.12; page 21, section 3.2 -3.3; page 25, section 9.1.2.4; section 9.1.1.7; page 26, section 9.1.2.5; page 33, 14.11.1.2; page 33, section, 14.11.1.4; page 34, section 14.11.1.2; and section 14.11.1.3; page 39, section 15.4.5.11
2.5 Increased Caregiver Confidence
Families have access to effective needed services and supports. Caregivers feel increased confidence in their ability to manage future problems and they know how to find and access services and effectively address crises. This is accomplished in creating individualized plans during CFT and CFTMs. This is also trained to in Wraparound CORE Days 2, 3 & 4 trainings, YP and PP professional Growth Trainings, and Institute Trainings. This is also assessed through feedback in the WFI and Family Satisfaction surveys, reassessment in CANS and at Commencement. Progress is also discussed during monthly POC Presentations, and monthly Site Support meetings. Please refer to the Matrix of all the trainings and Meetings Matrix along with Core Wraparound Training power points and corresponding agenda. Please also refer to Direct Services Contract Agreement, Attachment A, page 15, section 2.72; page 21, section 3.2.4; page 21, section 3.3; page 11, section 2.47; page 12, section 2.51; 2.52; page 16, section 2.73; page 16, section 2.75, page 20, section 3.1.2 – 3.1.5 . Please also refer to Support Services Contract Agreement, Attachment A, page 1, section1.1.5; page 14, section 2.72; page 19, section 3.1.4; page 20, section 3.2.4; page 23, section 7; page 26, section 9.1.2.4; page 33, section 14.11.1.1; page 34, section 14.11.1.4; page 39, section 15.4.5.11.
2.6 Stable and Least Restrictive Living Environment
Youth experience permanency and stability in their community-based living situation. Youth do not experience a new placement in an institution (such as detention, psychiatric hospital, treatment center, or STRTP) and/or have not moved between residential settings. The OC SSA Quality Assurance Staff Specialist tracks placement changes for youth. At the time of commencement, OC Wraparound experiences an average of 88% of youth remain in a family-based setting at the time of commencement. This is tracked on a monthly basis. This is accomplished by ensuring that Individualized CFTMs are provided to ensure that individualized needs an strengths are provided and met. This is also trained to at Wraparound CORE training Days 1-4, monthly Institute trainings, (PP-YP-CC Supervisor) Professional Growth Trainings. This is also addressed in the following meetings: monthly POC presentations, monthly Site Support meetings, upon review of proposed Commencements, Safety Plan meetings, Technical Assistance meetings, Utilization Review/Site Reviews meetings. Please refer to the Matrices of Trainings and Meetings. Please also refer to Direct Services Contract Agreement, Attachment A, page 11, section 2.51 and 2.52; page 16, section 2.73; page16, section 2.74; page 16, section 2.75; page 18, section 2.87; page 19, section 2.91; page 20, 3.1.2; page 20, section 3.1.4; page 22, section 5.3; page 23, section 5.4; page 24, section 5.4.4; page 27, section 5.21; page 29, section 6.8.6; page 31, section 6.11.4; page 44, section 10.1.4; page 49, section 12.4.1.18A; page 58, section 17.7.1.2; page 59, section 17.7.1.6; page 73; section 17.7.7.14; page 74, section 17.7.7.16; page 11, section 2.47; page 21, section 3.2 -3.3
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Youth experience stability with regard to their behavioral health, necessitating fewer or no visits to the hospital. This is trained to and assessed at Emergency CFTMs, CANS, and Safety planning. This is also trained to in Wraparound CORE training, day 4, MediCal Training provided after Core training, in OCIMS training, monthly Institute training and Professional Growth trainings for each role type (YP,CC, and Supervisor trainings). This is also thoroughly evaluated in collaboration with behavioral health – HCA and again at Commencement. Wraparound teams are expected to enter information regarding placement changes into the OCIMS database and is tracked on placement changes. This is trained to in ECFTM, CANS, Safety planning – CORE day (4) resources – MediCal Training, OCIMS, Institute and Professional Growth – Collaboration with HCA – Commencement. Please refer to the Matrix of all the trainings and Meetings Matrix as well as OCIMS and Core Power Point Trainings and corresponding agendas.
2.8 Reduction in Crisis Visits
Youth and natural supports are able to avert most crises and manage most impending crises without professional support safety planning. This is trained to in monthly Institute Trainings, the various Professional Growth trainings for each role type (YP-PP-CC) and consulted on during monthly Site Support meetings and monthly POC Presentations. Please refer to the Trainings Matrix and Meetings Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 29, sections 6.8 to 6.12; page 36, sections 8.2-8.6; page 102, section 17.7.1.15; page 105, section 17.7.3.5 and 17.7.4.4; page 111, section 17.7.6.18.
2.9 Positive Exit from HFW
Youth and their families exit HFW based on stabilization and adequate progress in meeting needs; youth, and families are not discharged from Wraparound due to an adverse event. This is accomplished by having a careful review of all progress reports and review of proposed Commencements prior to a case closing. Once all members of the Wraparound team are in agreement with commencement, the Care Coordinator prepares a commencement which a Wrapround supervisor reviews and approves. The Cases are reviewed by the WRIT team composed of Child Welfare Supervisor Liaisons, Probation staff, and Health Care Agency staff in order to ensure that services and supports are in place and that all efforts are truly exhausted and that progress on goals was achieved. This is also trained to in Wraparound CORE Training, OCIMS day 3 training and the various professional growth trainings for each role type. This is also addressed at monthly Site Support meetings and monthly POC Presentations. Please refer to the Trainings Matrix and Meetings Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page Contract page 23, section 5.4; 5.4.4; page 24, section 5.5; page 24, section 5.5; page 25, section 5.6; page 32, section 6.17.5; page 47, section 12.4; page 49, section 12.4.1.17; page 69, section 17.7.6.7; page 72, section 17.7.7.3; page 80,m section 18.2.8.2; page 80, section 18.2.8.5; page 4, section 2.9; page 11, section 2.46.1. Page 23, section 5.4.4 specifically outlines that the team is to support the family versus abandoning the family to move toward maximum positive functioning, free from reliance on formal supports.
Engagement
3.1 Orientation
3.1 a
All families engaging in Wraparound Services receive an overview of the principles and phases of Wraparound. Assigned Senior Social Workers are expected to review Wraparound with families, prior to referring and upon referral, Wraparound team members review principles with the family and explain the process and expectations. This is trained to through Wraparound Overview Training, which is provided prior to CORE training, in CORE Wraparound training, day 1, OCIMS training day 1, at monthly Institute Trainings. This is also addressed at monthly Site Support meetings, at Technical Assistance meetings, monthly POC presentations, Utilization Review/Site Reviews meetings, and at Initial F2F Meetings. Please refer to the Trainings Matrix and Meetings Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 76, section 18.2.1, page 23, section 5.4.
3.1b
All staff engaging in Wraparound Services receive training on legal and ethical considerations and are expected to communicate these to families. These expectations are laid out in the accomplished the following trainings: Wraparound CORE Training, day 1, Overview Training, OCIMS day 1, monthly Institute Trainings, Critical Thinking trainings, Professional Growth Trainings for all role types (CC, YP, PP, and Supervisor), Institute Trainings, MediCal Training (Fraud Waste and Abuse). This is also addressed at Monthly Site Support meetings, TA meetings, monthly POC presentations, Utilization Reviews/Site Reviews, and Initial F2F Meetings.
3.1c
All staff engaging in Wraparound Services receive training on the role of each team member including the family and natural supports and Tribes in the case of an Indian child and are expected to share this with families. This is accomplished through providing trainings such as Wraparound CORE Training, Natural Supports training, separate trainings for each new role type, NEW CC, YP, and PP Trainings. This is also addressed in monthly POC presentations, and during development of Safety Plans and Initial F2Fmeeitngs. Please refer to the Trainings Matrix and Meetings Matrix. Please refer to OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 58, section 17.7.1.2
3.2 Safety and Crisis stabilization
3.2a
Initial crisis and safety concerns are discussed during engagement. If pressing concerns are brought forward, the team develops an immediate crisis response plan which is provided to the family and is documented in the OCIMS database. This is accomplished through ECFTMs, Safety planning, CFTs, Initial F2F meetings, monthly POC Presentations, monthly Site Support meetings. This is also trained to in Wraparound CORE training, day 1 – 2, OCIMS training, MediCal Training, and Critical Thinking Training. Please refer to the Trainings Matrix and Meetings Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 23, section 5.4 and page 25, section 5.7.
3.2b
The crisis plan is used to inform, but not replace, the HFW Safety Plan developed during the Plan Development phase. This is accomplished through ECFTMs, Safety planning, CFT (Add to existing Safety Plan). Additionally each WRAP provider has an Crisis 24/7 on call procedure. All crisis plans are added to the existing safety Plan. This is also addressed at monthly POC Presentations, monthly Site Support meetings. This is also trained to in Wraparound CORE training, days 1 – 2, OCIMS training, and MediCal Training. Please refer to the Trainings Matrix and Meetings Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 5; sections 2.22- 2.22.2; page 14, sections 2.65- 2.65.1; page 15, sections 2.51.
3.2c
All families are provided with information regarding how to access 24/7 crisis response when needed. During the WRAP Intake (1st Face-2-Face), teams provide information to families. This is also addressed in CFTMs in the Engagement Phase and reiterated in all Safety Plans. This is also trained to in Wraparound Core training, day 3 (replace “Team Contact/Emergency Contact Information” to “24/7 Crisis response” and in OCIMS Training, Day 2. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 22, section 4.3 and page 27, sections 5-20.
3.3 Strengths, Needs, Culture and Vision Discovery
3.3a
A Family Vision is completed with every family and documented in the youth’s chart in the OCIMS database during the Engagement phase. This is competed during the Strengths gathering, Initial CFTM. This is also trained to in Wraparound CORE Training, Day 1 and OCIMS training, day 2. This is also addressed in monthly POC Presentations and assessed for in Utilization Reviews/Site Reviews. Please refer to the Trainings Matrix and Meetings Matrix, along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 14, section 2.65-2.65.1; page 23, section 5.4.2; page 24, section 5.6.2; page 25, section 5.8; page 32, section 6.17.5.
3.3b
A Strengths, Needs, Culture Discovery document is initiated with every youth, and family, is included in the youth’s chart, is updated at least every 90 days, and the team adds new strengths, needs, and cultural preferences as they are discovered. The document is provided to new team members as they are identified. This is accomplished through Strength’s Gathering, Initial CFTMs. During the development of Plans of Care. Subsequent CFTMs and POCs. This is trained to in Wraparound CORE Training, Day 1, OCIMS training, day 2 and New CC Training. This is also assessed during monthly POC Presentations, Utilization Reviews/Site Reviews. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 44, section 10.1.5; page 12, section 2.51; page 12, section 2.65; page 23, section 5.4.1-5.4.2.
3.4 Engage All Team Members
3.4a
A natural supports inventory is completed with all youth and families and is documented in the child or youth’s case file. This is accomplished throughout the life of every open Wraparound case; Strength’s Gathering, Intake (F-2-F), CFTMs. This is also trained to in Wraparound Core training, day 3, New CC training, OCIMS Training- day 2, Professional Growth Training (Supervisor, CC, PP, & YP). This is also reviewed and assessed at Commencement to ensure that the youth and family have sufficient and well-documented natural supports. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 59, section 17.7.1.2; page 73, section 17.7.7.14
3.4b
Children’s System of Care partners are identified, included, and engaged in the HFW team. This is accomplished through CFTMs, monthly POC Presentations, Consultations, TA Meetings, Intake (F-2-F), development of POCs, and monthly Site Support visits. This is also trained to at Wraparound Core training, day 2, OCIMS training, day, New CC trainings. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 11, section 2.44; page 80, section 18.6.
3.4c
The HFW team works with the youth and family to identify potential team members (including formal, natural supports and Tribes, and discusses their role on the team. This is accomplished at Strength’s Gathering, Intake (F-2-F), CFTMs. This is also trained to in Wraparound Core training, day 3, New CC training, OCIMS Training, day 2, and Professional Growth Trainings (Supervisor, CC, PP, & YP). Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 23,section 5.4.2; page 32, section 6.16 & 6.17.4.
3.4d
Engagement and team building activities are documented in the youth’s file in OCIMS database. This is trained to in OCIMS Training, day 1, 3 & 4, Wraparound CORE training, day 1, MediCal training, Facilitation Training, and CC Professional Growth. This is also completed following CFTMs during the Engagement Phase. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 23, section 5.4.1; 26, section 5.15. page 77, section 18.2.1.1
3.5 Arrange Meeting Logistics
3.5a
Staff are flexible in working hours and scheduling meeting times and locations to accommodate family and Wraparound Team needs. This is trained to in Wraparound CORE training day 1, New CC training, OCIMS Training, days 1, 2 & 3. This is also addressed during monthly Site Support Visits. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 21, section 4; 35, section 54.2; page 29, section 6.5; page 45, section 10.1.8.1; page 62, section 17.7.2.8
3.5b
Staff are trained to work collaboratively with families and the other members of the HFW team to schedule meetings that are in alignment with family needs and preferences as well as maximizing participation. This is trained to at Wraparound CORE training, day 1 and 2, New CC training, OCIMS Training, days 1,2 and 3, and Institute Trainings. This is also addressed at monthly Site Support Visits. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 20, section 3 (all); page 25, section 5.9; page 26, section 5.15; page 35, section 54.2; page 29, section 6.5; page 44, section 10.1.4; page 45, section 10.1.8.1, page 62, section 17.7.2.8; page 11, section 2.44; page 16, section 2.73.
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
4.1a
Before the HFW plan of care is developed, team agreements, a team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file. This is completed through Strength’s Gathering and Initial CFTMs. This is also CORE Training- Day 1, 2 & 3, OCIMS training- day 2, Facilitation training, New CC Training, New PP Training. A Team Mission statements is also completed and documented in the OCIMS database. Please refer to Direct Services Contract, Amendment, page 12 5.4.2. While the current POC does not include a Mission Statement, it does include a Vision statement. OC SSA plans to incorporate a Mission statement into the POC in addition to the current vision statement. Currently the database that OC SSA utilizes is set up to upload the Vision statement. The OCIMS database currently used cannot easily and readily be upgraded without completing a major enhancement. For the time being, the mission and vision will be included in one section, in the current POC form, in order to comply with the standards. Given that CWS CARES is expected to rollout this year in October 2026, OCSSA IT department has advised that they cannot easily make changes to our OCIMS database system to incorporate the Mission statement as this would be categorized as a Major Enhancement. Given competing priorities with the expected rollout of CARES, OCIT expects to be able to begin a major enhancement to make changes to OCIMS to accommodate new POC changes in April 2027. As a result, OC SSA intends to use the same POC with the Mission statement being added to the Vision section for now until OC SSA can update OCIMS to mirror the updated draft POC. Please see attached POC currently being utilized and Draft POC with Mission statement included. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 14, sections 2.65-2.65.1; page 23, section 5.4.2; page 32section 6.17.5.
4.1b
The youth’s and family members’ strengths identified in engagement are updated to reflect any additionally discovered strengths as they are identified regularly in the regularly updated POCs, CFTMS and ultimately documented and uploaded into the youth’s files in the OCIMS database. This occurs at Strength’s Gathering, and monthly CFTs. This id also trained to at CORE Training- Day 1, 2 & 3, OCIMS training, day 2, Facilitation training, New CC Training, New PP Training and in ongoing 1:1 meetings. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 14, section 2.65; page 23, section 5.4, 5.5, 5.6, 5.7, 5.8. 5.9, page 29, section 6.8; 6.8.8; page 30, section 6.9; 6.10, page 32, section 6.17.6.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
4.2a
Before the HFW plan of care is developed, underlying needs are identified and prioritized for each family and are documented in the youth’s file in the OCIMS database. This is accomplished during Wrap Consult when the Child Welfare Supervisor Liaisons complete a consult for prospective Wraparound cases that have been referred by Probation, Health Care Agency or Child Welfare in OC. This is also accomplished during the initial Contact (face to face) and initial CFT. This is also trained to during CORE, Day 3 training and OCIMS, Day 1& Day 2 training. This is also accomplished during Site Support meetings and POC Presentation Meetings. Please also refer to Wraparound referral form which clearly documents information gathering. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to the Direct Services Contract Agreement, Attachment A, page 4, section 2.11; page 7, section 2.30; page 10, section 2.40, page 11, section 2.46.1, page 12; section 2.51; page 14, section 2.64 & 2.65; page 16, section 2.73; page 20, section 3.1.2; page 21, section 4.1, page 22, section 4.3 and 5.3; page 23, section 5.4.1 and 5.4.2.
4.2b
Measurable goals and outcomes are developed from these identified needs (as opposed to behavior or deficit-based goal development) which is accomplished during Wrap Consults when the Child Welfare Supervisor Liaisons complete a consultation for prospective Wraparound cases that have been referred by Probation, Health Care Agency or Child Welfare in OC. This is also accomplished during the initial contact between the Care Coordinator and reporting party (Social Worker, Probation officer or HCA staff). This also accomplished during the initial face to face contact between the reporting party and Care Coordinator, and initial CFT with the family. This is also trained to during CORE- Day 2 & Day 3, OCIMS training, Day 1 & Day 2. This is also accomplished during Site Support and POC Presentation Meetings. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to the Direct Services Contract Agreement, Attachment A, page 4, section 2.11; page 7, section 2.30.1; page 10, section 2.40; page 11, section; 2.46.1, page 12, section, 2.51; page 14-2.64 & 2.65. page 16, section 2.73; page 20, section 3.1.2; page 21, section 4.1; page 22, section 4.3 and 5.3, page 23, sections 5.4.1 and 5.4.2; page 27, section 5.19; page 28, section 6.3; page 32, section 6.17.4; page 38, section 9.1; page 59, sections 17.7.1.7 and 17.7.1.8; page 63, section 17.7.3.2.
4.2c
Goals and outcomes are developed collaboratively with the youth, family, and the rest of the HFW team. This is also accomplished during the initial face to face contact between the Care Coordinator and the family and during the initial CFT. This is also addressed during monthly Site Support meetings, monthly POC Presentation meetings, and during Utilization Review/Site Reviews meetings. This is trained to in Wraparound CORE training and OCIMS meetings. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 20, section 3; page 21, section 3.3; page 23, section 5.4; page 2, section 5; page 63, section 17.7.3.2 and 17.7.3.7, page 73, section 17.7.7.8; page 20, section 3.1.
4.2d
Multiple individualized brainstormed strategies are documented in the youth’s file in OCIMS database. This is accomplished through CFT Meeting notes and Meeting Notes (Case Management) documented in the OCIMS database. This is trained to in OCIMS Training- Day 2, CORE training, Day 2, Facilitation Training, MediCal Training and New CC Training. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page, 38, section 9; page 21, section 3.3; page 37, section 8.9; page 44, section 10.1.5.1; page 58, section 17.7.1.1;page 60, section 17.7.1.16, and 17.7.1.17; page 61, sections 17.7.2.2 and 17.7.2.6; page 64, section 17.7.3.14-to 17.7.3.16; page 66, section 17.7.4.12; page 67, section 17.7.5.4; page 68, section 17.7.6.5 to 17.7.6.5.
4.2e
Care Coordinators (Facilitators) are trained to lead teams in identifying, prioritizing, and selecting strategies and developing action items. This is trained to during Facilitation Training, CORE- Day 1 & Day 2. New CC Training. This is also accomplished during initial face to face meetings between the Care Coordinators and family members and is also accomplished during initial and subsequent CFT and CFTM meetings. Please refer to the Trainings Matrix and Meetings Matrix along with CORE power points and corresponding agenda. Please also refer to Direct Services Contract Agreement, Attachment A, page 75, section 17.7.7.25; page 4, section 2.9. page 4, section 2.11; page 23, section 5.4; page 28 to 33, all of section 6.
4.2f
Steps are utilized to develop the individualized HFW Plan of Care in a team-based, collaborative environment which is accomplished during the initial face to face meeting between the Care Coordinator and the family during the intake and all subsequent meetings in CFTS/CFTMs and subsequent POCs. This is trained to during Wraparound CORE, Day 2 training, Facilitation Training and New CC Training. Please refer to the Trainings Matrix and Meetings Matrix along with CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 4, section 2.9 and all of 2.11; page 10, section 2.4; page 11, section 2.44; page 14, section 2.65; page 23, all of section 5.4; page 24 and all of 5.6 to 5.9; page 29, all of section 6.8; page 30, sections 6.9; 6.10; 6.11; page 31, section 6.14; page 32, section 6.17.4; 6.17.6; page 44, section 10.1.4; 10.1.5; page 45, section 10.1.8.1; page 45, section 10.1.8.3; page 72, section 17.7.7.8.
4.3 Develop an Individualized Child or Youth and Family Plan
4.3a
Care Coordinators (Facilitators) receive ongoing training and coaching to engage the team in a planning process that elicits multiple perspectives, builds trust and shared vision, and demonstrates the HFW principles. This is accomplished through various trainings and meetings. All Care Coordinators receive Wraparound CORE training and this is highlighted during Wraparound CORE Training, Day 2. They also receive Facilitation Training, New CC Training, and CC Supervision trainings. This is also accomplished via various discussions during monthly Site Support meetings, monthly Institute Trainings, monthly POC Presentation meetings and yearly Utilization Review/Site Reviews meetings. Please refer to the Trainings Matrix and Meetings Matrix along with CORE training power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page, section page 57, section 2.1, page 58, section 17. 1 & 17.3; page 61, section 17.7.1.21; page 64, section 17.7.13; page 68, section 17.7.6.10, page 70, section 17.7.6.34, page 74, section 17.7.7.26; page 77, section 18.2.3.
4.3b
The Plan of Care comprehensively integrates goals and objectives identified by all Children’s System of Care partners. Care Coordinators are trained to invite all system of care partners. This is trained to during Wraparound CORE- Day 3 training, OCIMS training, DAY 2, and New CC Training. This also occurs during the face to face meeting and Initial CFT/CFTM meeting. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page, 3, section 2.9; page 4, all of section 2.11; 2.12; page 10, section 2.40; section 2.44; page 11, section 2.46; page 14, section 2.65; page 23, all of section 5.4; page 24, all of section 5.6; 5.7; 5.8; page 29, section 6.8; 6.9; page 30, section 6.10; page 31, section 6.14; page 38, section 9; 9.5; page 42,, section 9.6; page 44, section 10.1.6; 10.1.8 As previously mentioned, the current the database utilized to capture Wraparound data (OCIMS Database) cannot easily and readily be upgraded without completing a major enhancement. Given that CWS CARES is expected to rollout this year in October 2026, OCSSA IT department has advised that they cannot easily make changes to our OCIMS database system to incorporate the new Life Domains as this would be categorized as a Major Enhancement. Given competing priorities with the expected rollout of CARES, OCIT expects to be able to begin a major enhancement to make changes to OCIMS to accommodate new POC changes in April 2027. As a result, the following Life Domains will be incorporated in the following sections in order to meet HFW standards: Tribal Connections into Culture, Legal into Money Matters, Developmental into Health and Medical, Finances is already included but is called Money Matters, Relationships into Family Relationships, Independent Living into Living Environment.
4.3c
The Plan of Care is documented in the child/youth’s file in the OCIMS database and is distributed to all team members, and meets all the criteria defined above. This is accomplished through Care Coordinators documenting the POC and distributing the POC during the Initial CFT/CFTM Meetings. This is also trained to in Wraparound CORE Training, Day 3, OCIMS Training-, DAY 2, and New CC Training. Please refer to the Trainings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 4, section 2.9; page 5, section 2.11; 2.34; page 14, section 2.65; page 23, section 5.4; 5.5 and 5.6; all of section 6; page 14, section 2.65.
4.3d
Procedures are in place to review Plans of Care for continuous quality improvement and to provide feedback to staff and supervisors/coaches for training and coaching purposes. This is accomplished through monthly POC Presentation Meetings, CC Supervision at individual contracted providers, monthly Site Support Meetings, Technical Assistance Meetings, Utilization Review/Site Reviews meetings. This is also trained to at Wraparound CORE- Day 3 training, OCIMS Day 2 Training, and Professional Growth trainings for CC and Supervisor roles. This is also accomplished through OC SSA QA Spot Checks. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page, 14, section 2.65; page 69, section 17.7.6.
4.4 Develop a Crisis and Safety Plan
4.4a
An individualized crisis and safety plan is documented in the youth’s file in OCIMS, which identifies potential safety, high risk and crisis situations with proactive and reactive crisis management strategies chosen by the family members and including who should be called for support 24/7. This is accomplished through Emergency CFTMs and Safety planning. Additionally, each Wraparound contracted provider has a Crisis 24/7 on call procedure to ensure families have a quick response to crisis. All crisis plans are added to the existing safety Plan. This is also assessed and discussed for training purposes at monthly POC Presentations, monthly Site Support meetings. This is also trained to at Wraparound CORE Training, day 2 & 3, OCIMS Training, Day 2, and MediCal Training. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 75, section 17.7.7.25; page 4, section 2.9; page 58, section 17.7.1.2; page 72, section 17.7.7.14; page 73, section 17.7.7.16.
4.4b
Care Coordinators (Facilitators) receive ongoing training and coaching to engage the team in a planning process that elicits multiple perspectives, is done in a collaborative environment and demonstrates the HFW principles. This is accomplished through various trainings and meetings. All Care Coordinators receive Wraparound CORE training and this is highlighted during Wraparound CORE Training, Days 1 and 2. They also receive Facilitation Training, New CC Training, and CC Supervision trainings. This is also accomplished via various discussions during monthly Site Support meetings, monthly Institute Trainings, monthly POC Presentation meetings and yearly Utilization Review/Site Reviews meetings. Please refer to the Trainings Matrix and Meetings Matrix along with CORE training power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 4, section 2.9; page 57, section 2.1, page 58, section 17. 1 & 17.3; page 61, section 17.7.1.21; page 64, section 17.7.13; page 68, section 17.7.6.10, page 70, section 17.7.6.34, page 74, section 17.7.7.26; Page 75, section 17.7.7.25.
page 77, section 18.2.3.
4.4c
Crisis and safety plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes. This is accomplished through CFT meetings, monthly Site Support Meetings, and is trained to in Wrapround CORE training, days 1 and 2, New CC Training, Institute Trainings. Please refer to the Trainings Matrix and Meetings Matrix along with CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 75m, section 17.7.7.25; page 4, section 2.9; page 58, section 17.7.1.2; page 72, section 17.7.7.14; and page 73, section 17.7.7.16.
Implementation
5.1 Implement The Plan of Care
5.1a
The Care Coordinators (Facilitators) leads the team to review strategies and action items at HFW team meetings (e.g., use of meeting agendas and meeting minutes that address action item completion and document progress), track individual assignments, check-in to support meeting timelines and deliverables, and adjust strategies and action items as needed. This is accomplished through various trainings and meetings. All Care Coordinators receive Wraparound CORE training and this is highlighted during Wraparound CORE Training, Day 1, 2 and 3. They also receive Facilitation Training, New CC Training, CC Supervision trainings and OCIMS day 2 training. This is also accomplished via various discussions during monthly Site Support meetings, monthly Institute Trainings, monthly POC Presentation meetings and yearly Utilization Review/Site Reviews meetings. Please refer to the Trainings Matrix and Meetings Matrix along with CORE training power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, Page 4, section 2.9; pg. 32, section 6.17.1 through .7; page 30, section 6.9; page 49, section 12.4.1.17; page 58, sections 17. 1 & 17.3; page 61, section 17.7.1.21; page 68, section 17.7.6.10, page 70, section 17.7.6.34, page 74, section 17.7.7.26; page 77, section 18.2.3.
5.1b
Staff receive training and coaching on implementing the plan of care in alignment with the HFW principles. Training and processes address celebrating successes as they occur. This is accomplished by providing Wraparound Core Training, monthly Institute trainings, Professional development trainings specific to Supervisors, Care Coordinators, Youth Partners and Parent Partners. This is also trained to in OCIMS Training, days 2 & 3, Facilitation Training, NEW CC Training, Critical Thinking Training, and Wrap Around Overview Training. This is also addressed and discussed in monthly POC meetings, monthly Site Support meetings, Technical Assistance meetings. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas Please also refer to Direct Services Contract Agreement, Attachment A, page 52; 65; 68; pages 76-81; page 39, section 9.3.1.4; page. 49, section 12.4.1.17; page 77, section 18.2.1.
5.2 Review and Update The Plan of Care
5.2a
Reviews of strategies, progress, and action items occurs in a HFW team meeting setting. This is accomplished through review of CFTM Agenda Notes, Technical Assistance Notes, during monthly POC Presentation Meetings, monthly Site Support meetings, Meeting Notes, Emergency CFT Agenda reviews. This is also trained to in Wraparound CORE training Day 3 and Facilitation Training. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 4, section 2.9- 2.11; page 14, section 2.65 and 2.65.1; page 30, section 6.8.9; page 30, section 6.9; page 32, section 6.17.5; page 52, section 13.1.3; page 15, section 2.71; page 20, section 3.1.5, page 23, section 5.4.1 to 5.4.7
5.2b
The Care Coordinators (facilitators) lead the team to adjust the plan accordingly as successes occur, as new needs are identified, or as new strategies and action items are selected, and the updated plan is documented in the youth’s file. This is accomplished and observed through CFTM Agenda Notes, in Technical Assistance meeting Notes, POC Presentation Meetings, Meeting Notes, Emergency CFT Agenda notes, Site Support Visits. This is also trained to in Wrapround CORE training, Day 3, OCIMS Training day 2, and Facilitation Training. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 23, section 5.4.1 through 5.4.7; page 60, section 17.7.10; page 30, section 6.8.9; page 24, section 5.4.3; page 59, section 17.7.1.5 and 17.7.1.6.
5.2c
The Care Coordinators (facilitator) documents and communicates completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the POC. These updates are communicated to all team members, at a minimum, through the use of team meeting minutes. This is accomplished through CFTM Agenda Notes, Technical Assistance Notes and discussed during monthly POC Presentation Meetings, monthly Site Support meetings, Meeting Notes, and in Emergency CFT Agendas. This is trained to during Wraparound CORE training, Day 3, OCIMS training, days 2 & 3, and Facilitation Training. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 39, section 9.3.1.5; page 41, section 9.5.1; page 76-80, entire section 18; page 60, section 17.7.1.10; page 32, section 6.16; page 32, section 6.17.2 through 6.17.6.
5.2d
Forms are updated and individualized to meet the youth, family, and team’s changing needs. This is accomplished through various trainings and meetings. This is trained to in Wraparound CORE Training, Day 3, OCIMS days 2 and 3, Facilitation Training, New CC Training, and CC Supervision trainings. This is also accomplished via coaching and supervision in various discussions during monthly Site Support meetings, monthly POC and monthly Presentation meetings. This is also observed through review of the CFTM Agenda notes, Technical Assistance notes meeting notes and Emergency CFT agendas. Please refer to the Trainings Matrix and Meetings Matrix along with CORE training power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 4, section 2.9- 2.11; page 14, section 2.65 and 2.65.1; page. 30, section 6.8.9; page 30, section 6.9; page 32, section 6.17.5; page 52, section 13.1.3; page 15, section 2.71; page 20, section 3.1.5, page 23, section 5.4.1 to 5.4.7; page 39, section 9.3.1.5; page 41, section 9.5.1; page 76- 80, entire section 18; page 6, section 17.7.1.10; page 32, section 6.16; page 32, section 6.17.2 through 6.17.6.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
5.3a
Team agreements are utilized, reviewed regularly, and present at HFW team Meetings. This is evident and well documented in Team action forms, POCs, Progress summaries, the family story, monthly CFT Agendas, IP-CANS, Meeting Notes, and Emergency CFT Agendas. This is also trained to in Wraparound CORE training (day 3); safety plan training, and Facilitation Training. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 14, section 2.65.1; page 14, section 2.65-2.65.1; page 23, section 5.4.2, page 32, section 6.17.5; page 23, section 5.4.2.
5.3b
Care Coordinators (Facilitators) receive ongoing training and coaching on building, engaging, and maintaining effective teams. This is accomplished through various trainings and meetings. All Care Coordinators receive Wraparound CORE training and this is highlighted during Wraparound CORE Training, Day 2, OCIMS day 2, and Facilitation Training, Facilitation Training, New CC Training, and CC Supervision trainings. This is also accomplished via various discussions during monthly Site Support meetings, monthly Institute Trainings, monthly POC Presentation meetings and yearly Utilization Review/Site Reviews meetings. Please refer to the Trainings Matrix and Meetings Matrix along with CORE training power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page, section page 57, section 2.1, page 58, section 17. 1 & 17.3; page 61, section 17.7.1.21; page 64, section 17.7.13; page 68, section 17.7.6.10, page 70, section 17.7.6.34, page 74, section 17.7.7.26; pg. 77 – 18.2.1.1; pg. 77 – 18.2.3.
5.3c
Use of natural supports are monitored over time and teams are provided feedback through coaching and supervision. This is accomplished through monthly POC Presentation Meetings, Site Support Visits, Utilization Review/Site Reviews and through reviewing WFI survey results. This is also trained to in Wraparound CORE training Day 3; OCIMS day 2, Facilitation Training, agency’s respective trainings; Natural Supports training; Institute Trainings. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 69, section 17.7.6.12; page 59, section 17.7.1.5 and 17.7.1.6; page 76, section 80, entire section 18.
5.3d
There are processes for orienting new team members (including formal and natural supports) to the team which include explaining the HFW process, reviewing current plans and strategies, and engaging in team building exercises. This is reviewed and assessed during monthly POC Presentation Meetings, monthly Site Support Visits. This is also trained to in Wraparound CORE training Day 3, OCIMS Training Day 2, Facilitation Training, Natural Supports training; review of WFI survey results, and Institute Trainings. This is also accomplished during Utilization Reviews/Site Reviews and each contacted provider respective trainings. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 69, section 17.7.6.12; page 59, section 17.7.1.5 and 17.7.1.6; page 76- 80, entire section 18.
Transition
6.1 Develop a Transition Plan
6.1a
The Care Coordinator (facilitator) leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process. This is trained to in Core training, days 1-4, New POC training, New CC and New YP training, Facilitation training, OCIMS days 2 and 3, Flex fund training, and Overview training. This is also reiterated at monthly Site Support meetings, and monthly POC Presentations. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page, 71, section 17.7.6.25; page 23, section 5.4.2
6.1b
Once the determination has been made, the Care Coordinator (facilitator) leads the team in creating an individualized transition plan that identifies needs, services, and supports, distributes the plan to all team members, and documents the plan in the youth’s file. This is trained to in Core training days 1-4, New POC training, New CC and New YP training, Facilitation training, OCIMS days 2 and 3, Flex fund training. This is also reiterated at monthly Site Support Meetings and monthly POC Presentations. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 71, section 17.7.6.25; page 23, section 5.4.2; page 30, section 6.11.
6.1c
The development of the individualized transition plan occurs in a team based, collaborative environment and Care Coordinators (facilitators) receive training and coaching to this process. This is trained to in Wraparound Core training days 1-4, New POC training, New CC and New YP training, Facilitation training, OCIMS days 2 and 3, Flex fund training. This is also reiterated and addressed regularly at monthly Site Support meetings and monthly POC Presentations. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 71, section 17.7.6.25; page 23, section 5.4.2.
6.1d
The team verifies that services and supports identified in the transition plan will persist past formal HFW and that the family is able to access them, including post adoption services if applicable. This is trained to in Wraparound Core training days 1-4, New POC training, New CC and New YP training, Facilitation training, OCIMS days 2 and 3, Flex fund training. This is also reiterated at monthly POC Presentations and Site Support meetings. When reviewing for quality assurance at commencements, the WRIT reviews and ensures that services and supports are identified in the transition plan. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 71, section 17.7.6.25; page 23, section 5.4.2.
6.2 Develop a Post-Transition Safety Plan
6.2a
The individualized crisis and safety plan is updated to reflect transition (or a new transition crisis and safety plan is completed) and documented in the youth’s file in OCIMS database. The plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies that maximize use of natural support and that are chosen by the family. This is trained to in Core Days 2-3, OCIMS Days 2-3, , New POC training, New CC and New YP training, Facilitation training, Critical Thinking training, and Overview Training. This is also accomplished through consultations at monthly Site Support and monthly POC Presentations. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 15, section 2.71; page 14, section 2.65.1; page 15, section 2.71; page 24, section 5.4.3; page 24, section 5.4.3; page 25, section 5.7; page 30, section 6.11.
6.2b
The development of the crisis and safety transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process. This is trained to in Wraparound Core Training Days 2-3, OCIMS Training Days 2-3, New POC training, New CC and New YP training, Facilitation training, Critical Thinking training, and Overview Training. This is also accomplished via consultations with teams at monthly Site Support meetings, monthly POC Presentations meetings. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page, 71, section 17.7.6.25; page 23, section 5.4.2; page 31, section 6.12; page. 3, section 2.9; page 12, section 2.54.1.
6.2c
Processes are in place to review crisis and safety plans for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes. This is trained to in Wraparound Core Days 2-3, OCIMS Training Days 2-3, New POC training, POC Presentations, New CC and New YP training, Facilitation training, Critical Thinking training, and Overview training. This is also reviewed and consulted on during monthly Site Support meetings, monthly POC meetings and during Utilization Review/Site Reviews meetings. This is also assessed by the WRIT team at the time of commencements for quality assurance. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page, 12, section 2.54.1; page 71, section 17.7.6.25; page 59, section 17.7.1.2; page 73, section 17.7.14; page 59, section 17.7.1.6; page 52, section 13 to 14; page 23, section 5.4.2.
6.3 Create a Commencement and Celebrate Success
6.3a
The transitions out of the Wraparound process are celebrated according to the family’s culture, values, and preferences as evidenced in that OC Wrap trains staff to celebrate the youth and family, by practicing the wrap principals ensuring they are individualized and culturally competent. OC Wraparound provide a 4-day training called Wrap Core Training Day to all Wrapround staff. During CORE training, staff are trained in the 10 principals of wraparound and the 4 phases of wrap which include understanding cultural competency and cultural humility when working with families and using their culture, values and preferences in not only creating the plan of care but also when celebrating the family’s success in the wrap process. OC wrap also provides a new Wraparound staff with trainings (New Care Coordinator training, New Youth Partner training, New Parent Partner training) that trains staff on being culturally sensitive and understanding when working with youth and families. The OC Wraparound staff are also required to participate in a Wraparound Flex Funds training and a Wraparound data base systems training (OCIMS) where staff are trained on the use and documentation of flex funds to meet the family’s needs which include cultural and religious needs. OC Wraparound staff also participate in monthly Plan Of Care presentations where Plan of Cares are reviewed and Wraparound teams are given feedback on meeting and documenting the family’s needs which include the youth and family’s cultural needs, while not losing sight of the family’s values and preferences. Celebrating the families according to their culture, values, and preferences is also captured in the contract between OC Social Services the agency contacted to provide direct Wraparound services. In attachment A of the Direct Services contract, page 20 section 3.1.4 under outcome objectives states contractor shall provide culturally responsive services, which are individualized for each participant and participant’s family’s culture, values, norms, strengths, needs, and preferences, and build on the use of naturally occurring community and family supports and resources. Also under page 38, section 9 to 9.53 of attachment A regarding flex funds usage states, Flex Funds are accessible for needed supports and services of Wrap OC. Flex Funds may be used for emergencies and/or crisis/safety stabilization, implementation strategies and interventions, recognition activities related to milestone achievements, and celebrations supporting transition.
6.3b
Orange County Social Services administrative structures are supportive of engaging in celebration of Wraparound for each family as evidenced that OC Wrap provides multiple trainings to new and existing staff. A support structure in place to support and encourage of engaging in celebrations for families participating in the Wraparound process. OC wrap trains staff in the OC Wraparound Core Training Day 1 through day 4 when staff are trained regarding the county agencies that refer to Wraparound on how those agencies provide support in not only celebrating the Wraparound process for families, but also the level of support the referring party can provide in such celebrations. In the Core Training, staff are also provided with a training on linking and partnering with community resources to help the family work through and celebrate their success in the Wraparound process. The OC Wrap administrative structure encourages accessing and utilizing flex funds via Flex Funds Training and the database system training (OCIMS) where staff are taught to access appropriate use of flex funds and documenting such use of flex funds. All new OC Wrap staff are mandated to participate in their role specific trainings which include, New Care Coordinator training, New Youth Partner training, New Parent Partner training, where each role is taught the expectations of the administrative structure in accessing and using flex funds to celebrate families who are participating in the Wraparound process. The OC Wraparound administrative structure also includes Plan of Care presentations where once per month private agencies are asked to present selected Plan of Cares to the WRIT team. Each provider agency is then provided with feedback not only on the Wraparound process but also on the use of flex funds on engagement, identifying ways to overcome barriers, and maintaining and celebrating the family. The administrative structure also includes the WRIT team visiting each contacted private agency monthly for a site support visit where in part celebrating families in the wraparound process are discussed. At the site support visits, the administrator will review flex funds and celebrations but also linking families to community partners who can help support and celebrate the family’s success in Wraparound. Wraparound teams are encouraged to invite the family’s Wrap team to celebrations involving the entire family and work around the family’s schedule to ensure the family and team members are available to attend. This is also captured in the contract between OC Social Services the agency contacted to provide Direct Services, Attachment A of the contract, page 20 section 3.1.4. Under outcome objectives, the contract states the contractor (provider) shall provide culturally responsive services, which are individualized for each participant and participant’s family’s culture, values, norms, strengths, needs, and preferences, and build on the use of naturally occurring community and family supports and resources. Also under section page 38, section 9 of attachment A regarding flex funds usage states, Flex Funds are accessible for needed supports and services of Wrap OC. Flex Funds may be used for emergencies and/or crisis/safety stabilization, implementation strategies and interventions, recognition activities related to milestone achievements, and celebrations supporting transition. Please also refer to Direct services contract page 43, section 9.7.1; page 12, sections 2.5 & 2.51
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
7.1a
SSA had a parent mentor contract in place where parents who had experienced Wraparound and had successfully reunified with their children provided input by participating in various committees. However, the contract was terminated due county budget constraints. The Program Director for FSN, who is also a parent advocate, serves as the parent voice in many committees. FSN gathers responses to the Family Satisfaction Survey and WFI, the FSN Program Director is involved in community planning and policy development and communicates Wraparound parent/caregivers concerns and/or challenges to help make decisions regarding local HFW Implementation. The plan is to develop quarterly to biannual meetings/forums to survey youth and caregivers separately for input on their experiences with Wraparound in order to seek valuable information to help guide practices/processes. Please also refer to Direct Services Contract Agreement, Attachment A, page, 26; section 5.13.
7.1b
Yes, Family Satisfaction Surveys are completed at commencement and results are utilized to help guide service planning and implementation, policy and procedure development and quality improvement. WFI questionnaire is administered at the fourth month of services and results are utilized to drive services planning, policy and procedures, workforce development and quality improvement. This is trained to in Wraparound CORE and in OCIMS training. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas Please also refer to Direct Services Contract Agreement, Attachment A, page 18, section 2.86, page 60, section 17.7.1.17; page 63, section 17.7.3.4; page 76, section 17.7.7.3; page 80, section 18.2.8.7. Please also refer to Support Services Contract Agreement, Attachment A, page, 1, section 1.1.5; page 14, section 2.72; Page 17, section 2.86; page 19, section 3.1.4 and 3.2.5; page 20, section 3.2.4; page 23, section 7; pg.25, 9.1.1.7; page 26, section 9.1.2.4 and 9.1.2.5; page 33, section 14.11.1.1- 14.11.1.4; page 34, 14.11.1.2- 14.11.1.3; page 39, 15.4.5.11; page 39, 15.4.5.12. Please also refer to the Amended Support Services Contract page 10, section 17.3.2.5; page Please also refer to the Direct Services Contract Attachment A page 16, section 2.72, page 21, section 3.2.4, Re: WFI- SUPPORT SERVICES CONTRACT- Attachment A. – pg. 1, 1.1.5; pg.17, 2.86; pg. 19, 3.1.4; pg. 20, 3.2.5. pg. 23, 7.2; pg.25, 9.1.1.7; pg. 26, 9.1.2.5. pg. 34, 14.11.1.2- 14.11.1.3; pg.39, 15.4.5.12. The plan is also to develop quarterly to biannual meetings to survey youth and caregivers about their experience with Wraparound in order to help inform policies and practices and processes.
7.2 Community Leadership Team
7.2a
Wraparound Oversight Group (WOG) is made up of executive leadership from SSA, Probation and HCA. There is shared responsibility to ensure HFW is practiced at the organizational and systems levels. This meeting is held quarterly. We also hold Wraparound Provider, Executive Director and WRIT Meetings- every two months. Participants include: SSA, Probation, HCA, Wraparound support services (Executive Director , Resource Specialist, Parent Partner Trainer- FSN) Wraparound direct services providers (executive directors, program directors, supervisors). Purpose of the meeting is to provide update, identify any system barriers, review Outcomes. There is also a System of Care (SOC) meetings in which leaders from OC SSA, Probation, and Health Care agency along with community representation such as Education, Regional Center, Juvenile Justice Commission represented and Wraparound remains an agenda item for update, discussion and consultation. Please refer to the Meetings Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 19, section 2.88, page, 52, section 13.1.6.
7.2b
Wraparound Oversight Group (WOG) is made up of executive leadership from SSA, Probation and HCA. There is shared responsibility to ensure HFW is practiced at the organizational and systems levels. This meeting is held quarterly. We also hold Wraparound Provider, Executive Director and WRIT Meetings- every two months. Participants include: SSA, Probation, HCA, Wraparound support services (Executive Director , Resource Specialist, Parent Partner Trainer- FSN) Wraparound direct services providers (executive directors, program directors, supervisors). Purpose of the meeting is to provide update, identify any system barriers, review Outcomes. There is also a System of Care (SOC) meetings in which executive leaders from OC SSA, Probation, and Health Care agency along with community representation such as Education, Juvenile Justice Commission represented and Wraparound remains an agenda item for update, discussion and consultation. SOC will be extending an invitation to include Tribes. Please refer to the Meetings Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 19, section 2.88, page, 52, section 13.1.6.
7.2c
Wraparound Oversight Group (WOG) is made up of executive leadership from SSA, Probation and HCA. There is shared responsibility to ensure HFW is practiced at the organizational and systems levels. WOG serves the purpose of ILT. This meeting is held quarterly. We also hold Wraparound Provider, Executive Director and WRIT Meetings- every two months. Participants include: SSA, Probation, HCA, Wraparound support services (Executive Director, Resource Specialist, Parent Partner Trainer- FSN) Wraparound direct services providers (executive directors, program directors, supervisors). Purpose of the meeting is to provide update, identify any system barriers, review Outcomes. There is also a System of Care (SOC) meetings in which leaders from OC SSA, Probation, and Health Care agency along with community representation such as Education, Juvenile Justice Commission represented and Wraparound remains an agenda item for update, discussion and consultation. This serves as the ILT. Please refer to the Meetings Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 19, section 2.88, page, 52, section 13.1.6.
7.3 Eligibility and Equal Access
7.3a
Minimum service eligibility criteria is clear and supports equity in access to services as evidenced by the contract that OC Social Services has between OC Social Services and its contracted provider agencies under population to be served. Under the Direct Services Contract page 43, section 1 population to be served, states OC Wraparound participants include child/youth and Non-Minor Dependent (NMD) who meet any of the following criteria: ages birth to eighteen (0-18) years, who have been adjudicated as either a dependent or ward of the juvenile court, and who are at risk of or placed in a Residential/Short-Term Residential Treatment Program (STRTP) placement; Non-Minor Dependents (NMD’s) pursuant to WIC Section 11400(v), which is a foster youth who has attained the age of eighteen (18) years while in foster care and is younger than twenty-one (21) years; have an approved or potential place to reside in the community with a parent/guardian, relative caregiver, non-related extended family member (NREFM) or Resource Parent (formerly foster parent) who has agreed to participate in Wrap OC; in placement or at risk of placement in residential/STRTPs, or Juvenile Detention Facility. As described in the Amended Direct Services contract agreement on page 2, providers are to comply with all licensing standards which includes affording Wraparound to you youth have stepped down from STRTP’s as per FFPSA. The eligibility criteria and equity in access to participate in OC Wraparound is also trained to in CORE Training day 2 when staff are trained on the differences in referral sources and how youth and families are referred to OC Wraparound from their perspective referring agencies (Social Services/Health Care Agency/Probation. The eligibility criteria is also trained to OC Wraparound Overview where new Wraparound staff including referring parties are trained on the eligibly criteria including on the most recent update that all youth who are stepping down from Short-Term Residential Treatment Programs (STRTP) must be referred to a Wraparound program. OC Wraparound has also included a community based outreach program titled, the Multi-Disciplinary Consultation Team (MDCT), which in collaboration with the Health Care Agency, is in place to provide families who have no formal county contact, referral/linkage to County and Contracted outpatient mental health services and linkages to community resources which may include access to OC Wrapround on a time limited bases in order to prevent County Wardship and or County Dependency and meet the needs of the most marginalized community members. Please refer to Direct Services contract page 2, section 1. Please refer to Training Matrix. The current OC SSA policy last revised in January 2020, identifies the service criteria (policy # D-0511) but is currently being updated to include all HFW criteria and ACL 25-47 references, along with FFPSA. None the less, the county is committed to meeting all eligibility criteria for all youth referred as outlined in ACL-25-47.
7.3b
The youth that meet established eligibility criteria are able to receive services and are not excluded based on the severity or nature of their needs in OC Wraparound which is covered in the Direct Services contract that OC Social Services has between OC Social Services and its contracted provider agencies under population to be served on page 1, sections 1 and 2, population to be served, states OC Wraparound participants are the youth and families with the highest needs and who are marginalized. The youth include child/youth and Non-Minor Dependent (NMD) who meet any of the following criteria: ages birth to eighteen (0-18) years, who have been adjudicated as either a dependent or ward of the juvenile court, and who are at risk of or placed in a Residential/Short-Term Residential Treatment Program (STRTP) placement; Non-Minor Dependents (NMD’s) pursuant to WIC Section 11400(v), which is a foster youth who has attained the age of eighteen (18) years while in foster care and is younger than twenty-one (21) years; have an approved or potential place to reside in the community with a parent/guardian, relative caregiver, non-related extended family member (NREFM) or Resource Parent (formerly foster parent) who has agreed to participate in Wrap OC; in placement or at risk of placement in residential/STRTPs, or Juvenile Detention Facility. Behaviors that youth may have but not limited to under the contract between OC Social Services and the contracted provider agencies are: frequent running away, gang involvement, tagging, property destruction, self-harming, possession of deadly weapon(s), adjudicated sex offenders, possession of alcohol and/or drugs for use or sale, juvenile perpetrator, substance abuse disorder, fire- starter, sexualized behavior, sexual exploitation, multiple placements, minor criminal behavior, oppositional/defiant behavior, aggression, assaultive toward others, educational deficiencies, habitual school truancy and/or other school-related behavior problems, post-traumatic stress, behaviors beyond control of parent(s) or primary caregiver(s), recognized mild developmental disorder, significant mental health disorders, one or more hospitalizations in a mental health facility, and/or Participants who may have previously received other intensified services. In addition, Participants may have been raised in families with multi-generational criminal justice involvement, social services involvement, and/or mental health disorders. No youth are excluded based on the severity or nature of their needs. OC Wrap staff are also required to participate in OC Wraparound CORE training day 1-4 where staff are trained in working with marginalized communities and youth with the highest needs and linking such youth to need resources and services. Orange County staff along with contracted agency staff are also provided with an OC Wraparound Overview training that covers the youth that are served on OC Wrap and how OC Wrap contracted agencies are trained in working with all youth regardless of the severity or nature of their needs. Please refer to the Meeting Matrix and Training Matrix.
7.3c
OC Wraparounds Service access is tracked, and waitlist times are monitored on a weekly basis during WRIT weekly meetings. OC Social Services has representatives from the Orange County referring agencies, OC Social Services, OC Probation and OC Health Care agency who are members of the Wraparound Review & Intake Team (WRIT). OC Social Services and OC Probation do not have waitlists for services. OC Health Care Agency will have a waitlist that is tracked on a weekly basis. Every week the Wraparound Review and Intake Team (WRIT) meet to review and assign referrals and discussions on held regarding all youth referred to Wraparound and those who may be on a waitlist. The Wraparound Review & Intake Take Team (WRIT) also reviews closures on weekly basis. When a youth referred by the OC Health Care Agency is closed in Wraparound, the Health Care liaison will access the Heath Care Agency waitlist for a youth who needs Wraparound services and his is done on a weekly basis. It is anticipated that the OC Health Care Agency waitlist will improve with the incorporation of high-fidelity wraparound to the Full-Service Partnership Programs. Please refer to Meeting Matrix of list of meetings and frequency. Please also refer to Direct Services contract page pg. 19, section 2.90.
7.3d
OC Wraparound provides an amount of funding that is sufficient to ensure appropriate staff and ability of staff to provide 24/7 support to families in crisis. OC Wraparound has a funding model that is covered in the contract that OC Social Services has between OC Social Services and its contracted wraparound provider agencies. As evidenced in Direct Services contract page 19, section 2.91; page. 22, section 4.3; page 27, section 5.20; page. 31, section 6.12. The Wrap OC model, approved by the County of Orange Board of Supervisors and CDSS, which details the county’s plan to use Wraparound funding to provide eligible child/youth/NMD with family-based service alternatives to STRTP care. The Wrap OC funding model utilizes a combination of funding from both child welfare services and the HCA as the County’s Mental Health Plan. HCA contracts with the Wraparound provider agencies in coordination with OC Social Services to reimburse the Wraparound provider agencies for the Medi-Cal eligible services under CalAIM. Child welfare services funding enables Wrap OC to provide strength-based, flexible services and supports to Participants and their families. No distinction is made between source of the Wraparound referral (SSA-child welfare, Probation or HCA-Behavioral health). As a result, any family that demonstrates a true need, funding is made available to meet the need. Also in Attachment A under section 16, the annual budget for services is documented where it covers billing requirements and reimbursements service providers. In the contract between OC Social Services and its contracted Wraparound provider agencies it is also documented in Attachment A section 4 under Hours of Operation, that the OC wrapround provider agencies shall arrange for twenty-four (24)-hour, seven (7) days a week, on-call availability for OC Wraparound participants and their families to address crisis/emergency needs, including an in-person response to crisis calls during hours of operation and after hours, in an effort to stabilize a crisis. OC Wrap has ensured sufficient funding to provide appropriate staffing and ability of staff to provide 24/7 support to families in crisis.
7.3e
The County of Orange and/or its providers publicize High Fidelity Wraparound services to families and to potential referral sources. Orange County Social Services along with OC Probation and OC Health Care Agency provide oral presentations to referral sources on an ongoing basis. Referrals to the Wraparound program are continuously being made on a weekly basis. Newly hired staff at Social Services, Probation and the Health Care Agency are provided with brochures and referral paperwork on OC Wraparound services. The brochures are also shared with colleagues who may not be aware of OC Wraparound and who may have families who would benefit from OC Wraparound. The information provided to all referring agency staff includes information on how to refer youth and family to Wraparound who may be interested in services and who meet the referring requirements. The Wraparound Review & Intake Team (WRIT) meets weekly and part of the discussion in outreaching and publicizing high fidelity Wraparound to potential referral sources. Access to Wraparound is also posted on SSA’s SharePoint site. SSA Wraparound Liaisons also make regular All Staff presentations across SSA including new hire staff to communicate how staff can refer to Wraparound.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
8.1a
High fidelity direct services and supports are in place to meet the immediate individualized needs of youth and families in OC Wraparound. This is evident in the Direct Services contract that OC Social Services has between OC Social Services and its contracted Wraparound provider agencies (currently 3 agencies) in attachment A, Section 1 and 2, the contract clearly identifies the population to be served and that Individualized Services are provided. The contract notes that services will be tailored to the specific, unique needs of participant and/or Participant’s family; incorporating a flexible, creative approach to treatment planning based on an assessment of needs, resources, and family strengths; and including the use of formal and informal supports and services. This is evidenced on page 12, section 2.51. Also in Direct Services contract, Attachment A, page 38, section 9, Flex Fund Standard, documents how the provider agency shall use flex funds to meet the unique and immediate individualized needs of youth and families while being purposeful, effective, creative and not fostering financial dependency on Wraparound. In the Direct Services contract in Attachment A page 57, section 17, it is documented that the provider agencies shall have staff that meet the county education and experience requirements, with language skills and cultural awareness necessary to communicate fully and effectively with participants and participants’ families in accordance with high fidelity Wraparound standards. The contact also lays out job duties for a Care Coordinator, Parent Partner, Youth Partner and a Wraparound Clinician with duties all meeting wraparound standards evident on page 57, section 17 (all of 17). OC Wraparound also provides a 4 full day Wraparound CORE training to all wraparound staff that covers meeting the immediate and individual needs of the youth and family. On days 2 and 3 of Wraparound CORE Training, staff are trained on needs for the youth and family as well as crisis safety planning. Wraparound staff are also provided with a flex fund training that covers ways to utilize flex funds to meet the needs of youth and families and the immediate and crisis safety planning for youth and families. Please refer to Training Matrix and Meeting Matrix.
8.1b
Workforce development and staffing is clearly identified, including required roles or functions from Workforce Development standard has been incorporated into the OC Wraparound Process. In the Direct Services contract that OC Social Services has between OC Social Services and its 3 contracted Wraparound provider agencies, the contract clearly notes in attachment A, page 57 all of section 17, staffing requirements are outlined along with, minimum requirements for each role in OC Wraparound. This is also noted on page 43, all of section 10. OC Wraparound staff shall be able to read, write, speak, and understand English and demonstrate the ability to prepare clear, complete, and concise case notes, reports, etc., in both English and the specified languages (bilingual staff). The OC Wraparound Care Coordinator has 21 duties listed in the contract. The OC Wraparound mental health clinician has 11 duties listed in the contract. The Parent Partner role has 16 duties listed in the contract. The Wraparound Youth Partner has 31 duties listed in the contract. OC Wraparound Program Director role has 19 duties listed in the contract. The OC Wraparound Quality Assurance Coordinator has 11 duties listed in the contract. The Wraparound Supervisor role has 34 duties listed in the contract. OC Wraparound also has committees spelled out in the contract that OC Social Services and its contracted wraparound provider agencies (see Direct Services contract, Attachment A Section 2, Definitions under 2.88) that provide oversight, support and guidance to the Wraparound process that includes evaluation, trainings, workforce and policy development. In the contract under Attachment A Section 18, Training, provides a framework of required trainings that staff must participate in when they are first hired or move positions within OC Wraparound and ongoing trainings for professional development for all staff. OC Wrapround provides 16 ongoing trainings for staff. OC Wraparound continues to develop trainings to meet the needs of the youth and families served. Training provided include but not limited to Wraparound CORE Training provided bi-annually (4 full days for all new staff and those who have moved positions within OC Wraparound), Wraparound Overview (monthly) , New Parent Partner Training/New Care Coordinator Training/New Youth Partner (provided bi-annually), Medi-Cal Documentation Training (provided bi-annually), Facilitation Training (provided bi-annually), Critical Thinking Training (provided bi-annually), Data Base Training – Orange County Integrated Management System – (OCIMS) provided quarterly (4 full days), Special Incident Report Training (provided quarterly), Flex Funds Training (provided quarterly), Wraparound Institute (provided monthly), Wraparound Professional Growth for Youth Partners / Wraparound Professional Growth for Parent Partners / Wraparound Professional Growth for Care Coordinators / Wraparound Professional Growth for Supervisors (provided every 2 months). The list of trainings above provides OC Wraparound staff with continued professional growth and development. OC Wraparound continues to develop trainings to meet the needs of the youth and families served. Please refer to Direct Services Contract- Attachment A, page. 57, All of section 17; page 43, All of section 10; page 19, section 2.88; page 26, section 5.13; page 27, section 5.16.1; page 52, All of section 13; page 57, section 17.1; page 58, section 17.3; page 61, section 17.7.1.19; page; 61, section 17.7.1.21; page 64, section 17.7.3.13; page 65, section 17.7.4.6; page 66, section 17.7.4.8; page 66, section 17.7.4.12; page 68, section 17.7.5.11, 17.7.6.3; page 69, section 17.7.6.10-11; pg. 70, section 17.7.6.17, 17.7.6.19; pg. 71, section 17.7.6.34; pg. 75, section 17.7.7.26; pg. 76, All of section 18; Please refer to list of trainings.
8.1c
OC Wrapround has developed and created a secured web-based database called the Orange County Intervention Management System (OCIMS) that is used to track and document all Wraparound activities with youth and families. The data base is discussed in the Direct Services contract Attachment A Section page 2, section 2. The contract states that a case management database developed in a collaborative effort between Orange County Information Technology (OCIT), Social Services Agency (SSA), Health Care Agency (HCA), Probation Department (Probation) and Wrap OC Provider Agencies to track and monitor all Wraparound activities (see Attachment A Section 2, 2.1 Administrators Data Base). OCIMS tracks the referral process which includes, family contacts, Wraparound phases, Plan of Care, youth and family needs and interventions, youths’ location, Medi-Cal eligibility, meetings (CFT’s/Emergency CFT’s/ in person and phone contacts), flex funds use, youths’ mental health status, youths’ education, court process (if applicable), family risk factors and behavioral history of the youth and family. OCIMS provides numerous reports to show success and also areas that need improvement. Due to the complexity of the OCIMS database, staff are required to attend an OCIMS training that is provided specific to each Wraparound Role in Wraparound over a full 4-day period. OCIMS training is also required for all staff who move positions (promotions) within OC Wraparound and to staff who need a re-fresher training. OC Wraparound also utilizes the HCA Integrated Records Information System (IRIS) to submit Medi-Cal eligible claims for assessment, case management/intensive care coordination, mental health rehabilitation services/intensive home based services, and crisis intervention, as well as enter data in IRIS for the Child and Adolescent Needs and Strengths (CANS). OC Wraparound provides a Medi-Cal Documentation Training to all new staff, and as a refresher to all staff (See Attachment A Section 18, 18.2.7 Medi-Cal Training). Data collection and management has assisted OC Wrap in streamlining the OC Wrapround process for youth and families in the communities we serve. Please see Direct Services contract pg. 36, All of section 36, Attachment A, pg. 2, 2.1; pg. 37, 8.9; pg. 39,9.3.1.6 & 9.3.1.8; pg. 44, 10.1.3; pg. 46, 10.1.12; pg. 47, All of section 12; pg.60, 17.7.1.17 and 18; pg. 6.17.7.3.16; pg. 66, 17.7.4.17; pg. 67, 17.7.5.2 & 3 & 5 & 7; pg. 69, 17.7.6.13; pg. 72, 17.7.7.7; pg. 73, 17.7.7.9; pg. 75, 17.7.7.27; pg. 78, 18.2.3.1; pg. 79, 18.2.7.6 & 8.6. Please also see list of Trainings Matrix noting OCIMS training.
8.2 Equitable Funding Across System Partners
8.2a
The Wraparound Oversight Group (WOG) which includes Child Welfare, Probation and Child Behavioral Health (Health Care agency) executive and administrative leadership, that includes contracts an finance meets regularly to discuss budget, including potential resources available across the Children’s System of Care. Health Care Agency and OC SSA also meet monthly to discuss budget and identify any barriers or issues in funding the program. Additionally, our support services contract provider is responsible for obtaining local resources (in-kind donations) and information about local resources. Our Direct Services Providers also have internal access to local community resources and make significant efforts to access these resources prior to requesting flex funds. Please refer to the Meetings Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 25, section 5.9 & 5.15; page 31, section 6.14, page 44, section 10.1.5; page. 45, section 10.1.8.3; page. 49, section 12.4.1.18; page. 60, section 17.7.1.11; page 64, section 17.7.3.12.
8.2b
The Wraparound Oversight Group (WOG) which includes Child Welfare, Probation and Child Behavioral Health (Health Care agency) executive and administrative leadership, contracts and finance from each agency meets regularly to discuss budget, including potential resources available across the Children’s System of Care. Health Cre Agency and OC SSA also meet monthly to discuss budget and identify any barriers or issues in funding the program. Additionally, our support services contract provider is responsible for obtaining local resources (in-kind donations) and information about local resources. Our Direct Services Providers also have internal access to local community resources and make significant efforts to access these resources prior to requesting flex funds. Please refer to the Meetings Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 19, section 2.88; page 25, section 5.9 & 5.15; page 31, section 6.14, page 44, section 10.1.5; page. 45, section 10.1.8.3; page. 49, section 12.4.1.18; page. 60, section 17.7.1.11; page 64, section 17.7.3.12.
8.2c
Cost sharing agreements between Child Welfare, Probation, and Behavioral Health are in place and this is discussed at the Wraparound Oversight Group (WOG) meetings where budget, including potential resources available across the Children’s System of Care. HCA participants are funded with Wrap funds are discussed In October 2019, SSA and Probation Wraparound entered into a Memorandum of Understanding under which, beginning May 2019, Probation began to reimburse SSA for Wraparound services provided to Probation participants. Please also refer to Direct Services Contract Agreement, Attachment A, page 19, section 2.88.
8.2d
The Wraparound Oversight Group (WOG) which includes Child Welfare, Probation and Child Behavioral Health (Health Care agency) meets regularly to discuss budget, including potential resources available across the Children’s System of Care. Health Cre Agency and OC SSA also meet monthly to discuss budget and identify any barriers or issues in funding the program. Additionally, our support services contract provider is responsible for obtaining local resources (in-kind donations) and information about local resources. Our Direct Services Providers also have internal access to local community resources and make significant efforts to access these resources prior to requesting flex funds. Please refer to the Meetings Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 19, section 2.88; page 25, section 5.9 & 5.15; page 31, section 6.14, page 44, section 10.1.5; page. 45, section 10.1.8.3; page. 49, section 12.4.1.18; page. 60, section 17.7.1.11; page 64, section 17.7.3.12.
8.3 Cost Savings are Reinvested
8.3a
The Wraparound Oversight Group (WOG) which includes Child Welfare, Probation and Child Behavioral Health (Health Care agency) administrative and executive leadership teams meet regularly to discuss budget, including potential resources available across the Children’s System of Care. Health Cre Agency and OC SSA also meet monthly to discuss budget and identify any barriers or issues in funding the program. Please refer to the Meetings Matrix. Please also refer to Direct Services Contract Agreement, Attachment A, page 19, section 2.88; page 25, section 5.9 & 5.15; page 31, section 6.14, page 44, section 10.1.5; page. 45, section 10.1.8.3; page. 49, section 12.4.1.18; page 56, section 16.1; and 16.2; page. 60, section 17.7.1.11; page 64, section 17.7.3.12.
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
8.4a
Yes, flexible funds are available and included as a part of the funding plan for HFW. This is trained to in CORE day 3-4, Flex Funds Training, OCIMS Training day 2-3, Wraparound Overview Training, Flex Funds Training, and new Care Coordinator training. This is also discussed and consulted on during monthly Site Support Meetings and biannual Utilization Reviews/Site Reviews. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page, 9, section 2.34; page 11 all of section 2.46; all of pages page 38 thru 43.
8.4b
Processes to access and manage flexible funds are articulated and include timely access for families that meet urgent needs, a defined approval process that includes the evaluation criteria defined above, a process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied. This is trained to in CORE day 3-4, Flex Funds Training, OCIMS Training day 2-3, Wraparound Overview Training, Flex Funds Training, and new Care Coordinator training. This is also discussed and consulted on during monthly Site Support Meetings and biannual Utilization Reviews/Site Reviews. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page, 9, section 2.34; page 11 all of section 2.46; all of pages page 38 thru 43.
8.5 Collaborative Oversight of Flex Funds
8.5a
Flex fund use and availability is documented and transparently communicated to funders and providers, including information regarding the amount, purpose and HFW team recommendation of the request. This is addressed and reiterated at monthly Site Support Meetings, and Site Reviews. This is trained to on Wraparound CORE day 3-4, Flex Funds Training, OCIMS Training day 2-3, Wraparound Overview Training, Flex Funds Training, new Care Coordinator training. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 11, section 2.46; page 38 thru 43.
8.5b
Flex funds are pooled (per agency) and held to meet the needs of all families served. Each agency is allotted $325,000, per year, to meet the needs of the families served. There is no differentiation between SSA, HCA and Probation nor amounts allotted. If a family is receiving Wraparound, they qualify equally for funds. It is important to note that no agency has run out of flex funds as this is tracked and monitored to ensure all families receive services needed. This is trained to in Wraparound CORE day 3-4, Flex Funds Training, OCIMS Training day 2-3, Wraparound Overview Training, monthly Institute Trainings, Flex Funds Training, new CC training. This is also addressed at monthly Site Support Meetings and Site Review meetings along with monthly POC presentations. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 11, section 2.46; page 38 thru 43, page 54, section 16. Please refer to existing OC SSA Policy D-0511 dated 8/13/2007. An updated draft is being developed which will also include this language of pooling funds to meet the need of families and children receiving Wraparound.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
8.6a
Each contracted Wrapround Provider is funded with $325,000 to cover flex funds, per agency. Wraparound in general in OC is funded by braided funding of a fixed amount of 2011 Realignment is provided to the County to fund all realigned mandated programs. Thus, Wraparound Trust funds consist of 40% 2011 Realignment and a 60% Net County Cost required match. Also, providers submit for MediCal reimbursement through Health Care Agency. CORE day 3-4, Flex Funds Training, OCIMS Training day 2-3, Wraparound Overview Training, Site Support Meeting , Site Review, Flex Funds Training, new CC training. Flex funds is trained to at Wraparound CORE training, day 3-4, Flex Funds Training, OCIMS Training day 2-3, Wraparound Overview Training, Flex Funds Training, and new Care Coordinator (facilitator) training. This is also discussed at monthly Site Support Meetings and monthly Site Reviews. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 19, section 2.88; page 56 section 16.1 (medical dollars).
8.6b
Currently each contracted provider’s budget is $3,550,000 per year, per contracted provider. Providers typically expend approximately 71% of their maximum obligation budgets and none of the providers are near exceeding their Maximum Obligation. Please refer to Direct Services Contract Agreement, Attachment A, page, section contract Pg. 56 section 16.1 (medical dollars) to 16.5. Additional funding sources available that are often considered are CFT Funds which allows for housing and rental assistance, PNP Tutoring services available through the PNP Tutoring Contract (OCCTAC), support services through the Family Support Network (FSN) Support Services Contract, services and support from FaCT, the 15 Family Resource Centers in Orange County, OC Navigator (services and supports website for all needs in OC), CalWorks services, Regional Center of Orange County, other contracts such as Bringing Families Home with temporary and long term housing assistance, Bridge Child Care Services, and other Food and housing services. Each agency exhausts all internal and community resources that are developed within their own agency.
8.6c
No single funding source requirements limit families from accessing flexible funds to meet their needs. All families needs are met at any given time. Each contracted Wrapround Provider is funded with $325,000 per year to cover flex funds, per agency. None of the agencies have been at or near meeting their flex fund spending. Additional funding sources are also available and carefully assessed/considered. Additional resources regularly considered are: CFT Funds which allows for housing and rental assistance, PNP Tutoring services available through the PNP Tutoring Contract (OCCTAC), support services through the Family Support Network (FSN) Support Services Contract, services and support from FaCT, the 15 Family Resource Centers in Orange County, OC Navigator (services and supports website for all needs in OC), CalWorks services, Regional Center of Orange County, other contracts such as Bringing Families Home with temporary and long term housing assistance, Bridge Child Care Services, and other Food and housing services. Each agency exhausts all internal and community resources that are developed within their own agency. Please also refer to Direct Services Contract Agreement, Attachment A, page 56 section 16.1 and 16.2 (medical dollars). This is trained to at CORE day 3-4, Flex Funds Training, OCIMS Training, days 2-3, Wraparound Overview Training, new CC training, and monthly Wraparound Institute training. This is also addressed at monthly Site Support Meetings and Site Reviews, Flex Funds Training. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
9.1a
Yes, the demographic composition of the population served is monitored and processes are in place to recruit/hire staff according to population needs. Please refer to the OICMS training materials for days 3 & 4; Wraparound Overview; WRIT Weekly report, which is tracked at weekly WRIT Meetings. Each contracted agency sends out an agency employee roster every month, which includes language capabilities. This expectation is also noted in the Direct Services Contract Agreement, Attachment A, page 29, sections 6.8.2, 6.8.3; page 30, section 6.11.1; page 34, sections 7.4,7.4.1, 7.4.1.1-1.3; page 57, sections 17.1, 17.2, 17.3 & 17.4;
9.1b
When unable to recruit/hire according to cultural, racial, and linguistic needs, efforts are made to meet families’ needs for cultural representation through alternative means such as engaging natural or formal supports on the HFW team. Please refer to OCIMS training materials for days 1-4; CORE training materials for days 1, 2, & 3; Natural Supports Training; Wraparound Intake; Wraparound Commencement & Site review tool. This expectation is noted in the Direct Services Contract Agreement, Attachment A, page 6, sections 2.24, 2.25; page 20, sections 3.1.4, 3.1.5; page 60 Section 17.7.1.18; page 65 Section 17.7.4.2; page 57, Section 17.1 – 17.2 – 17.3 Pg 68 17.7.6; page 6, section 2.24 -2.25 (cultural Competency); page 13, Section 2.56; page 20, section 3.1.4; page 22, section 5.3, page 26, section 5.13 & 5.16 & 5.17; page 12, section 2.51 & 2.52; page 73, section 17.7.7.14 (natural Supports); page 74, section 17.7.16
9.1c
When unable to provide a staff member who can provide services in the family’s language, a translator is utilized. The Social Services Agency has a Language Line & American Sign Language (ASL) contract; additionally, the Health Care Agency (HCA) has a free translation line, which the contracted providers can also access. Please refer to the Core training materials for days 1- 4. This expectation is noted in the Direct Services Contract Agreement, Attachment A, page 22, section 5.3; page 27, section 5.16.2, 5.17, 5.17.1. Additionally, families are welcome to invite natural supports or any other person the family wishes to invite to CFT meetings.
9.2 Tribally Responsive Workforce
9.2a
Staff are trained across the board on the importance of traditions, and values, as well as how to ensure respectful communication, collaboration, and advocacy. Training is being developed to train staff on tribal sovereignty, traditions, and values, as well as how to ensure respectful communication, collaboration, and advocacy regarding tribal sovereignty. Please refer to the Core training materials for days 1-4 & OCIMS training, days 1-4, for additional training materials. Further, staff will be trained on this topic regularly through Wraparound Institute Trainings and the following Professional Growth Trainings: Sup. CC, YP, PP. Please note that the Wraparound referral form is also in the process of being modified in order to reflect information being gathering related to tribal matters. The Direct Services Contract Agreement will be updated during the next contract cycle to be inclusive of tribal related matters. For now, please refer to Direct Services contract Attachment A, pg. 6, 2.24 & 2.25; pg. 20, 3.1.4; pg. 29, 6.8.3; pg. 11, 2.44; pg. 14, 2.64; pg. 18, 2.88; page 26, 5.15; pg. 78, 18.2.4 and 18.25.
9.2b
Training is being developed for HFW teams to build partnerships with tribal representatives, encouraging participation in tribal traditions and ceremonies and understanding the value of services and supports that the Tribe can offer, when serving an Indian child. Please refer to the Core training materials for days 1-4; Wraparound Institute Trainings; the following Professional Growth Trainings: Sup. CC, YP, PP. Please note that the Wraparound referral form is also in the process of being modified in order to reflect information being gathering related to tribal matters. The Direct Services Contract Agreement will be updated during the next contract cycle to be inclusive of tribal related matters.
9.3 Flexible and Creative Work Environment
9.3a
Program quality and improvement measures are routinely evaluated through the following processes: Utilization Review/Site Reviews, Site Support Meetings, Plan of Care (POC) meetings; WRIT/Directors & Supervisor Quarterly Meetings; Wraparound Monthly Institute Trainings for professional development, Family Satisfaction Survey, WFI, Technical Assistance (TA) Meetings, Professional Growth Training Series for Supervisors, Care Coordinators, Youth Partners & Parent Partners; Wraparound Core Training Days 1-4; OCIMS Training Days 1-4. Data Monitoring is done via Monthly Progress Report, Monthly Tickler Report; Monthly Phase & Progress report; Quarterly Contracts Review. Please refer to the Direct Services Contract, Attachment A, page 11, section 2.44; Attachment A, Page 15, section 2.69; Attachment A, Pages 52-53, section 14.1 -14.4; Attachment A, Pages 76- 80, & entirety of section 18; Attachment A, Pages 81 -82, sections 19.1 – 19.2.3
9.3b
Cohesion is promoted and evaluated through the following processes: Utilization Review/Site Reviews, Site Support Meetings, Plan of Care (POC) meetings; WRIT/Directors & Supervisor Quarterly Meetings; Wraparound Monthly Institute Trainings for professional development, Family Satisfaction Survey, WFI, Technical Assistance (TA) Meetings, Professional Growth Training Series for Supervisors, Care Coordinators, Youth Partners & Parent Partners; New Care Coordinators/ Parent Partners/ Youth Partners Training Series; Wraparound Core Training Days 1-4; OCIMS Training Days 1-4. Please refer to the Direct Services Contract, Attachment A, Pages 28 – 33, section 6 in its entirety. Attachment A, Pages 52-53, section 14.1 -14.4. Attachment A, pages 76- 81, & entirety of section 18. Attachment A, Page 73, section 17.7.7.8.
9.3c
Open Communication is evaluated through the numerous meetings and trainings which include the following processes: Utilization Review/Site Reviews, Site Support Meetings, Plan of Care (POC) meetings; WRIT/Directors & Supervisor Quarterly Meetings; Wraparound Monthly Institute Trainings for professional development, Family Satisfaction Survey, WFI, Technical Assistance (TA) Meetings, Professional Growth Training Series for Supervisors, Care Coordinators, Youth Partners & Parent Partners; New Care Coordinators/ Parent Partners/ Youth Partners Training Series; Wraparound Core Training Days 1-4; OCIMS Training Days 1-4. Please refer to the Direct Services Contract: Attachment A, Page 60, section 17.7.1.15. Attachment A, Page 65, section 17.7.4.1. Attachment A, Page 68, section 17.7.6.2. Attachment A, Pages 69-70, section 17.7.6.16. Attachment A, Pages 80-81, sections 18.3 – 18.8. Attachment A, Pg. 74, section 17.7.7.22.
9.3d
Creating a clear sense of mission and compliance with HFW philosophy (principles, values, phases and activities) is monitored through the following processes: Utilization Review/Site Reviews, Site Support Meetings, Plan of Care (POC) meetings; WRIT/Directors & Supervisor Quarterly Meetings; Wraparound Monthly Institute Trainings for professional development, Facilitation Training, Critical Thinking Training, Family Satisfaction Survey, WFI, Technical Assistance (TA) Meetings, Professional Growth Training Series for Supervisors, Care Coordinators, Youth Partners & Parent Partners; New Care Coordinators/ Parent Partners/ Youth Partners Training Series; Wraparound Core Training Days 1-4; OCIMS Training Days 1-4. Please refer to the Direct Services Contract: Attachment A, pages 76- 81, & entirety of section 18.
9.4 Hiring, Performance Evaluation, and Job Descriptions
9.4a
Each of the above roles or functions are met within the HFW program either through a unique position or through combining positions with clearly defined role descriptions and responsibilities.
The roles and functions meet the HFW program standards through a unique position or through combining positions with clearly defined role descriptions and responsibilities. These roles & functions are defined and described through the following: Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Additionally, these roles and functions are reviewed in the following training series: Professional Growth Training Series for Supervisors, Care Coordinators, Youth Partners & Parent Partners; New Care Coordinators/ Parent Partners/ Youth Partners Training Series; Utilization Review/Site Reviews, Site Support Meetings, Plan of Care (POC) meetings. Please refer to the Training matrix list. Please refer to the Direct Services Contract: Attachment A, page 54, section 16; Attachment A, Page 55, item 16.1. Attachment A, Page 57, section 17 in its entirety, which describes all the roles for Care Coordinator, Mental Health Clinician, Parent Partner, Program Director, Quality Assurance Coordinator, Wraparound Supervisor, Youth Partner. Additional Administrative positions include Community Involvement Coordinator; Executive Director; and Executive Assistant, each at five hundredths (.05) FTE; and HR Director; HR Recruiter; HR Assistant; Quality Assurance Supervisor; and Regional Programs Director, each at one tenth (.10) FTE.
9.4b
The roles and functions meet the HFW program standards through a unique position or through combining positions with clearly defined role descriptions and responsibilities. These roles & functions are defined and described through the following: Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Additionally, these roles and functions are reviewed in the following training series: Professional Growth Training Series for Supervisors, Care Coordinators, Youth Partners & Parent Partners; New Care Coordinators/ Parent Partners/ Youth Partners Training Series; Utilization Review/Site Reviews, Site Support Meetings, Plan of Care (POC) meetings. Please refer to the Training matrix list. Please refer to the Direct Services Contract: Attachment A, page 54, section 16; Attachment A, Page 57, section 17 in its entirety, which describes all the roles for Care Coordinator, Mental Health Clinician, Parent Partner, Program Director, Quality Assurance Coordinator, Wraparound Supervisor, Youth Partner. Additional Administrative positions include Community Involvement Coordinator; Executive Director; and Executive Assistant, each at five hundredths (.05) FTE; and HR Director; HR Recruiter; HR Assistant; Quality Assurance Supervisor; and Regional Programs Director, each at one tenth (.10) FTE. Attachment A, Pages 54- 55, item 16.1 – 16.3
9.4c
The roles and functions meet the HFW program standards through a unique position or through combining positions with clearly defined role descriptions and responsibilities. These roles & functions are defined and described through the following: Core training – days 1-4; OCIMS training – days 1-4; Professional Growth Training Series for Supervisors, Care Coordinators, Youth Partners & Parent Partners; New Care Coordinators/ Parent Partners/ Youth Partners Training Series; Utilization Review/Site Reviews, Site Support Meetings, Plan of Care (POC) meetings. Please refer to the Training matrix. Please refer to the Direct Services Contract: Attachment A, page 54, section 16; page 57, all of section 17 which describes all the roles for Care Coordinator (page 58, section 17.7.1), Mental Health Clinician (page 61, section17.7.2), Parent Partner (page 62, section 17.7.3), Program Director (page 65, section 17.7.4), Quality Assurance Coordinator (page 67, section 17.7.5), Wraparound Supervisor (page 68, section 17.7.6), Youth Partner (page 72, section 17.7.7). Additional Administrative positions include Community Involvement Coordinator; Executive Director; and Executive Assistant, each at five hundredths (.05) FTE; and HR Director; HR Recruiter; HR Assistant; Quality Assurance Supervisor; and Regional Programs Director, each at one tenth (.10) FTE. Please refer to the Direct Services Contract: Attachment A page 55, item 16.1 (5).
9.4d
The hiring process includes opportunities that allow candidates to demonstrate specific attitudes and skills essential to the position, which is noted in the Direct Services Contract, Attachment A, page 58, section 17.2, 17.3, 17.4, 17.5, 17.6, and all of 17.7. The hiring process for Wraparound staff incorporates defined minimum qualifications for each position, along with structured opportunities for candidates to demonstrate the attitudes and skills essential to the role. Each Wraparound position Care Coordinator, Clinician, Parent Partner, Program Director, Quality Assurance Coordinator, Wraparound Supervisor and Youth Partner) includes required qualifications such as relevant education, lived experience, specialized training, and competencies aligned with Wraparound values. Please refer to the Direct Services Contract: Attachment A, pages 61- 76: Care Coordinator, page 61, section 17.7.1.22, Clinician, page 62, 17.7.2.12, Parent Partner, page 64, 17.7.3.17; Program Director, page 67, 17.7.4.20, Quality Assurance Coordinator, page 68, 17.7.5.12, Wraparound Supervisor, page 71, 17.7.6.35 and Youth Partner, page 76, 17.7.7.32.
During screening and interviews, candidates are evaluated through scenario based questions and inquiries about the ability to complete role specific tasks. Both of which are designed to assess the skills identified in the job qualifications, including cultural humility, family engagement, collaboration, problem-solving, and strength based practice. By aligning required qualifications with practical assessment activities, the hiring process ensures applicants can demonstrate both their technical readiness and their commitment to Wraparound principles.
Additionally, this is evident through the recruitment, selection and training process of Parent Partners. This is noted in the Support Services contract, Attachment A, page 21, section 5.3 and 5.4, page 24, section 9, page 31, all of section 14, page 38, section 15.4 page 43, all of section 1; all of section 5;
9.4e
Employees are provided clear expectations for their performance in Core Training, days 1-4; OCIMS training, days 1-4; Professional Growth Training Series for Supervisors, Care Coordinators, Youth Partners & Parent Partners; New Care Coordinators/ Parent Partners/ Youth Partners Training Series; Utilization Review/Site Reviews, Site Support Meetings, Plan of Care (POC) meetings: Please refer to the Direct Services Contract: Attachment A page 76, all of section 18.0). Please refer to the Training matrix. Employees receive frequent feedback and coaching to support their success through the same trainings as listed above. Additionally, through Utilization Reviews/Site Reviews, Technical Assistance meetings, Family Satisfaction Survey & WFI results; Monthly Institute Trainings. Each employee receives monthly individual supervision and on-going guidance as needed as well as an annual performance evaluation for staff assigned for supervision: Please refer to the Direct Services Contract: Attachment A, page 79, section 18.2.8; page 80, section 18.4, section 18.5 and section 18.6 and Attachment A, page 71, section 17.7.6.26. Additionally, the WRIT team is available to provide further guidance and support as needed: Please refer to the Direct Services Contract: Attachment A page 19, section 2.90.
9.5 Workforce Stability
9.5a
Cost analyses are conducted prior to issuing the Request for Proposals (RFP) for Wraparound service providers to ensure that recommended wages align with the cost of living in the geographic area where services will be implemented. The cost analyses served as a foundational step in the development of the Wraparound service provider contract. this is completed by SSA contracts prior to the development of the contract.
9.5b
WRIT works strategically and meets on a weekly basis to maintain manageable workloads for staff, ensuring that there is an equitable distribution of cases across the three contracted provider agencies and also strives to ensure that contracted provider agencies are not assigned an excessive number of cases simultaneously. Please refer to Direct Services Contract, Attachment A, page 33 all of section 7, page 33, section 7; page 58, section 17.7
9.5c
As part of the contract and application process, each contracted agency is asked to identify promotion process and opportunities for advancement. All providers share their plans in their proposed request for proposals and at no time is it prohibitive for those with lived experiences to advance. Administrative exceptions are in place, in case they are needed. All staff are afforded opportunities to participate in additional trainings that may be offered by community-based organizations, private non-profit agencies and county entities. Orange County Wraparound contract administrators do not determine wage increases and leadership opportunities for employees of the contract providers. However, the Orange County Wraparound contract administrators actively support and advocate for both when employees demonstrate merit and meet qualifications for a proposed promotion.
9.5d
All staff are afforded opportunities to participate in additional trainings that may be offered by community based organizations, private non-profit agencies and county entities. Providers set their staffing budgets within their budgets proposed at time of request for proposal submissions and agree to those rates when they sign contracts. If contracted providers propose increases, as long as they are within their proposed budgets and salaries, they can make those decisions. Orange County Wraparound contract administrators do not determine wage increases and leadership opportunities for employees of the contract providers. However, the Orange County Wraparound contract administrators actively support and advocate for both when employees demonstrate merit and meet qualifications for a proposed promotion.
9.6 High Fidelity Training Plan
9.6a
All staff in HFW Orange County receive initial HFW training through the following methods: All staff receive ongoing training both in general Wraparound (CORE training) and in their specific role through formal trainings, meetings, coaching, peer shadowing, and/or supervision. All staff receive booster trainings at least annually in general Wraparound and in their specific roles. Clinical Supervisors and HFW Supervisors/Managers attend general Wraparound training as well as receive initial, ongoing, and booster trainings specific to their leadership/supervisory role. The primary training formats are: Core Training, days 1-4; OCIMS training, days 1-4. Please see Training Matrix for a comprehensive list of all required trainings per role. Please see entire list of all mandated trainings for reach role type and in general the list of trainings described by title and frequency. All trainers that provide OC Wrapround Core training have received training from Wraparound 101 Foundations for Fidelity Training Curriculum. Please note than UC Davis Staff Rebekah Cox and Dawne Shaw were present when all of OC Wraparound county, contracted Provider staff (Program Directors and Supervisors), Health Care Agency staff and Probation staff (trainers) attempted to complete Wraparound CORE training T4T in October 2023. We were advised that OC Wraparound did not need to complete the T4T since we were planning to utilize our own Core training, as long as we completed a crosswalk, ensuring that we covered all items from UC Davis Wraparound Foundational Training. OC SSA has indeed completed a crosswalk to ensure that Wraparound OC Core training covers all topics covered in Foundational Wraparound training from UC Davis.
9.6b
All staff in HFW Orange County receive initial HFW training through the following methods: All staff receive ongoing training both in general Wraparound (CORE) and in their specific role through formal trainings, meetings, coaching, peer shadowing, and/or supervision. All staff receive booster trainings at least annually in general Wraparound and in their specific roles. Clinical Supervisors and HFW Supervisors/Managers attend general Wraparound training as well as receive initial, ongoing, and booster trainings specific to their leadership/supervisory role. The primary training formats are: Core Training, days 1-4; OCIMS training, days 1-4. Please see Training Matrix for a comprehensive list of all required trainings per role.
9.6c
All staff in HFW Orange County receive initial HFW training through the following methods: All staff receive ongoing training both in general Wraparound and in their specific role through formal trainings, meetings, coaching, peer shadowing, and/or supervision. All staff receive booster trainings at least annually in general Wraparound and in their specific roles. Clinical Supervisors and HFW Supervisors/Managers attend general Wraparound training as well as receive initial, ongoing, and booster trainings specific to their leadership/supervisory role.
9.6d
All staff in HFW Orange County receive initial HFW training through the following methods: All staff receive ongoing training both in general Wraparound and in their specific role through formal trainings, meetings, coaching, peer shadowing, and/or supervision. All staff receive booster trainings at least annually in general Wraparound and in their specific roles. Clinical Supervisors and HFW Supervisors/Managers attend general Wraparound training as well as receive initial, ongoing, and booster trainings specific to their leadership/supervisory role. The primary training formats are: Core Training, days 1-4; OCIMS training, days 1-4. Please see Training Matrix for a comprehensive list of all required trainings per role.
9.6e
An ICWA training will be given once annually to all roles providing HFW. The Wraparound referral will be revised to include a mechanism to provides services and supports for Indian child/youth. We are also including in our referral form a mechanism to identify Indian child/youth.
9.7 Community-based Training Program
9.7a
Youth, families and peer partners with current or prior Wraparound experience are meaningfully incorporated into the delivery of required Wraparound trainings. Parents are included in CORE Wraparound Training, Day 4 by having them present and describe how participating in Wraparound services impacted thei lives. Youth have also been included in YP training by having them present. Please refer to the Trainings Matrix and along with CORE power points and New Youth Partner training along with corresponding agendas.
9.7b
Community partners (HCA and Probation) are part of the WRIT team and part of the training committee. All of CFS, HCA and Probation has been invited to attend Overview Wraparound training. As part of the System of Care Meetings (SOC), updates are provided with regards to Wraparound. A more targeted approach will be made to offer Wraparound Overview training to more community partners moving forward so they can be of support to HFW efforts. Please refer to the Trainings Matrix along with CORE power points and corresponding agendas.
9.8 Coaching and Supervision
9.8a
All staff are provided with an initial training that covers values, skills, and knowledge related to HFW principles, phases and activities, and the effective use of flex funds to meet a family’s needs. This is accomplished through Overview Training, which is offered monthly for new staff. The material is covered in greater depth during Flex Fund Training, Wraparound CORE Training and OCIMS Training, specifically on Days 2 and 4. It is also reinforced during monthly Site Support Meetings, POC Presentations, and Technical Assistance Meetings. Additionally, newer staff shadow more experienced staff prior to being assigned Wraparound referrals. Referrals are then assigned in a staggered manner to support staff in learning and effectively applying Wraparound principles and processes. Please also refer to Direct Services Contract Agreement, Attachment A, page 38-41, section, 9-9.4.1.10; page 76-81, section, 18-18.8. Additional information can be found on the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas.
9.8b
All staff have access to supervision or coaching 24/7 as needed. Please refer to Direct Services contract page 60, section 17.7.1.15 where it indicates that Care Coordinators (Facilitators) provide supervision, direction, support, and/or emergency crisis management to Parent Partners and Youth Partners, twenty-four (24) hours a day, seven (7) days a week, including holidays, utilizing an on-call system after business hours. Program directors also provide clarification, direction, support, and emergency crisis
management to direct services staff, twenty-four (24) hours a day, seven (7) days a week, including holidays, utilizing an on call system after business hours as noted in Direct Services contract page 65, section 17.7.4.4. Last Wraparound Supervisor provides supervision, direction, support, and emergency crisis management to direct service staff twenty-four (24) hours a day, seven (7) seven days a week, including holidays, utilizing an on-call system after business hours as noted on page 70, section 17.7.6.18 in Direct Services Contract
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.1a
Orange County Intervention Management System is a database system used to track Wraparound data and create reports through the collaborative efforts of SSA, HCA, and Probation and contracted Wraparound Providers. The database system is utilized to collect data and generate reports regarding Wraparound OC services. It is a vital communication tool between Care Coordinating Agencies (CCA) and the Wraparound Review and Intake Team along with its constituents. Outcomes are tracked regarding school performance, number of natural supports, placement of a youth in a family like setting and frequency of placement moves and whether they are in a family like setting. The WRIT team confirms that there is a current safety plan in place at time of commencement and confirms that families are connected to natural supports and family resources centers. Flex funds are also captured and monitored in this system. Please also refer to Direct Services Contract Agreement, Attachment A, page 21, section 3.2 goals and 3.3 strategies.
10.1b
Relevant child-serving entities (minimally child welfare, probation, behavioral health, and providers) enable sharing of information necessary to implement the local CQI evaluation plan. This is accomplished through WRIT/Director/Supervisor Meeting, WRIT Meetings, Wrap OC Institute Training, Wrap OC Professional Growth Trainings, OCIMS Training (Day 1), Utilization Reviews/Site Reviews and monthly Support Visits. The following reports are also utilized: monthly Phase & Progress Report, monthly Progress Report, monthly Tickler Report, Family Satisfaction Survey, and WFI report. Please also refer to Direct Services Contract Agreement, Attachment A, page 16, section 2.72; page 18, section 2.86; page 52-55, section 14.1; page 78, section 18.2.4; page 78, section 18.2.5; page 81-82, section 19-19.2.3. Additional information can be found on the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas.
10.1c
Collected data is current, accurate, and used to inform and improve practice locally and assure accountability for achievement of desired outcomes. This is accomplished through the use of the following quality assurance reports: Phase & Progress Reports, Monthly Progress Reports, Monthly Tickler Reports, Family Satisfaction Surveys, and WFI Reports. Information is also reviewed and shared through the following meetings and trainings: monthly Support Visits, Utilization Reviews/Site Reviews, WRIT/Director/Supervisor Meetings, WRIT Meetings, Wrap OC Institute Training, Wrap OC Professional Growth Trainings, and OCIMS Training (Day 1). Please also refer to Support Services Contract Agreement, Attachment A, page 16, section 2.72; page 18, section 2.86; page 52-55 , section 14-14.4 ; page 80-82, Section 18.3-19.2.3; Additional information can be found on the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas.
10.1d
Data is collected at the level closest to the individual and subsequently uploaded in an appropriate format for analysis at the next appropriate level. This is accomplished through the Family Satisfaction Survey and WFI Report. This information is also reviewed at OCIMS Training (Day 1). Please also refer to Direct Services Contract Agreement, Attachment A, page, section page 16, section 2.72; page 18, section 2.86.
10.2 Evaluation Metrics & Outcomes
10.2a
Yes, data is utilized to improve practice with youth and families, including giving staff timely feedback from data or reports relevant to their service provision and using data to identify staff training needs. We achieved this by running various Outcomes and Compliance reports in OCIMS (database) such as: Referral Summary; Face to Face and Plan of Care CFT statistical compliance; Length of Wraparound Service; Wrap Flex Fund report; Wrap Phase & Progress Report; Graduation Report; Family Satisfaction Survey and Wraparound Fidelity Index Survey reports. Please refer to the Trainings Matrix and Meetings Matrix. Please also refer to OCIMS Day 1 thru 4; Site Review; Support Visits; Phase & Progress Report; Progress Report; Tickler. This is also accomplished by reviewing Family Satisfaction Survey and WFI results. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 15; 3.2.1-3.4 page 21; 19.1-19.2.3 page 81-82; 12.7.1 page 50, section 2.69. Please also refer to Provider Network Program Tutoring Services Contract Agreement, Attachment A, page 9, section Service requirements 6.11 thru 6.24 Youth Academic assessments.
10.2b
Yes, Data is utilized to identify and address program needs to better serve families and improve overall program effectiveness. We accomplish this by running various Outcomes and Compliance reports in OCIMS such as: Wraparound Status Report that contains family demographics such as Gender; Primary Language of youth and caregiver (one factor to consider in hiring staff so we are able to match the family with a wrap team); and age group ; Family members receiving CalWORKs; placement of youth at the start and end of Wraparound. We also run Wrap Flex Fund report, which identifies family needs by service categories parallel to their Life Areas of concern.; Wrap Phase & Progress Report; Graduation Report (used to identify reasons for commencement such as Family/Youth made progress towards goals or Family is no longer interested in Wraparound). We also regularly review Wraparound Fidelity Index surveys conducted for families that have been through the wraparound process for at least 4 months and share results with Providers in various meetings. Reports assess Wraparound OC’s fidelity strengths and areas for more growth. OC Wrap has been very successful in running High fidelity Wraparound for many areas. One area we are focusing on improvement is building up Natural supports for families. OC Wraparound also reviews and assesses Training evaluations after every training administered I order to assess for improvement from learners. Please refer to the Trainings Matrix and Meetings Matrix. This is reviewed and trained to in OCIMs Day 1 thru 4. This is also reviewed and assessed in the following meetings: Site Review; Support Visits; Phase & Progress Report; Progress Report; Tickler. This is also captured in Family Satisfaction Surveys and WFI results which are regularly reviewed and shared with providers. Please refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 15; 3.2.1-3.4 page 21; 19.1-19.2.3 page 81-82; 12.7.1 page 50, section 2.69. Please also refer to Support Services Contract Agreement, Attachment A, page, 41 & 42 Overview section 1.1.5 ; 2.72. Please also refer to Provider Network Program Tutoring Services Contract Agreement, Attachment A, page , section 1; Population served section 1.1.1 thru 1.2.2; pages 26 & 27. Please also refer to Wraparound referral form which clearly documents data elements that are gathered and captured. For information gathering.
10.2c
Yes, please refer to answer in 10.2 b. In addition, data is utilized to identify and communicate system barriers to the Community Leadership Team by reviewing Plans of Care, notes, safety plans, during Presentation meetings, Technical Assistance Meetings, Site Support meeting, Phase & Progress Reports; Progress Report; Tickler; results of Family Satisfaction Survey and WFI. Overarching barriers or issues are discussed in weekly WRIT meetings, Directors & Sups meeting, Program Director, Executive Director and WOG meetings. This high-level meeting takes place in order to ensure the model’s standards are met at the organizational and systems level, fostering local accountability and resource development. This ILT oversees policy, training, and strategic planning, ensuring services remain family-centered and community-based. Items typically addressed are OCIMS CCA Oversight, Progress Reports Ticklers, Family Satisfaction Survey & WFI results in order to help guide processes and identify barriers to overcome. Please refer to the Trainings Matrix and Meetings Matrix. Please also refer to OCIMS Day 1 training thru Day 4. Please also refer to the Trainings Matrix and Meetings Matrix along with OCIMS and CORE power points and corresponding agendas. Please also refer to Direct Services Contract Agreement, Attachment A, page 15; 3.2.1-3.4 page 21; 19.1-19.2.3 page 81-82; 12.7.1 page 50, section 2.69.
Fidelity Indicators
1.1 Timely Engagement and Planning
Sycamores’ approach to Timely Engagement and Planning is grounded in High Fidelity Wraparound (HFW) principles and aligns with California HFW Standards and Los Angeles County Department of Mental Health (DMH) Full Service Partnership (FSP HFW) requirements. Timely engagement is treated as foundational to effective service delivery, emphasizing early and persistent outreach, culturally responsive practices, and ongoing collaborative planning with youth and families. These expectations are formalized through agency policies and procedures, the Sycamores HFW Comprehensive Practice Guide, references to California HFW Standards, and the LA County DMH FSP HFW Program Service Exhibit.
Standard 1.1(a): First contact within 10 calendar days of referral
Sycamores meets the requirement for first contact by initiating Outreach and Engagement activities within 24 hours of referral receipt. Face to face engagement occurs within 24 hours for youth in hospital, psychiatric, emergency room, or urgent care settings, and within 72 hours for youth in community or institutional settings such as juvenile halls, probation camps, or STRTPs. Engagement efforts are persistent, strengths based, and culturally responsive, continuing until the family is successfully engaged or outreach is discontinued following consultation with LA County DMH. Evidence of these practices includes Avatar EHR referral records, outreach notes documenting contact attempts, EHR timestamps indicating first contact and face to face engagement, outreach logs and progress notes, and referral and engagement entries in LA County DMH Service Request Tracking System (SRTS) and Wraparound Tracking System (WTS), (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.1 Timely Engagement and Planning Practice Guideline, pages 1-4).
Standard 1.1(b): Completion of Wraparound Plan of Care within 30 calendar days
Following engagement and enrollment, the Facilitator leads the Child and Family Team (CFT) in collaboratively developing a Wraparound Plan of Care within 30 calendar days of the start of services. The Plan of Care reflects the youth and family’s vision, strengths, needs, individualized strategies, and defined team roles, and serves as the guiding framework for service coordination and implementation. Supporting artifacts include signed Wraparound Plans of Care, Plan of Care completion dates documented in Avatar EHR, intake and enrollment documentation, and CFT meeting notes that support plan development (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.1 Timely Engagement and Planning Practice Guideline, pages 1-4).
Standard 1.1(c): Review of the Plan of Care every 30–45 calendar days
Sycamores ensures that the Child and Family Team reviews the Wraparound Plan of Care during CFT meetings held at least every 30–45 days. These reviews assess progress toward goals, the effectiveness and relevance of strategies, emerging needs, and continued alignment with family priorities. Documentation of these practices is found in CFT meeting agendas and minutes, progress notes explicitly referencing Plan of Care review, and updated action items documented within Avatar EHR (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.1 Timely Engagement and Planning Practice Guideline, pages 1-4).
Standard 1.1(d): Update and distribution of the Plan of Care at least every 90 days
The Wraparound Plan of Care is formally updated, redistributed to all team members, and documented in the youth’s record at least every 90 days, or more frequently as circumstances change. Updates reflect progress toward outcomes, revised goals or strategies, and newly identified supports or services. The Plan of Care is treated as a living document that evolves with the family’s needs. Evidence includes dated versions of updated Plans of Care, documentation of distribution (such as EHR access records, email logs, or signatures), and records of revisions entered into Avatar EHR (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.1 Timely Engagement and Planning Practice Guideline, pages 1-4).
Standard 1.1(e): Feedback to staff and supervisors for CQI purposes
Sycamores provides ongoing feedback to staff and supervisors regarding adherence to engagement and planning timelines as part of its Continuous Quality Improvement (CQI) process. Supervisors monitor referral, engagement, and Plan of Care timelines through review of Avatar EHR documentation, internal tracking spreadsheets, and KPI dashboards. Feedback related to performance and fidelity is delivered through supervision and case review processes and is used to inform coaching and improvement efforts. Artifacts supporting this requirement include supervisor case review notes, internal tracking tools, KPI dashboard reports, and supervision documentation that reflects feedback and CQI discussions (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.1 Timely Engagement and Planning Practice Guideline, pages 1-4).
Standard 1.1(f): Staff training on timely engagement strategies
Timely engagement expectations are embedded in staff onboarding, reinforced through supervision, and addressed through ongoing training. Staff receive instruction on outreach timelines, county and contract requirements, and culturally responsive strategies for engaging families who may be difficult to locate or hesitant to participate. Completion of these trainings is documented through the HFW New Hire Orientation Passport and maintained in Human Resources files. Additional artifacts include training curricula, sign in sheets, supervision documentation referencing engagement coaching, and HR training completion records (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.1 Timely Engagement and Planning Practice Guideline, pages 1-4).
Across all components of standard 1.1, Sycamores supports timely engagement and planning through robust documentation and monitoring systems. Engagement and planning activities are documented in Avatar EHR, LA County DMH SRTS and WTS systems, and Child and Family Team progress notes. Supervisory review and KPI tracking are used to monitor timeliness and fidelity. Planned enhancements, including integration of the Wraparound Plan of Care template into the EHR, will further strengthen documentation consistency, leadership oversight, and fidelity monitoring.
Supporting Documents:
✔1.1 Timely Engagement and Planning Practice Guideline (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.1 Timely Engagement and Planning Practice Guideline, pages 1-4).
✔Avatar NX Pre-Admit Screen Shot (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.1, page 33)
✔Avatar NX COS Notes Screen Shot (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.2, pages 34-35)
✔ LA County SRTS Screen Shot (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.3, pages 36-44)
✔ KPI Dashboard Screen Shot- Referral to Intake dashboard (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.4, page 45)
✔LA County Plan of Care (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.5, pages 46-52)
1.2 Led by Youth and Families
Current practice at Sycamores demonstrates alignment with this standard by identifying family voice and choice as a foundational principle of HFW and embedding it throughout all aspects of service delivery. Youth and families are explicitly recognized as the primary decision makers, and the Wraparound process is described as one developed with families rather than something done to them. Child and Family Teams (CFTs) are intentionally structured to ensure youth and caregivers have meaningful opportunities to share their perspectives and actively influence the development of strategies and supports. All HFW team members share responsibility for elevating and integrating youth and family voice, with the Facilitator playing a central role in guiding the team process, creating space for participation, and supporting informed family decision making (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.2 Led by Youth and Families Practice Guideline, pages 5-7).
Standard 1.2(a): Elicitation of Family Perspectives
The elicitation and incorporation of youth, caregiver, and Tribal perspectives is addressed through clear practice expectations at Sycamores. Team members actively solicit youth and caregiver input across all phases of Wraparound and support open dialogue to ensure each voice is heard and understood. When differences in perspective arise, teams work collaboratively to reach shared understanding and consensus, taking into account developmental considerations such as age, cognitive ability, and capacity for participation. For Indian youth, practice guidelines explicitly require that the Tribe’s voice be heard and incorporated alongside youth and caregiver perspectives, consistent with the standard’s requirement for equal Tribal participation (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.2 Led by Youth and Families Practice Guideline, pages 5-7).
Standard 1.2(b): Documentation and Case Record Standards
Youth and family voice is formally documented through foundational elements of the Plan of Care, demonstrating compliance with documentation requirements under the Standard. The Family Vision and Team Mission are developed early during engagement and planning, reflect the family’s long-term goals and desired outcomes, and serve as a stable anchor for decision making unless significant changes occur (e.g., placement change or court mandates). Family values, culture, expertise, capabilities, interests, and skills are actively elicited and documented, while strengths are updated over time as the team’s understanding of the family system deepens. This information serves as the basis for individualized strategy development and evaluation of progress Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.2 Led by Youth and Families Practice Guideline, pages 5-7).
Standard 1.2(c): Coaching, Supervision, and Fidelity Monitoring
At Sycamores, supervisory oversight and coaching further support fidelity to youth and family led practice. Supervisors routinely observe Child and Family Team meetings to assess how effectively youth and family voice is elicited and integrated. Plans of Care and selected progress notes are reviewed for clear evidence that family voice and choice are reflected in the vision, goals, and strategies. These activities are used to reinforce Wraparound principles, identify strengths in practice, and provide targeted coaching to build staff skill and confidence, consistent with the Standard’s supervisory expectations (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.2 Led by Youth and Families Practice Guideline, pages 5-7).
Standard 1.2(d): Family Feedback and Continuous Quality Improvement
Ongoing feedback from youth and families is systematically gathered and utilized. Structured feedback is obtained using the Wraparound Fidelity Index–EZ (WFI EZ), along with informal feedback gathered through CFT meetings and regular care coordination contacts. Supervisor observations also contribute insight into the family experience of Wraparound. Feedback is used to reinforce effective practice, identify opportunities for improvement, and inform supervision, coaching, and training efforts, aligning with the Standard’s requirement for routine feedback mechanisms (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.2 Led by Youth and Families Practice Guideline, pages 5-7).
Supporting Documents:
✔1.2 Led by Youth and Families Practice Guideline (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.2 Led by Youth and Families Practice Guideline, pages 5-7).
✔LA County Plan of Care (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.5, pages 46-52)
✔LATC Observation-Coaching Tool (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.6, pages 53-62)
✔Annual Satisfaction Survey (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.7, pages 63-80)
✔WFI-EZ (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.12, pages 107-110).
1.3 Strength-Based
Sycamores’ High Fidelity Wraparound (HFW) program implements a fully integrated, strengths based approach that is consistent with and exceeds the requirements outlined in Standard 1.3: Strength Based. Strength identification and utilization are embedded throughout engagement, planning, service delivery, supervision, and quality improvement processes. Functional strengths of the youth, family, team members, and community supports are consistently identified, documented, reviewed, and actively used to guide decision making and service planning, rather than treated as a standalone activity.
Standard 1.3(a): Strengths Inventory Development and Ongoing Use
Within HFW practice at Sycamores, a comprehensive strengths inventory is developed for the youth, family, Child and Family Team (CFT) members, and identified community and natural supports. Strengths are functional and actionable, emphasizing how each strength can be applied to support goals, address needs, and advance the family’s vision. This inventory is not static; it is continuously reviewed and updated as engagement deepens and as new information emerges. Strengths are routinely reviewed during CFT meetings and inform discussion, planning, and problem solving. The consistent emphasis on “what is working” reinforces a solution focused team culture and promotes engagement and shared accountability (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.3 Strength Based Practice Guideline, pages 8-10).
Standard 1.3(b): Use of the Integrated Practice – Child and Adolescent Needs and Strengths (IP CANS) for Strength Identification
The IP CANS is a required and critical component of strengths identification within Sycamores’ HFW model. It provides a structured framework for identifying youth and family strengths while supporting a shared practice language across team members. However, strength identification extends beyond the IP CANS and is enriched through ongoing engagement with the youth, family, and team. Staff actively elicit functional strengths through dialogue, observation, and relationship based practice. These strengths are contextualized and translated into actionable strategies within the Plan of Care, ensuring they are used meaningfully rather than documented descriptively (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.3 Strength Based Practice Guideline, pages 8-10).
Standard 1.3(c): Ongoing Coaching and Training in Strengths Based Practice
Sycamores ensures that strengths based practice is reinforced through ongoing coaching, reflective supervision, and targeted training. Supervisors play a key role in reviewing Plans of Care to assess the quality of identified strengths, ensuring they are functional, specific, and clearly linked to interventions and outcomes. Supervisory coaching focuses on helping staff deepen strengths discovery, translate strengths into actionable strategies, and maintain a strengths based perspective during complex or high risk situations. Supervisors model strengths based feedback by explicitly identifying and building on staff strengths during supervision (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.3 Strength Based Practice Guideline, pages 8-10).
Standard 1.3(d): Family Feedback and Continuous Quality Improvement
Sycamores utilizes multiple mechanisms to gather feedback from youth and families regarding their experience of strengths based services. The Wraparound Fidelity Index–EZ (WFI EZ) is a primary tool used to assess whether families feel their strengths are recognized, valued, and utilized throughout the Wraparound process. Additional feedback is collected through satisfaction surveys and ongoing interactions with families. This feedback is systematically reviewed and used to reinforce strong practice, identify areas for growth, and inform individual coaching, team level training, and broader quality improvement efforts (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.3 Strength Based Practice Guideline, pages 8-10).
Sycamores’ implementation of a strengths based approach within High Fidelity Wraparound demonstrates clear alignment with Standard 1.3. Strengths are actively identified, thoughtfully documented, and consistently applied across all levels of practice—from direct service delivery to supervision and quality improvement. This integrated approach ensures that strengths meaningfully drive planning, decision making, and outcomes for youth and families, consistent with Wraparound principles and fidelity expectations.
Supporting Documents:
✔1.3 Strength Based Practice Guideline (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.3 Strength Based Practice Guideline, pages 8-10).
✔LA County Plan of Care (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.5, pages 46-52)
✔LATC Observation-Coaching Tool (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.6, pages 53-62).
✔IP-CANS Assessment (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.8, pages 81-85).
✔Strengths Summary Sample (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.9, pages 86-87).
✔Sample Strengths Training (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.10, pages 88-101).
✔Questions to Identify Strengths (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.11, pages 102-106).
✔WFI-EZ (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.12, pages 107-110).
✔Child/ Adolescent Full Assessment (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.13, pages 111-118).
1.4 Needs Driven
High-Fidelity Wraparound (HFW) services and supports are needs-driven and focused on addressing the highest priority underlying needs of the youth and family. Needs statements reflect the underlying reasons why problematic situations or behaviors are occurring, rather than being framed as deficits, behaviors, diagnoses, or service requirements. The Wraparound process continues until identified needs are sufficiently met. The Integrated Practice – Child and Adolescent Needs and Strengths (IP-CANS) assessment is a required component for needs identification, prioritization, and planning.
Standard 1.4(a): Identification and Prioritization of Underlying Needs
At Sycamores, a needs-driven approach is foundational to all High-Fidelity Wraparound practice and guides assessment, planning, and service delivery. Underlying needs are identified early in the Wraparound process and prioritized before the development of goals, strategies, or services. Teams intentionally distinguish between surface-level behaviors and the unmet needs driving those behaviors, recognizing that sustainable change occurs only when core needs are effectively addressed. Needs are collaboratively identified with the youth and family to ensure alignment with their lived experience and perspective. Identified needs are documented in both the Plan of Care and the IP-CANS and are framed as underlying conditions rather than deficits, diagnoses, or service gaps. All strategies included in the Plan of Care demonstrate a clear and direct connection to prioritized needs, ensuring that interventions remain purposeful and individualized (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.4 Needs Driven Practice Guideline, pages 11-13).
Integration of Needs into Planning and Service Delivery -At Sycamores, needs serve as the organizing framework for all service planning and implementation. Plans of Care explicitly demonstrate alignment between identified needs, existing strengths, and selected strategies. During ongoing Child and Family Team meetings, teams regularly revisit prioritized needs to monitor progress, assess effectiveness, and determine whether adjustments to planning or strategies are required. When teams experience limited progress, repeated crises, or stalled outcomes, there is an intentional return to examining underlying needs. In these circumstances, structured tools such as the Needs Egg are used during supervision and case consultation to promote deeper clinical exploration and ensure that needs have been accurately identified and prioritized. This reflective practice supports fidelity to needs-driven planning and prevents service-driven or behavior-focused responses (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.4 Needs Driven Practice Guideline, pages 11-13).
Standard 1.4(b): Supervisor Coaching, Modeling, and Fidelity Monitoring
Supervisors play a critical role in reinforcing needs-driven practice through ongoing coaching, modeling, and fidelity monitoring. HFW Supervisors routinely integrate discussion of underlying needs into individual and group supervision, case consultation, and clinical review, alongside consideration of family history, strengths, and cultural context. Supervisors intentionally guide staff in shifting from behavior-focused conceptualizations to needs-based formulations, particularly in complex or high-risk cases. Plans of Care are reviewed to ensure that needs are clearly defined, strategies are directly linked to those needs, and planning reflects a needs-driven rather than service-driven approach. In addition, supervisors observe Child and Family Team meetings and review documentation, including progress notes, to assess adherence to this principle. Clinical Supervisors provide additional oversight related to IP-CANS fidelity, ensuring that identified needs are accurately reflected in assessment and planning processes (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.4 Needs Driven Practice Guideline, pages 11-13).
Standard 1.4(c): Training and Skill Development
Sycamores provides ongoing training and coaching to ensure staff competency in needs-driven practice. Training focuses on identifying underlying needs, developing clear and meaningful needs statements, distinguishing behaviors from the needs driving those behaviors, and utilizing needs-focused planning over behavior-focused or service-driven approaches. Skill development is reinforced through supervision, real-time feedback, and case consultation (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.4 Needs Driven Practice Guideline, pages 11-13).
Standard 1.4(d): Transition Based on Needs Being Met
Transition from Wraparound services is guided by the team’s shared determination that identified needs have been sufficiently met. Transition planning is collaborative and includes meaningful input from the youth, family, and team members. Decisions regarding transition are not based solely on duration of service or task completion but on whether the underlying needs that led to Wraparound involvement have been adequately addressed and stabilized. Documentation clearly reflects the relationship between identified needs and the rationale for transition (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.4 Needs Driven Practice Guideline, pages 11-13).
Finally, at Sycamores, multiple methods are used to monitor fidelity to needs-driven practice and inform continuous quality improvement. Family feedback is collected using the Wraparound Fidelity Index–EZ (WFI EZ) to assess whether services address what matters most to youth and families. In addition, supervisor observations of Child and Family Team meetings and review of Plans of Care provide ongoing insight into practice quality. Feedback from these sources informs supervision, coaching, and systemic quality improvement efforts (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.4 Needs Driven Practice Guideline, pages 11-13).
Supporting Documents:
✔1.4 Needs Driven Practice Guideline (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.4 Needs Driven Practice Guideline, pages 11-13).
✔LA County Plan of Care (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.5, pages 46-52).
✔LATC Observation-Coaching Tool (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.6, pages 53-62).
✔Needs Egg (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.14, page 119).
✔Sample Needs Training (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.15, pages 120-136).
✔ Case Consultation Template (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.26, page 195).
✔WFI-EZ (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.12, pages 107-110).
✔Family Assessment of Support System Tool – FAST (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.17, pages 165).
✔IP-CANS Assessment (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.8, pages 81-85).
✔Strengths Summary Sample with Brainstormed Needs (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.9, pages 86-87).
1.5 Individualized
At Sycamores, no two Wraparound Plans of Care are the same. Each Plan of Care is developed through a collaborative Child and Family Team (CFT) process that centers the youth and family voice and intentionally avoids reliance on standardized or default service approaches. Plans are designed to reduce harm over time and promote long-term success by aligning strategies with the family’s daily life, culture, values, natural supports, and community resources. When applicable, planning explicitly incorporates tribal engagement and cultural considerations for Indian children.
Standard 1.5(a): Flexible and Individualized Planning Tools
Sycamores utilizes documentation tools, including the Plan of Care, that allow for flexibility and creativity in service planning. These tools are structured to support individualized identification of needs, underlying drivers of behavior, strengths, outcomes, and strategies, rather than limiting teams to predefined interventions. Strategies documented in each Plan of Care must be clearly linked to identified needs and strengths and must be feasible within the family’s real-life context. Plans of Care are routinely reviewed to ensure that:
✔ Strategies reflect individualized needs and strengths rather than standardized services;
✔ Natural supports, informal networks, and community-based resources are meaningfully incorporated;
✔ Outcomes and strategies are relevant, culturally responsive, and family-driven.
(Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.5 Individualized Practice Guideline, pages 14-16).
Standard 1.5(b): Ongoing Training and Coaching for Staff
Sycamores provides ongoing training and coaching to ensure staff consistently deliver flexible, creative, and individualized services. Training focuses on:
✔ Identifying underlying needs and drivers rather than surface-level behaviors;
✔ Avoiding default or standardized service responses;
✔ Designing strategies that align with family culture, values, and daily routines;
✔ Incorporating natural supports and community resources.
Coaching occurs through supervision, case consultation, and real-time feedback, reinforcing the expectation that individualized planning is an ongoing, active practice rather than a one-time task (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.5 Individualized Practice Guideline, pages 14-16).
Standard 1.5(c): Facilitator Training and Coaching in Individualized Planning
Sycamores provides ongoing training and coaching to staff to strengthen their ability to design flexible, creative, and highly individualized strategies. Training emphasizes moving beyond traditional service models and developing interventions that fit the unique preferences, culture, routines, and environments of each family. Facilitators play a central role in ensuring the HFW process remains individualized. At Sycamores, Facilitators receive targeted training and coaching to strengthen their ability to lead Child and Family Teams in developing customized Plans of Care. Facilitator responsibilities include:
✔ Leading structured conversations that explore multiple creative options;
✔ Challenging teams when plans become repetitive or overly service-driven;
✔ Ensuring the youth and family’s voice, preferences, culture, and values guide all planning decisions;
✔ Supporting teams in adapting strategies over time based on effectiveness and family feedback.
Ongoing coaching supports Facilitators in refining their skills to guide teams toward meaningful, individualized solutions (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.5 Individualized Practice Guideline, pages 14-16).
Standard 1.5(d): Routine Review of Individualized Plans of Care
Sycamores routinely reviews Plans of Care to ensure they reflect individualized, strength-based planning. Supervisors assess plans for:
✔Clear alignment between identified strengths, needs, and strategies;
✔Evidence that strategies are customized rather than standardized;
✔Inclusion of natural supports, informal networks, and community-based resources;
✔Responsiveness to cultural considerations and family preferences.
Supervisor review is conducted through documentation audits, observation of CFT meetings, and case consultation. This process allows supervisors to provide targeted coaching and support continuous improvement in individualized practice. In addition, Supervisors reinforce these expectations through individual supervision, case consultation, and direct observation of CFT meetings. Supervisors play a critical role in ensuring fidelity to individualized practice. Through routine review of Plans of Care, supervisors assess the degree to which strategies are customized and aligned with identified strengths and needs. Case consultations are used to challenge teams when plans become repetitive, overly service-driven, or insufficiently individualized. Observation of CFT meetings allows supervisors to evaluate how effectively facilitators and teams generate, refine, and adjust individualized strategies in real time. Feedback from these activities is used to inform staff coaching and professional development (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.5 Individualized Practice Guideline, pages 14-16).
Standard 1.5(e): Family Feedback and Continuous Quality Improvement
Sycamores routinely elicits family feedback regarding their experience of receiving individualized and responsive services. The Wraparound Fidelity Index – EZ (WFI-EZ) is used to assess whether families perceive services as tailored to their unique needs and preferences. Additional feedback is gathered through satisfaction surveys and ongoing communication with families. Family feedback is actively used for continuous quality improvement efforts, including identifying training needs, reinforcing effective individualized practices, and providing targeted feedback to staff and supervisors (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.5 Individualized Practice Guideline, pages 14-16).
Sycamores is committed to the High-Fidelity Wraparound (HFW) principle of Individualized Practice, ensuring that services and supports are uniquely tailored to meet the specific needs, strengths, values, culture, and preferences of each youth and family. Individualization is a foundational expectation across all phases of the Wraparound process and is reflected consistently in planning, implementation, supervision, training, and quality improvement activities. Through flexible documentation, ongoing staff and Facilitator training, structured supervisory review, and routine family feedback, Sycamores demonstrates full alignment with HFW Standard 1.5. Individualization is embedded throughout the Wraparound process and supported by intentional systems that promote creativity, cultural responsiveness, and family-driven planning.
Supporting Documents:
✔ 1.5 Individualized Practice Guideline (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.5 Individualized Practice Guideline, pages 14-16).
✔LA County Plan of Care (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.5, pages 46-52).
✔LATC Observation-Coaching Tool (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.6, pages 53-62).
✔Case Consultation Template (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.26, page 195).
✔Strengths Summary Sample with Brainstormed Needs (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.9, pages 86-87).
✔IP-CANS Assessment (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.8, pages 81-85).
✔Strengths Summary Sample (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.9, pages 86-87).
✔Sample Strengths Training (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.10, pages 88-101).
✔Questions to Identify Strengths (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.11, pages 102-106).
✔Needs Egg(Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.14, page 119).
✔Sample Needs Training (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.15, pages 120-136).
✔Sample Natural Supports Training (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.16, page 137-164).
✔WFI-EZ (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.12, pages 107-110).
✔Cultural Humility Sample Training (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.20, pages 168-169).
1.6 Use of Natural and Community Based Supports
At Sycamores, the intentional use of natural and community-based supports is a foundational element of the High-Fidelity Wraparound (HFW) practice model. Natural supports—including family members, friends, neighbors, faith-based connections, and other trusted individuals identified by the family—are viewed as integral and valued members of the Child and Family Team (CFT), rather than as peripheral participants. The HFW process prioritizes early and ongoing identification, engagement, and integration of natural and community-based supports to strengthen team functioning and ensure sustainability of outcomes. Plans of Care are intentionally grounded in the family’s community and everyday environments, with strategies designed to reduce reliance on formal services over time while increasing natural, informal, and community-based supports. This approach reflects a long-term focus on stability, connectedness, and resilience within the youth and family’s own support network.
Standard 1.6(a): Natural and Community Supports Inventory
Sycamores ensures that natural and community-based supports are identified, documented, and updated throughout the Wraparound process. Facilitators and Parent Partners work collaboratively with families to identify individuals and resources that provide emotional, practical, cultural, and social support. Natural supports are currently documented through:
✔ Identification of natural supports as members of the Child and Family Team;
✔ Attendance and participation of natural supports in CFT meetings;
✔ Inclusion of natural supports within the HFW Plan of Care, including assignment of roles, strategies, and action steps.
(Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.6 Use of Natural and Community Based Supports Practice Guideline, pages 17-19).
To further strengthen this practice, Sycamores is actively developing a more formal Natural Supports Inventory, which will be incorporated into the Plan of Care. This inventory will capture:
✔ Natural supports who participate directly in CFT meetings;
✔ Supports who provide assistance outside of formal team settings;
✔ Evolving supports as relationships deepen or new connections are identified over time.
The inventory will be maintained and updated on an ongoing basis by the Facilitator and/or Parent Partner to ensure accuracy and relevance as family needs and supports change (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.6 Use of Natural and Community Based Supports Practice Guideline, pages 17-19).
Standard 1.6(b): Staff Training and Coaching on Natural Supports
Sycamores provides ongoing training, coaching, and supervision to ensure staff have the skills necessary to identify, engage, and integrate natural and community-based supports effectively. Facilitators, Parent Partners, and Family Specialists receive training focused on:
✔ Mapping and identifying natural supports;
✔ Engaging natural supports in a culturally responsive and family-driven manner;
✔ Navigating complex family dynamics that may impact participation;
✔ Building strategies that intentionally reduce reliance on formal services by strengthening informal and community-based supports.
Supervisors reinforce these skills through coaching, reflective supervision, and case consultation. Staff are supported in problem-solving barriers to natural support engagement and in developing creative strategies that promote sustainability beyond formal service involvement (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.6 Use of Natural and Community Based Supports Practice Guideline, pages 17-19).
Standard 1.6(c): Review of Plans of Care for Inclusion of Natural Supports
HFW Plans of Care at Sycamores are routinely reviewed to ensure meaningful inclusion of natural and community-based supports. Supervisors review Plans of Care during supervision and case consultation to assess:
✔ Inclusion of natural supports as team members;
✔ Integration of natural supports into strategies and action steps;
✔ Balance between formal services and informal/community-based supports;
✔ Progress toward gradually reducing reliance on formal services.
Case consultation is used to identify when teams may be overly dependent on formal supports and to collaboratively develop strategies that strengthen and expand the family’s natural support network. This ongoing review process ensures fidelity to HFW principles and supports long-term sustainability (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.6 Use of Natural and Community Based Supports Practice Guideline, pages 17-19).
Standard 1.6(d): Family Feedback and Continuous Quality Improvement
Sycamores routinely solicits family feedback regarding their experience with natural support engagement as part of a comprehensive continuous quality improvement process. Families are asked to provide input on whether they feel supported in identifying and involving natural supports and whether those supports are meaningfully included in the Wraparound process. Feedback is gathered through multiple methods, including:
✔ Wraparound Fidelity Index – EZ (WFI-EZ);
✔ Ongoing family interactions and team observations;
✔ Quality assurance reviews and follow-up communication as applicable.
This information is analyzed and used to:
✔ Reinforce effective practice;
✔ Identify areas for improvement in engaging natural supports;
✔ Inform supervision, training, coaching, and program-level improvements.
Family feedback is also shared with staff and supervisors to strengthen individual practice and overall program fidelity (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.6 Use of Natural and Community Based Supports Practice Guideline, pages 17-19).
Through intentional identification, engagement, integration, supervision, training, and feedback, Sycamores ensures that natural and community-based supports remain a central component of the High-Fidelity Wraparound process. This practice aligns with HFW Principles 4 and 5 and promotes sustainable, community-rooted outcomes for youth and families.
Supporting Documents:
✔1.6 Use of Natural and Community Based Supports Practice Guideline (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.6 Use of Natural and Community Based Supports Practice Guideline, pages 17-19).
✔Family Assessment of Support System Tool – FAST (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.17, pages 165).
✔LA County Plan of Care (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.5, pages 46-52).
✔Case Consultation Template (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.26, page 195).
✔Sample Natural Supports Training (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.16, page 137-164).
✔WFI-EZ (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.12, pages 107-110).
✔Connections Map (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.18, page 166).
✔Support System By Domain tool (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.19, page 167).
1.7 Culturally Respectful and Relevant
Sycamores’ High-Fidelity Wraparound (HFW) program demonstrates full alignment with the standard for culturally respectful and relevant practice. Consistent with Wraparound Principle 6, HFW teams recognize that a family’s traditions, values, heritage, and lived experiences are sources of strength and are essential to effective engagement, individualized planning, and sustainable outcomes. Cultural understanding is not treated as a discrete task, but as an intentional and ongoing process that informs all aspects of service delivery before, during, and after formal Wraparound involvement.
Standard 1.7(a): Strengths, Needs, and Culture Discovery Completed Prior to Plan of Care Development
At Sycamores, a strengths, needs, and culture discovery is completed during early engagement and prior to the development of the Plan of Care, ensuring that cultural considerations meaningfully guide individualized planning from the outset. Cultural discovery is understood broadly and may include, but is not limited to, family traditions, values, language preferences, spiritual beliefs, family roles, community connections, and lived experiences. This information is clearly documented within required clinical and Wraparound documentation, including the Mental Health Full Assessment, Plan of Care, Child and Adolescent Needs and Strengths (IP CANS), and other relevant case records. Cultural strengths and preferences are identified alongside needs to support balanced, strength-based planning. As families’ identities and circumstances evolve, cultural information is revisited and updated to ensure continued relevance and responsiveness. These practices ensure that the Plan of Care reflects the whole family context rather than relying on assumptions or generic approaches (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.7 Culturally Respectful and Relevant Care Practice Guideline, pages 20-21).
Standard 1.7(b): Ongoing Staff Coaching and Training in Culturally Respectful Practice
Sycamores provides ongoing training, supervision, and coaching to support staff in effectively eliciting, understanding, and integrating culture into planning and service delivery. Training emphasizes approaching cultural exploration with curiosity, humility, and respect; avoiding assumptions; and recognizing culture as dynamic and multifaceted. Staff are supported in adapting communication styles, engagement approaches, and intervention strategies to align with family culture and preferences.
In addition, Supervisors play an active role in reinforcing culturally responsive practice through regular supervision, case consultation, observation, and documentation review. Cultural considerations are discussed routinely alongside strengths, needs, and strategies, ensuring they are not treated as secondary to clinical goals. Supervisors observe Child and Family Team (CFT) meetings to assess how effectively culture is elicited, respected, and reflected in team dialogue, decision-making, and planning. Plans of Care are reviewed to confirm that cultural factors are clearly embedded within identified strengths and strategies. This combination of formal training, reflective supervision, and real-time feedback supports continuous staff skill development and fidelity to culturally respectful and relevant practice (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.7 Culturally Respectful and Relevant Care Practice Guideline, pages 20-21).
Standard 1.7(c): Family Feedback and Continuous Quality Improvement
Sycamores routinely elicits feedback from youth and families regarding their experience of culturally respectful and relevant services and uses this information for continuous quality improvement. Families are asked whether they feel understood, respected, and meaningfully included within the Wraparound process, with specific attention to how culture is acknowledged and incorporated. The Wraparound Fidelity Index‑EZ (WFI‑EZ) is utilized as a primary tool to assess family perception of fidelity, including culturally responsive practice. In addition, Sycamores gathers feedback through annual satisfaction surveys, quality assurance phone calls, and ongoing interactions between staff and families. Feedback is systematically reviewed and used to reinforce effective practice, identify opportunities for growth, and inform training, coaching, supervision, and program improvement efforts. When trends or concerns are identified, supervisors provide targeted feedback and support to staff to strengthen culturally responsive engagement and implementation (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.7 Culturally Respectful and Relevant Care Practice Guideline, pages 20-21).
In alignment with the standard, Sycamores HFW teams prioritize connecting families to culturally relevant community resources and natural supports that can remain in place after formal Wraparound services conclude. This may include community‑based organizations, faith‑based supports, culturally specific programs, and trusted informal supports identified by the family. These connections are incorporated into the Plan of Care when appropriate and are intended to promote sustainability, empowerment, and long‑term success beyond service closure (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.7 Culturally Respectful and Relevant Care Practice Guideline, pages 20-21).
Through intentional cultural discovery, comprehensive documentation, ongoing staff development, supervisory oversight, and systematic use of family feedback, Sycamores’ High-Fidelity Wraparound program fully meets the requirements of Standard 1.7. Culturally respectful and relevant practice is embedded throughout engagement, planning, service delivery, and transition, ensuring that families’ cultures are honored as fundamental strengths and that services remain meaningful, effective, and sustainable.
Supporting Documents:
✔1.7 Culturally Respectful and Relevant Care Practice Guideline (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.7 Culturally Respectful and Relevant Care Practice Guideline, pages 20-21).
✔LA County Plan of Care (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.5, pages 46-52).
✔LATC Observation-Coaching Tool (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.6, pages 53-62).
✔Case Consultation Template (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.26, page 195).
✔Strengths Summary Sample with Brainstormed Needs (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.9, pages 86-87).
✔Strengths Summary Sample (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.9, pages 86-87).
✔Sample Strengths Training (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.10, pages 88-101).
✔WFI-EZ (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.12, pages 107-110).
✔Cultural Humility Sample Training (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.20, pages 168-169).
✔Child/ Adolescent Full Assessment (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.13, pages 111-118).
1.8 High-Quality Team Planning and Problem Solving
Sycamores implements High‑Fidelity Wraparound (HFW) with a strong emphasis on high‑quality team planning and collaborative problem solving. In alignment with HFW principles of team‑based practice and collaboration (Principles 7 and 8), Child and Family Teams (CFTs) are intentionally composed of formal service providers and natural supports who work together to develop, implement, and monitor individualized Plans of Care that reflect the unique strengths, needs, and priorities of the youth and family.
At Sycamores, team planning is grounded in shared ownership, mutual accountability, and respect for diverse perspectives. Team members actively participate in decision‑making, take responsibility for assigned action steps, and collaborate to support positive outcomes. The Wraparound process is structured to foster optimism, commitment, and momentum among team members, even when teams are addressing complex or high‑risk situations. Facilitators are supported through supervision, coaching, and training to maintain solution‑focused discussions, manage differences of opinion, and build consensus in service of family‑identified goals.
Standard 1.8(a): Team Agreements are Created and Documented
Each Child and Family Team at Sycamores establishes clear team agreements at the outset of the Wraparound process. These agreements including ground rules are developed collaboratively with the youth, family, and team members to set shared expectations for communication, participation, follow‑through, and respect for differing perspectives. Agreements are documented in the youth’s file and revisited as needed to support effective collaboration and evolving team dynamics (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.8 High-Quality Team Planning and Problem Solving Practice Guideline, pages 22-24).
Standard 1.8(b): Feedback on Team Engagement and Collaboration is Routinely Elicited
Sycamores utilizes multiple methods to solicit feedback from families and team members regarding their experience of team engagement, collaboration, and shared decision‑making. Family feedback is systematically gathered using the Wraparound Fidelity Index–EZ (WFI‑EZ), which assesses key components of Wraparound fidelity, including teaming and collaboration. Additional feedback is obtained through supervisor observations of CFT meetings, supervision discussions, case consultations, and periodic quality assurance reviews. These mechanisms allow Sycamores to assess how effectively teams are functioning and to identify both strengths and areas for improvement in team processes (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.8 High-Quality Team Planning and Problem Solving Practice Guideline, pages 22-24).
Standard 1.8(c): Feedback is Used for Continuous Quality Improvement
Feedback received from families and team members is actively used to support continuous quality improvement. Supervisors review fidelity and engagement data with staff during individual and group supervision to reinforce effective teaming practices and address identified challenges. Feedback informs targeted coaching, training, and professional development, particularly in areas such as facilitation skills, conflict resolution, and consensus‑building. Program‑level trends identified through fidelity measures and supervisory review are used to inform ongoing training and program development to strengthen team functioning across the agency (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.8 High-Quality Team Planning and Problem Solving Practice Guideline, pages 22-24).
Standard 1.8(d): Plans of Care and Meeting Minutes Reflect Shared Ownership and Follow‑Through
Sycamores routinely reviews Plans of Care and CFT meeting minutes to ensure that shared ownership and accountability are clearly reflected in documentation. Action steps and strategies are assigned to specific team members, with clear expectations for follow‑through and timelines. Progress is reviewed at subsequent meetings, and teams collaboratively adjust strategies based on outcomes and emerging needs. Supervisors review documentation during supervision and case consultation to assess the quality of collaboration, coordination among team members, and progress toward goals. This review process supports consistency, accountability, and fidelity to the Wraparound model (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.8 High-Quality Team Planning and Problem Solving Practice Guideline, pages 22-24).
Through intentional team formation, structured collaboration, ongoing feedback, and supervisory support, Sycamores demonstrates consistent implementation of high‑quality team planning and problem solving within High‑Fidelity Wraparound. These practices ensure that Child and Family Teams function as cohesive, accountable, and solution‑focused partnerships that center the voice and priorities of youth and families while promoting fidelity and continuous quality improvement.
Supporting Documents:
✔1.8 High-Quality Team Planning and Problem Solving Practice Guideline (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.8 High-Quality Team Planning and Problem Solving Practice Guideline, pages 22-24).
✔LA County Plan of Care (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.5, pages 46-52).
✔LATC Observation-Coaching Tool (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.6, pages 53-62).
✔Case Consultation Template (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.26, page 195).
✔WFI-EZ (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.12, pages 107-110).
✔Team Development Sample Training (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.21, pages 170-186).
✔CFT Agenda with Ground Rules (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.22, page 187).
✔Family Engagement Structure with Caregiver (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.23, page 188).
✔Staff Engagement Tool (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.24, page 189).
✔Team Tool Kit (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.25, pages 190-194).
1.9 Outcomes Based Process
Sycamores’ High Fidelity Wraparound (HFW) model utilizes a structured, outcomes based process to ensure that services are intentional, measurable, and responsive to the evolving needs of youth and families. The HFW team systematically monitors progress toward identified needs, completion of action items, and the effectiveness of strategies outlined in the Plan of Care. Progress is reviewed routinely and used to inform timely adjustments to planning and service delivery, consistent with the Principles of High Fidelity Wraparound.
Needs statements serve as the foundation for planning and are directly linked to measurable outcomes that reflect meaningful change for the youth and family. Objective data from standardized instruments, including the IP CANS and Pediatric Symptom Checklist (PSC), along with internal Key Performance Indicator (KPI) dashboards, are integrated into Child and Family Team (CFT) discussions to support informed decision making. Data is used to guide planning, reinforce effective strategies, and address barriers, while maintaining the team’s focus on family driven goals rather than data in isolation.
Standard 1.9(a): The HFW Plan of Care includes specific, measurable strategies and action items with timeframes
Plans of Care are developed collaboratively by the Child and Family Team and include clearly defined strategies and action steps tied directly to identified needs. Each strategy specifies expected outcomes, assigned responsible team members, and established timeframes for completion. Outcomes are designed to measure progress toward meeting underlying needs rather than task completion alone, ensuring that planning remains meaningful and focused on sustainable change. Plans of Care are structured to allow for clear tracking of progress over time (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.9 Outcomes Based Process Practice Guideline, pages 25-27).
Standard 1.9(b): Action item completion is tracked by facilitators and updated at HFW team meetings, or more often as needed
HFW Facilitators are responsible for tracking action item completion and documenting progress toward outcomes. This information is reviewed during regularly scheduled Child and Family Team meetings and more frequently when progress is limited or circumstances change. Team discussions focus on identifying barriers, celebrating progress, and collaboratively problem solving to support successful implementation of the Plan of Care. This approach supports accountability while maintaining a strengths based, solution focused process (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.9 Outcomes Based Process Practice Guideline, pages 25-27).
Standard 1.9(c): Forms and processes allow strategies and action items to be adjusted or changed as needed, and changes are communicated to all team members
Plans of Care are intentionally designed to remain flexible and responsive to changes in youth and family needs. Based on ongoing progress monitoring and team review, strategies and action items may be modified, added, or discontinued. All changes are clearly documented and reviewed with the Child and Family Team to ensure shared understanding and alignment. Updated Plans of Care are distributed to all team members to support consistent implementation (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.9 Outcomes Based Process Practice Guideline, pages 25-27).
Standard 1.9(d): There is a process in place for who will complete the IP CANS and how the IP CANS will be shared amongst all team members
The IP CANS is completed by trained and certified staff in accordance with agency and county requirements. Responsibility for completion is clearly defined within program procedures. Results from the IP CANS are used to inform identification of needs and strengths and to monitor change over time (updated at CFT meetings throughout all phases of HFW) Relevant findings are shared with the Child and Family Team, as appropriate, to enhance team understanding and support collaborative decision making, while maintaining confidentiality standards (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.9 Outcomes Based Process Practice Guideline, pages 25-27).
Standard 1.9(e): Data from the IP CANS is used to support tracking and team decision making, but does not replace tracking of needs, goals, and action item completion
IP CANS data is integrated into the Wraparound process as one of multiple data sources used to inform planning and progress monitoring. Along with PSC results and KPI dashboard data, IP CANS findings support team discussions regarding progress, emerging needs, and service adjustments. While standardized measures are critical to objective assessment, they do not replace the team’s ongoing tracking of needs, outcome progress, and action item completion, which remain central to planning for transition and sustainability (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.9 Outcomes Based Process Practice Guideline, pages 25-27).
Outcomes based practice is reinforced through supervision, case consultation, and fidelity monitoring. Supervisors regularly review Plans of Care to ensure strategies are measurable and aligned with identified needs. Fidelity to the Wraparound model is monitored through documentation review, CFT meeting observations, supervision, and the Wraparound Fidelity Index – EZ (WFI EZ). At the program level, outcome data is reviewed through staff meetings, supervision, and the HFW Practice Council to support continuous quality improvement, identify trends, and inform training and program development (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.9 Outcomes Based Process Practice Guideline, pages 25-27).
Supporting Documents:
✔1.9 Outcomes Based Process Practice Guideline (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.9 Outcomes Based Process Practice Guideline, pages 25-27).
✔LA County Plan of Care (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.5, pages 46-52).
✔IP-CANS Assessment (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.8, pages 81-85).
✔WFI-EZ (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.12, pages 107-110).
✔LATC Observation-Coaching Tool (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.6, pages 53-62).
✔Case Consultation Template (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.26, page 195).
✔PSC Flyer (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation2.27, pages 196-197).
✔KPI Wraparound Dashboard (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.28, page 198).
✔HFW Practice Council Guide (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.29, pages 199-214).
1.10 Persistence
At Sycamores, persistence is embedded as a foundational practice across all High Fidelity Wraparound (HFW) services. Child and Family Teams (CFTs) consistently view setbacks, crises, and limited progress as signals that the Plan of Care may need to be revised, rather than as failures of the youth or family. Teams remain actively engaged with families, continuing services until identified needs are met and, with preference given to family voice and choice, the team determines that transition is appropriate.
Staff utilize a non blaming, solution focused approach, reframing challenges as opportunities to reassess needs, leverage strengths, and adapt strategies. This approach promotes sustained engagement and reinforces shared responsibility among team members, even during periods of repeated crisis or slow progress.
Standard 1.10(a): Plan Review, Revision, and Post Crisis Responsiveness
Sycamores teams continuously review and revise the Plan of Care in response to emerging needs, crises, or stalled progress. When challenges arise, teams revisit underlying needs, strengths, and strategies and engage in structured brainstorming to identify new or alternative approaches. Post crisis safety planning is incorporated following critical incidents to address both immediate stabilization and longer term risk reduction. Facilitators are trained to lead teams through plan revisions collaboratively, ensuring that adaptations remain aligned with family priorities and culturally responsive practices. Ongoing plan revision is documented and reviewed through supervision and case consultation (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.10 Persistence Practice Guideline, pages 28-29).
Standard 1.10(b): Access to Supervision, Coaching, and System Support
Sycamores ensures that staff have access to multiple layers of support to prevent teams from becoming “stuck” in complex or high need cases. Individual supervision and case consultation are routinely used to support problem solving, model persistence, and reinforce fidelity to the Wraparound model. Supervisors may attend CFT meetings or provide in field support to strengthen facilitation and team dynamics. Staff also collaborate with referral sources, Department of Children and Family Services (DCFS) or Juvenile Justice case carrying workers, and system partners, including Department of Mental Health (DMH) representatives such as the Liaisons and Navigators, to enhance coordination and identify solutions to system level barriers (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.10 Persistence Practice Guideline, pages 28-29).
For cases requiring enhanced problem solving, Sycamores utilizes Clinical Care Reviews (CCRs) to provide a structured forum for interdisciplinary consultation. CCRs include internal experts from Medication Support, Co Occurring Disorders (COD), Training, Research, Quality Management, and Clinical Leadership. These reviews offer targeted feedback and practical recommendations to strengthen engagement, revise strategies, and support ongoing service delivery. Teams incorporate CCR feedback into the Plan of Care and track adjustments through subsequent team meetings and supervision (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.10 Persistence Practice Guideline, pages 28-29).
Sycamores supports persistence by ensuring teams can access resources needed to address barriers to progress. Staff and supervisors collaborate to request and utilize Flexible Funding in alignment with the agency’s Flex Funds policy. When traditional resources are limited, teams engage in creative problem solving and collaboration with system partners to identify alternative supports. Resource challenges are addressed through coordinated advocacy, shared accountability, and system level engagement, ensuring that service limitations do not prematurely disrupt care (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.10 Persistence Practice Guideline, pages 28-29).
Standard 1.10(c): Training and Skill Development
Facilitators and supervisors receive ongoing training designed to strengthen persistence in practice. Training topics include post crisis safety planning, conflict resolution, and facilitation of effective team based brainstorming and plan revision. Skills are reinforced through coaching, supervision, and real time application in the field.
This continuous skill development equips staff to maintain engagement, navigate high conflict dynamics, and lead teams through repeated challenges while maintaining fidelity to the HFW model (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.10 Persistence Practice Guideline, pages 28-29).
Finally, Sycamores monitors persistence and team responsiveness through structured quality improvement processes. Family feedback is gathered using tools such as the Wraparound Fidelity Index – EZ (WFI EZ) and annual satisfaction surveys. Data are reviewed to assess the team’s ability to remain engaged, responsive, and solution focused during periods of challenge. Findings are used to inform individualized coaching, supervisory focus, and broader program improvements, reinforcing accountability to fidelity and family experience (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.10 Persistence Practice Guideline, pages 28-29).
Supporting Documents:
✔1.10 Persistence Practice Guideline (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.10 Persistence Practice Guideline, pages 28-29).
✔Annual Satisfaction Survey (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.7, pages 63-80)
✔Case Consultation Template (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.26, page 195).
✔WFI-EZ (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.12, pages 107-110).
✔Clinical Care Review (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.30, pages 215-219).
✔Conflict Resolution Sample Trainings, Coming to Consensus (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.31, pages 220-235).
1.11 Transitions as a part of the Fourth Phase of HFW
At Sycamores, transitions are an intentional and meaningful component of the High Fidelity Wraparound (HFW) model and occur during the fourth phase of Wraparound. Transition planning is embedded throughout service delivery and reflects the team’s shared confidence that the youth and family have achieved sufficient stability and progress toward their identified needs. Transitions at Sycamores are guided by readiness rather than timelines, and decisions are made collaboratively by the Wraparound team, with preference consistently given to the perspectives of the youth and family. Transition is never initiated due to administrative requirements or as a response to isolated adverse events. Instead, the process focuses on sustainability of progress, reduced reliance on formal services, and strengthened natural and community supports.
Standard 1.11(a): Transition Planning and Readiness
1. Transition planning at Sycamores begins early and is continuously integrated throughout the Wraparound process. Teams routinely discuss transition readiness during team meetings and supervision, using criteria such as progress toward meeting identified needs, stability of the family system, and the family’s confidence in maintaining gains with reduced formal support. Transition decisions are made collaboratively and include the youth, family, Facilitator, Parent Partner, Clinician, and identified team members. Youth and family voice and choice are prioritized in determining both the timing and the structure of the transition. Transition does not occur due to administrative mandates or system pressures and is not precipitated by isolated critical incidents (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.11 Transition as Part of Fourth Phase of HFW Practice Guideline, pages 30-32).
2. Gradual and Supported Transition Process
Sycamores ensures that transitions are gradual, structured, and supportive, avoiding abrupt or disruptive changes in services. As families demonstrate increased stability and independence, services are thoughtfully stepped down in a manner that maintains support during the transition period and prevents gaps in care. Teams intentionally maintain continuity and access to supports while reinforcing skills, confidence, and self efficacy developed throughout Wraparound. Families do not experience sudden loss of services due to administrative changes or system-related factors (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.11 Transition as Part of Fourth Phase of HFW Practice Guideline, pages 30-32).
3. Strengthening Natural and Community Supports
A primary focus of transition at Sycamores is long term sustainability beyond formal services. Teams actively identify, engage, and strengthen natural supports and community resources early in the Wraparound process to ensure continuity following transition. Families are connected to community based resources that align with their needs, culture, and preferences. When ongoing services are indicated, teams facilitate warm handoffs to new providers as a best practice, ensuring continuity, engagement, and shared understanding of family strengths and needs. Teams also support families in building confidence to independently access and utilize supports (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.11 Transition as Part of Fourth Phase of HFW Practice Guideline, pages 30-32).
4. Documentation of Transition
Transition planning and readiness are consistently documented at Sycamores and reviewed through ongoing team discussions and supervision. The Plan of Care and Crisis and Safety Plan reflect progress toward independence, increased stability, and reduced reliance on formal supports. Clinicians complete Transition Instructions with the family, documenting progress achieved, recommendations for ongoing services, and current medications, as applicable. The Wraparound Facilitator completes the LA County Department of Mental Health (DMH) Enrollment/Exit Form, including the transition date and reason for closing, in compliance with county requirements (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.11 Transition as Part of Fourth Phase of HFW Practice Guideline, pages 30-32).
Standard 1.11(b): Celebration of Transition
Transitions at Sycamores are recognized as meaningful accomplishments for the youth, family, and team. Celebrations are planned with full youth and family participation and are individualized to reflect their culture, values, and preferences. Administrative and programmatic structures support these celebrations, including the appropriate use of flexible funds, accommodation of staff time, and encouragement of team participation. Celebrations honor the accomplishments of the youth and family and reinforce the strengths based values of Wraparound (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.11 Transition as Part of Fourth Phase of HFW Practice Guideline, pages 30-32).
In addition, Supervisors at Sycamores provide active oversite and guidance throughout the transition process. Supervision and case consultation include discussion of transition readiness, sustainability of progress, and strengthening of natural supports. Supervisors review Plans of Care to ensure transitions are intentional, planned, and aligned with HFW principles. Staff are supported in navigating system level or administrative barriers that may impact effective transition planning (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.11 Transition as Part of Fourth Phase of HFW Practice Guideline, pages 30-32).
Transition practices are monitored to ensure fidelity to the HFW model and positive outcomes for youth and families. Sycamores gathers feedback from families through tools such as the Wraparound Fidelity Index – EZ (WFI EZ) and satisfaction surveys. Program leadership reviews data related to discharge reasons and outcomes to differentiate successful transitions from closures driven by other factors. Feedback and data are used to inform supervision, staff training, and ongoing program improvement through the HFW Practice Council (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.11 Transition as Part of Fourth Phase of HFW Practice Guideline, pages 30-32).
Supporting Documentation:
✔1.11 Transition as Part of Fourth Phase of HFW Practice Guideline (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, 1.11 Transition as Part of Fourth Phase of HFW Practice Guideline, pages 30-32).LA County Plan of Care (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.5, pages 46-52).
✔WFI-EZ (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.12, pages 107-110).
✔Transition Instructions (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.32, page 236).
✔DMH Enrollment/ Exit Form (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.33, page 237).
✔Graduation Certificate Sample (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.34, page 238).
✔Discharge OMA (Sycamores HFW Comprehensive Practice Guide, I.1, Fidelity Indicators, Supporting Documentation 2.35, pages 239-246).
Expected Outcomes
2.1 Youth and Family Satisfaction
Sycamores evaluates youth and family satisfaction through an agency wide annual satisfaction survey administered to caregivers and youth, when developmentally appropriate. Surveys are typically conducted during October and November and assess overall satisfaction with services, perceived progress, and experience with providers. Results are reviewed by program and agency leadership and used to identify strengths and areas for improvement. As fidelity implementation progresses, Sycamores plans to incorporate satisfaction related domains from the Wraparound Fidelity Index EZ (WFI EZ) to further strengthen satisfaction monitoring (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Section 2.1, Youth and Family Satisfaction, page 1).
Supporting Documents:
✔ 2.1 Youth and Family Satisfaction Practice Guideline (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Section 2.1, Youth and Family Satisfaction, page 1).
✔Satisfaction Survey (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, A, pages 6-23).
✔WFI-EZ (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, B, pages 24-27).
2.2 Improved School Functioning
Sycamores monitors educational progress using standardized assessments and county required reporting systems. Primary data sources include relevant CANS education items measuring attendance, academic performance, and school behavior, as well as Los Angeles County OMA data capturing attendance patterns, grades, suspensions, and expulsions. Data is collected at intake, at regular intervals, at key event changes, and at discharge, allowing staff to track and evaluate improvements in school engagement and functioning over time (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Section 2.2, Improved School Functioning, page 2).
Supporting Documents:
✔2.2 Improved School Functioning Practice Guideline (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Section 2.2, Improved School Functioning, page 2).
✔CANS (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, C, pages 28-31).
✔LA County OMA Forms -Baseline (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, D, pages 32-40).
✔LA County OMA Forms -Key Events Change (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, D, pages 41-48).
✔LA County OMA Forms – 3 Months (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, D, pages 49-50).
2.3 Improved Functioning in the Community
Sycamores assesses community functioning through data reflecting youth engagement, stability, and participation in community based activities. Primary sources include CANS Item 38 and selected Pediatric Symptom Checklist (PSC) domains. These tools are administered at intake, every six months, and at discharge. Data is reviewed to assess reductions in system involvement and increases in constructive community participation, with ongoing refinement to ensure meaningful measurement of community integration (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Section 2.3, Improved Functioning in the Community, page 2).
Supporting Documents:
✔2.3 Improved Functioning in the Community Practice Guideline (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Section 2.3, Improved Functioning in the Community, page 2).
✔PSC-35 (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, E, pages 51-52).
✔CANS (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, C, pages 28-31).
2.4 Improved Interpersonal Functioning
Sycamores evaluates interpersonal functioning by examining changes in family relationships, peer interactions, and emotional and behavioral functioning. Data sources include PSC scores and selected CANS interpersonal functioning items. Assessments are completed at intake, every six months, and at discharge. Sycamores continues refining indicators to ensure accurate measurement of improvements in family relationships, peer connections, and reductions in family stress and conflict (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Section 2.4, Improved Interpersonal Functioning, page 3).
Supporting Documents:
✔2.4 Improved Interpersonal Functioning Guideline (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Section 2.4, Improved Interpersonal Functioning, page 3).
✔CANS (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, C, pages 28-31).
✔PSC-35 (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, E, pages 51-52).
2.5 Increased Caregiver Confidence
Sycamores uses the Wraparound Fidelity Index EZ (WFI EZ) as the primary tool for assessing caregiver confidence and capacity. The WFI EZ captures caregiver reported confidence, ability to access supports, and perceptions of team collaboration. WFI EZ data is used to monitor caregiver growth over time, identify areas needing additional support, and inform coaching and program improvement activities (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Section 2.5, Increased Caregiver Confidence, page 3).
Supporting Documents:
✔2.5 Increased Caregiver Confidence Guideline (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Section 2.5, Increased Caregiver Confidence, page 3).
✔WFI-EZ (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, B, pages 24-27).
2.6 Stable and Least Restrictive Living Environment
Sycamores monitors placement stability using intake living arrangement documentation, Client Change Forms, discharge forms, and FSP OMA data. These sources track placement type and changes over time. Data is reviewed to assess reductions in placement disruptions and increased stability in family based or community based settings consistent with Wraparound principles (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Section 2.6, Stable and Least Restrictive Living Environment, page 4).
Supporting Documents:
✔2.6 Stable and Least Restrictive Living Environment Guideline (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Section 2.6, Stable and Least Restrictive Living Environment, page 4).
✔Client Change Form (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, F, pages 54-55).
✔LA County DMH Enrollment/ Exit Form (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, I, page 57).
✔LA County OMA Forms -Baseline (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, D, pages 32-40).
✔LA County OMA Forms -Key Events Change (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, D, pages 41-48).
✔LA County OMA Forms – 3 Months (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, D, pages 49-50).
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Sycamores evaluates reductions in crisis events and emergency service utilization through Special Incident Reports (SIRs) and OMA Key Event Change forms. These data track psychiatric hospitalizations, emergency room visits, and other crisis related service use. Information is reviewed to assess whether Wraparound services are effectively supporting stabilization and reducing reliance on emergency and crisis systems (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Section 2.7, Reduction in Inpatient, Emergency Department Admission for BH Visits, page 4).
Supporting Documents:
✔2.7, Reduction in Inpatient, Emergency Department Admission for BH Visits Guideline (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Section 2.7, Reduction in Inpatient, Emergency Department Admission for BH Visits, page 4).
✔Special Incident Report (SIR) (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, B, pages 24-27).
✔SIR KPI Dashboard (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, H, page 56).
✔LA County OMA Forms -Key Events Change (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, D, pages 41-48).
2.8 Reduction in Crisis Visits
Sycamores evaluates reductions in crisis events and emergency service utilization through Special Incident Reports (SIRs) and OMA Key Event Change forms. These data track psychiatric hospitalizations, emergency room visits, and other crisis related service use. Information is reviewed to assess whether Wraparound services are effectively supporting stabilization and reducing reliance on emergency and crisis systems (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Section 2.8, Reduction in Crisis Visits, page 4).
Supporting Documents:
✔2.8, Reduction in Crisis Visits Guideline (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Section 2.8, Reduction in Crisis Visits, page 4).
✔Special Incident Report (SIR) (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, B, pages 24-27).
✔SIR KPI Dashboard (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, H, page 56).
✔LA County OMA Forms -Key Events Change (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, D, pages 41-48).
2.9 Positive Exit from HFW
Sycamores tracks discharge outcomes using Los Angeles County DMH discharge forms and OMA discharge data. These sources document reasons for discharge, including goals met and transitions to lower levels of care. Discharge data is used to evaluate whether youth and families are exiting Wraparound in a planned, positive, and goal aligned manner (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Section 2.9, Positive Exit from HFW, pages 4-5).
Supporting Documents:
✔2.9, Positive Exit from HFW Guideline (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Section 2.9, Positive Exit from HFW, pages 4-5).
✔LA County DMH Enrollment/ Exit Form (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, I, page 57).
✔LA County OMA Forms -Key Events Change/Discharge (Sycamores HFW Comprehensive Practice Guide, I.2 Expected Outcomes, Supporting Documentation, D, pages 41-48).
Engagement
3.1 Orientation
Sycamores’ High Fidelity Wraparound (HFW) program ensures that all youth and families receive a timely, comprehensive, culturally responsive, and family-centered orientation to the Wraparound process. Orientation is not a single event but a continuous, layered process that begins at referral and continues through early engagement and intake, ensuring that families fully understand the principles, phases, legal and ethical considerations, and team member roles, including the family’s central role and the involvement of natural supports and Tribes when applicable.
Standard 3.1(a): Comprehensive Explanation of the HFW Process
In alignment with state certification standards, Sycamores ensures that the HFW process is fully explained to every family. Orientation includes a clear overview of the ten principles of High Fidelity Wraparound, the four phases of the Wraparound process (Engagement, Plan Development, Implementation, and Transition), and the expectations for collaborative, strengths-based, and outcomes-driven practice. Throughout orientation and early contacts, staff explain the shared responsibility of the Child and Family Team, emphasizing that the family and youth are the primary decision-makers. Natural supports—such as extended family members, friends, faith leaders, and community partners—are actively encouraged as equal members of the team. In cases involving an Indian child, orientation explicitly includes the role of the Tribe and respects Tribal sovereignty, cultural practices, and participation in planning and decision-making (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.1 Orientation Practice Guide, pages 1-3).
Referral Review and Team Assignment- Orientation is scaffolded through intentional preparatory activities that begin immediately upon referral. Site leadership reviews the referral packet to identify preferred language, clinical needs, safety concerns, and potential barriers to engagement, ensuring that outreach and orientation are responsive and individualized from the outset. A supervisor assigns a Wraparound team that may include a Wraparound Facilitator, Parent Partner, Clinician, and Family Specialist, based on the family’s needs and program capacity. The assigned team receives the referral packet and coordinates internally to plan timely intake and early engagement activities, reinforcing consistency of messaging during orientation (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.1 Orientation Practice Guide, pages 1-3).
Standard 3.1(b): Legal and ethical considerations &
Standard 3.1(c): The role of each team member including the family and natural supports and Tribes in the case of an Indian child
Initial Phone Contact and Early Orientation – Within 24 hours of assignment, the Wraparound Facilitator initiates outreach with the caregiver to begin orientation to HFW. During this initial contact, the Facilitator:
✔ Confirms the family’s referral and enrollment in Sycamores’ HFW program
✔ Introduces their role as the Wraparound Facilitator
✔ Provides a clear, family-friendly overview of HFW principles and the four phases of Wraparound
✔ Reviews the general roles of all team members, including the family, Facilitator, Parent Partner, Family Specialist, and Clinician
✔ Invites the family to begin identifying trusted individuals and natural supports they may want included on their Child and Family Team.
The Facilitator collaborates with the family to schedule both the clinical intake appointment and an initial face‑to‑face Strengths Chat with the Facilitator and Parent Partner. Appointments are scheduled at times and locations that are convenient and respectful of family needs, consistent with family‑driven and engagement principles.
(Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.1 Orientation Practice Guide, pages 1-3).
Enrollment, Clinical Intake, and Reinforcement of Orientation –
The assigned clinician completes the clinical intake as soon as possible, in accordance with contract standards requiring intake within 48 hours or the earliest availability of the family. Recognizing that many youth enter HFW with acute safety or crisis needs, intake is prioritized while remaining trauma‑informed and engagement‑focused. During intake, the Clinician:
✔ Completes all required enrollment documentation
✔ Reinforces orientation content, including Wraparound principles, phases, and team roles
✔ Reviews legal and ethical considerations, including confidentiality, informed consent, and youth and family rights
✔ Answers questions and clarifies expectations regarding participation in HFW.
(Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.1 Orientation Practice Guide, pages 1-3).
When youth are already receiving Specialty Mental Health Services (SMHS) from an external provider, families are informed of their choice to either continue with that provider or transition services to a Sycamores clinician and Family Specialist, reinforcing informed choice and family voice. Families are reminded of upcoming Strengths Chats and are provided with the NWI Wraparound Family Guide, which serves as an ongoing reference outlining the Wraparound process, team roles, principles, and expectations (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.1 Orientation Practice Guide, pages 1-3).
Language Access and Linguistic Responsiveness -Sycamores prioritizes meaningful access and participation by conducting orientation, intake, and ongoing communication in the family’s preferred language whenever possible. The program makes best efforts to employ bilingual staff and to language-match Wraparound Facilitators and Parent Partners with families. When language matching is not available, staff utilize Language Line services for phone communication and Sycamores’ internal Interpretation and Translation Services (ITS) for telehealth, in‑person interpretation, and translation of written materials. When needs exceed internal capacity, ITS coordinates services through contracted agencies, ensuring no family is excluded from full participation due to language barriers (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.1 Orientation Practice Guide, pages 1-3).
Documentation and Accountability -Completion of the initial orientation phone contact is documented in Sycamores’ Electronic Health Record (Avatar NX). Additional documentation related to enrollment and intake is completed in accordance with established Intake Policy and Procedure, ensuring transparency, accountability, and audit readiness (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.1 Orientation Practice Guide, pages 1-3).
Supporting Documents:
✔3.1 Orientation Practice Guide (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.1 Orientation Practice Guide, pages 1-3).
✔Interpretation and Translation Department (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation A, pages 16-17)
✔ Language Line Procedures (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation B, pages 18-19)
✔ General Operating Policy- Referral, Intake, and Assessment (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation C, pages 20-22)
✔ Wraparound Family Guide (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation D, pages 23-46)
3.2 Safety and Crisis stabilization
Sycamores’ High‑Fidelity Wraparound (HFW) program fully meets state standards for Safety and Crisis Stabilization by ensuring that immediate safety needs are identified, addressed, and continuously reviewed from initial engagement and throughout service delivery. Safety planning is embedded as a core component of engagement, stabilization, and team‑based decision‑making, allowing youth and families to meaningfully participate in the Wraparound process while maintaining safety. Sycamores’ practice reflects the HFW principle that crisis planning is proactive, strengths‑based, family‑driven, and responsive, and that safety planning informs—but does not replace—the broader Wraparound Plan of Care.
Standard 3.2(a): Identification of Initial Crisis and Safety Concerns and Development of an Immediate Crisis Response Plan
Sycamores ensures that safety and crisis stabilization needs are identified and addressed at the very beginning of services, as part of the HFW enrollment and Specialty Mental Health Services (SMHS) intake process. During initial engagement, the assigned clinician conducts a comprehensive assessment of safety needs in collaboration with the youth and family. This assessment incorporates youth and family input, referral information, clinical judgment, and identified risk factors. Based on this information, the clinician develops an initial HFW Safety and Crisis Plan with the youth and family to address any immediate safety concerns. The plan is developed in a manner that centers:
✔ Youth voice, in developmentally appropriate ways
✔ Family voice and choice
✔ Cultural considerations
✔ Identified strengths and existing protective factors
(Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.2 Safety and Crisis Stabilization Practice Guide, pages 4-6).
When pressing or acute safety concerns are identified, the Safety and Crisis Plan serves as the immediate crisis response plan, outlining clear, actionable steps the youth and family can take to prevent escalation and respond effectively in the moment. Families are provided with a copy of the plan and encouraged to keep it accessible. The HFW team continues to assess safety concerns throughout the Engagement phase and beyond, including monitoring for new or escalating risks, recent or ongoing crises, and behaviors that place the youth or others at risk (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.2 Safety and Crisis Stabilization Practice Guide, pages 4-6).
Standard 3.2(b): Relationship Between the Crisis Plan and the HFW Safety Plan Developed During Plan Development
Sycamores clearly communicates to families that the HFW Safety and Crisis Plan addresses immediate and emergent safety needs, while longer‑term safety goals and strategies are developed and integrated into the Wraparound Plan of Care during the Plan Development phase. The Safety and Crisis Plan is treated as a living document that is continually reviewed and revised as crises occur, new safety concerns emerge, or effective strategies are identified. Information gained through crisis events, plan revisions, and stabilization efforts directly informs:
✔Safety‑related goals and action steps in the Wraparound Plan of Care
✔Team understanding of triggers, warning signs, and protective factors
✔Continuity of care across phases of Wraparound
By design, the Safety and Crisis Plan supports immediate stabilization while strengthening and enhancing longer‑term, team‑based safety planning within the Wraparound framework (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.2 Safety and Crisis Stabilization Practice Guide, pages 4-6).
Standard 3.12c): Access to 24/7 Crisis Response: All families are provided with information regarding how to access 24/7 crisis response when needed.
Sycamores ensures that all families enrolled in HFW services are provided with clear information on how to access 24/7 crisis response. Each program provides families with the appropriate Sycamores Crisis Line number at the start of services, and this information is also documented within the Safety and Crisis Plan. The Sycamores Crisis Line is answered by a program clinician and is supported by an on‑call backup supervisor, including Licensed Psychiatric Social Worker (LPS) support when needed. Crisis response staff are trained and able to:
✔Assess safety concerns
✔Provide in‑the‑moment crisis intervention and stabilization planning
✔Review and support implementation of the Safety and Crisis Plan
✔Initiate involuntary holds when necessary to maintain safety, in accordance with applicable laws and regulations
(Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.2 Safety and Crisis Stabilization Practice Guide, pages 4-6).
In addition to Sycamores’ crisis response system, Safety and Crisis Plans include alternative resources such as 988 and emergency services when appropriate, ensuring families have multiple avenues for support during a crisis (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.2 Safety and Crisis Stabilization Practice Guide, pages 4-6).
Documentation and Accessibility -All safety and crisis stabilization activities are documented in the HFW Safety and Crisis Plan and in Progress Notes within Sycamores’ Electronic Health Record (Avatar NX). Families are provided with copies of their Safety and Crisis Plan and may also access the plan and additional resources through MyHealthePointe, supporting ongoing accessibility and family engagement (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.2 Safety and Crisis Stabilization Practice Guide, pages 4-6).
Supporting Documents:
✔3.2 Safety and Crisis Stabilization Practice Guide (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.2 Safety and Crisis Stabilization Practice Guide, pages 4-6).
✔Safety and Crisis Plan (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation E, pages 47-48)
✔Crisis Phone Training (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation F, pages 49-82)
✔Language Line Procedures (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation B, pages 18-19)
✔MyHealthePointe- EHR portal for Consumers/Families (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation G, page 83)
3.3 Strengths, Needs, Culture and Vision Discovery
Sycamores’ High‑Fidelity Wraparound (HFW) program fully operationalizes the requirements of Standard 3.3 through a structured, relational, and strengths‑based discovery process. Discovery at Sycamores is not a one‑time task or form completion; it is an ongoing, team‑based practice grounded in family voice, youth partnership, cultural humility, and shared meaning‑making. Strengths, needs, culture, and vision are continuously surfaced, documented, reflected back to the family, and intentionally used to guide engagement, planning, and decision‑making across all phases of Wraparound.
Standard 3.3(a): A Family Vision is completed with every family and documented in the youth’s chart during the Engagement phase.
Sycamores consistently develops a Family Vision with every youth and family during the Engagement phase, ensuring that planning is anchored in the family’s hopes for a better future rather than solely in presenting problems or service requirements. Following initial strengths discovery, the Facilitator partners with the youth and caregiver(s) in vision‑focused conversations, asking open‑ended questions such as: “If things were going well a year from now, what would life look like for your family?” These conversations are conducted relationally rather than through standardized forms, allowing the family’s language, values, and priorities to remain central (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.3 Strengths, Needs, Culture, Vision, Discovery Practice Guide, pages 7-11).
Facilitators listen for themes, shared aspirations, and areas of alignment between youth and caregiver perspectives, while gently redirecting deficit‑ or blame‑based statements back toward shared hopes and desired outcomes. The Family Vision is collaboratively refined into a clear, concise, and meaningful “bumper‑sticker” statement that:
✔Reflects the family’s voice and definition of success
✔Is realistic and aligned with court orders or mandates, when applicable
✔Is easily remembered and used by all team members to guide planning
Once finalized, the Family Vision is documented in the youth’s Plan of Care and maintained in the electronic health record. The vision is revisited regularly during Child and Family Team (CFT) meetings to ensure ongoing alignment as circumstances, insight, and goals evolve (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.3 Strengths, Needs, Culture, Vision, Discovery Practice Guide, pages 7-11).
Standard 3.3(b): A Strengths, Needs, Culture Discovery document is initiated with every youth and family, included in the youth’s chart, updated at least every 90 days, and shared with new team members.
Sycamores initiates a Strengths, Needs, Culture, and Vision Discovery Summary with every youth and family during Engagement. This document is a living, strengths‑based record that captures the family’s story, identity, priorities, and evolving understanding of what they need to thrive (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.3 Strengths, Needs, Culture, Vision, Discovery Practice Guide, pages 7-11).
Strengths‑Based Engagement and Discovery
Discovery begins with a Strengths Chat, facilitated by the Facilitator, Parent Partner, and Family Specialist. This conversation is intentionally relational and designed to shift the family’s experience from “being assessed” to “being understood.” Youth and caregivers are invited to share:
✔What brought them to Wraparound
✔When challenges began and what life has been like during difficult times
✔What has helped them get through hard periods
✔Times when things were going better and what was different
✔Natural supports and sources of connection
✔Values, traditions, and what matters most to their family
(Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.3 Strengths, Needs, Culture, Vision, Discovery Practice Guide, pages 7-11).
Staff remain attuned to resilience, survival, effort, meaning, and identity, while also observing contextual strengths within the home environment (e.g., routines, relationships, interests). Identified strengths are reflected back to the family to confirm accuracy and reinforce a strengths‑based narrative. Information gathered through discovery is translated into two complementary forms of documentation:
1. Strengths‑Based Narrative (Parent Partner): A written re‑telling of the family’s story that honors hardship while centering resilience, love, effort, and humanity, intentionally avoiding deficit‑based clinical language. This ensures strengths are actionable assets that directly inform planning and strategy development.
2. Comprehensive Strengths List (Facilitator)
(Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.3 Strengths, Needs, Culture, Vision, Discovery Practice Guide, pages 7-11).
Strengths are documented at a deeper level, including:
✔Descriptive strengths (personal qualities and characteristics)
✔Functional strengths (how those qualities help the family cope or problem‑solve)
✔Contextual strengths (when, where, and under what conditions strengths are most effective)
(Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.3 Strengths, Needs, Culture, Vision, Discovery Practice Guide, pages 7-11).
Identification of Needs
With strengths and vision established, the Facilitator and Parent Partner guide the youth, family, and CFT in identifying underlying needs across life domains (emotional, relational, safety, education, housing, cultural identity, health, and others) via life domain cards. Needs are clearly distinguished from services or goals and are defined as what must change for life to feel better for the youth and family Needs are first generated by the family, then expanded through team input, and reviewed together to ensure alignment with the family’s lived experience (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.3 Strengths, Needs, Culture, Vision, Discovery Practice Guide, pages 7-11).
Ongoing Discovery and Updates
Strengths, needs, culture, and vision discovery is ongoing throughout the Wraparound process. These elements are revisited and deepened during CFT meetings and informed by additional tools (e.g., CANS, the Family Assessment Support Tool (FAST), timelines, and connection maps). Facilitators update these components as needed in the Strengths Summary. The Discovery Summary:
✔Is maintained in the youth’s chart
✔Is updated at least every 90 days, and more frequently as new information emerges
✔Is reviewed with the family to ensure continued accuracy and voice
✔Is shared with new team members to ensure continuity, orientation, and fidelity to the family’s story
(Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.3 Strengths, Needs, Culture, Vision, Discovery Practice Guide, pages 7-11).
Through these practices, Sycamores demonstrates full alignment with Standard 3.3 by ensuring that strengths, needs, culture, and vision are foundational, documented, shared, and actively used to guide High‑Fidelity Wraparound practice. Discovery is family‑driven, culturally responsive, and continuously refined, supporting authentic engagement, effective planning, and sustained fidelity to Wraparound principles.
Supporting Documents:
✔3.3 Strengths, Needs, Culture, Vision, Discovery Practice Guide (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.3 Strengths, Needs, Culture, Vision, Discovery Practice Guide, pages 7-11).
✔Strengths Summary Questions (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation H, pages 84-88)
✔Strengths Summary Sample (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation J, pages 89-90)
✔Facilitating Change Training (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation K, pages 91-130)
✔Family Assessment of Support Tool – FAST (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation L, page 131)
✔Connections Map (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation M, page 132)
✔POC including team members (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation O, pages 137-141)
✔Facilitation Training Pat Miles (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation P, pages 143-192)
3.4 Engage All Team Members
Sycamores’ High‑Fidelity Wraparound (HFW) program demonstrates full alignment with Standard 3.4 by intentionally engaging all relevant Child and Family Team (CFT) members across the Children’s System of Care. Engagement is family‑driven, culturally responsive, and strengths‑based, and includes formal system partners, natural supports, and Tribal representatives for Indian children, as applicable. The HFW team actively facilitates participation, clarifies team roles and responsibilities, and cultivates a collaborative team culture that honors family voice and choice while ensuring system accountability and safety.
3.4(a): Natural Supports Inventory Completed and Documented -A natural supports inventory is completed with all youth and families and is documented in the child or youth’s case file.
Sycamores ensures that a comprehensive natural supports inventory is completed during the engagement phase for all youth and families enrolled in HFW. The assigned Parent Partner meets individually with the parent/caregiver to complete the Family Assessment Support Tool (FAST) and Connections Map. This facilitated discussion explores who the family relies on for support across multiple life domains, including family, friends, school/work, and community. The inventory process is relational and strengths‑focused, supporting families in identifying existing and potential natural supports while respecting family comfort and boundaries. Identified supports are documented in the youth’s electronic case record and are updated throughout the Wraparound process as new supports emerge or family needs evolve (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.4 Engage all Team Members Practice Guide, pages 12-14).
Standard 3.4(b): Identification and Engagement of Children’s System of Care Partners -Children’s System of Care partners who should be included on the HFW team are identified and engaged.
Sycamores’ HFW teams actively collaborate with youth and families to identify all relevant formal and system partners necessary to support the family’s vision, safety needs, and legal mandates. Mandatory system partners—including Child Welfare (DCFS) and/or Juvenile Justice (Probation)—are non‑negotiable members of the CFT to ensure awareness of court orders, safety considerations, and compliance requirements. Additional formal supports are identified based on the youth and family’s needs and may include mental health clinicians, school staff, Regional Center case managers, medical providers, CASA workers, Enhanced Care Management leads, and Foster Family Agency social workers, when applicable. Engagement strategies are individualized and may include CFT meeting participation, targeted coordination, or consultation to gather input that informs the Wraparound plan. All engagement efforts are conducted with appropriate Authorization to Use and Disclose Protected Health Information and are documented in the youth’s file (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.4 Engage all Team Members Practice Guide, pages 12-14).
Standard 3.4(c): Identification of Potential Team Members and Role Clarification -The HFW team works with the youth and family to identify potential team members (including formal, natural supports, and Tribes, in the case of an Indian child) and discusses their role on the team.
Sycamores’ HFW facilitators and Parent Partners engage youth and families in ongoing conversations about who should be involved in their Child and Family Team and how. Families are supported in identifying both formal and natural supports, including extended family, neighbors, coaches, faith leaders, tutors, attorneys, and trusted community members. The team intentionally discusses roles, expectations, and levels of participation, honoring that not all supports will attend meetings due to privacy preferences, scheduling constraints, or the nature of their relationship with the family. When direct participation is not appropriate, the HFW team may gather perspectives through collateral contact and incorporate that information into CFT discussions. For Indian youth and families, tribal representatives are identified and engaged in accordance with cultural practices and family preference. Family voice and choice remain central throughout the process (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.4 Engage all Team Members Practice Guide, pages 12-14).
Standard 3.4(d): Documentation of Engagement and Team‑Building Activities -Engagement and team‑building activities are documented in the youth’s file.
Sycamores’ HFW program documents all engagement and team‑building activities to demonstrate intentional facilitation of a positive and collaborative team culture. Facilitators and Parent Partners use structured and informal activities to foster trust, clarify roles, promote shared responsibility, and ensure that all voices are heard and valued. Engagement is viewed as an ongoing process, revisited as families gain comfort and as new supports are identified. Documentation reflects discussions about participation, outreach efforts, team dynamics, and strategies used to support collaboration and cultural responsiveness. All activities and engagement efforts are recorded in the youth’s case file, primarily through Progress Notes, ensuring transparency and fidelity to HFW principles (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.4 Engage all Team Members Practice Guide, pages 12-14).
Sycamores’ High‑Fidelity Wraparound program fully meets Standard 3.4 – Engage All Team Members by ensuring that all engagement activities are family‑driven, culturally responsive, well‑documented, and intentional. The program consistently identifies and involves key formal and natural supports, clarifies team roles, honors family choice, and maintains accountability to system requirements, demonstrating strong fidelity to HFW practice and state certification standards.
Supporting Documents:
✔3.4 Engage All Team Members Practice Guide (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.4 Engage all Team Members Practice Guide, pgs. 12-14).
✔Family Assessment of Support Tool – FAST (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation L, page 131)
✔Connections Map (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation M, page 132)
✔Authorization to Use and Disclose PHI (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation N, pages 133-135)
✔POC including team members (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation O, pages 137-141)
3.5 Arrange Meeting Logistics
Sycamores’ HFW Program ensures that all Child and Family Team meetings occur at times and in locations that prioritize family needs, voice, and choice, while promoting accessibility, equity, and safety. Meeting logistics are planned collaboratively with families and wraparound team members to support full participation by both formal and natural supports. Consideration is given to family schedules, cultural practices, history of trauma, and access needs, including transportation, language interpretation, and telehealth capability. This approach aligns with the HFW model’s emphasis on family-driven planning, shared decision-making, and strengths-based engagement, ensuring that logistics never serve as a barrier to authentic family participation.
Standard 3.5(a): Staff are flexible in working hours and scheduling meeting times and locations to accommodate family and Wraparound Team needs.
Sycamores’ HFW Facilitators and Parent Partners demonstrate flexibility in working hours and scheduling to accommodate family availability, competing responsibilities, and identified preferences. Meetings are scheduled at times that work for the family, including evenings or other non-traditional hours when needed, in order to support maximum participation and reduced family stress. Meeting locations are selected based on family choice, safety, and accessibility. Options may include the family home, community-based settings, school sites, or virtual platforms. Telehealth options are offered whenever in-person participation is not feasible, ensuring continuity of engagement and minimizing disruptions due to transportation, childcare, health, or scheduling barriers. This practice reflects a family-driven, youth-guided approach, recognizing that flexibility in logistics supports trust-building, engagement, and sustained participation in the wraparound process (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.5 Arrange Meeting Logistics Practice Guide, page 15).
Standard 3.5(b): Staff are trained to work collaboratively with families and HFW team members to schedule meetings aligned with family needs and preferences and maximize participation.
Sycamores ensures that HFW staff are trained to work collaboratively with families and all Wraparound Team members when planning meeting logistics. Facilitators and Parent Partners actively engage families in shared decision-making regarding meeting frequency, timing, location, and format, reinforcing the HFW principle of family voice and choice. Staff receive training in culturally responsive practice, trauma-informed engagement, and collaborative teaming, enabling them to anticipate and address barriers that may limit participation. Considerations include language preferences, interpretation or translation needs, transportation access, and technological supports for virtual meetings. When barriers are identified, staff take proactive steps to coordinate solutions, promoting equitable access for youth and families. Through this collaborative approach, meeting logistics are intentionally designed to support full team participation, strengthen natural supports, and align the wraparound process with family-defined priorities and strengths (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.5 Arrange Meeting Logistics Practice Guide, page 15).
Documentation Practices – While meeting logistics themselves are not documented as standalone entries, all Child and Family Team meetings are recorded in a Progress Note within the Electronic Health Record (Avatar NX). Documentation includes the date of the meeting, participants, and key discussions, demonstrating that meetings occurred as planned and that families and team members were engaged in the wraparound process (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.5 Arrange Meeting Logistics Practice Guide, page 15).
Sycamores’ current practices fully align with HFW Standard 3.5 by embedding flexibility, collaboration, cultural responsiveness, and trauma-informed principles into all aspects of meeting planning and logistics. By prioritizing family voice and choice and proactively addressing access needs, Sycamores ensures that meeting logistics support, rather than hinder, meaningful participation and fidelity to the High Fidelity Wraparound model.
Supporting Documents:
✔3.5 Arrange Meeting Logistics Practice Guide (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, 3.5 Arrange Meeting Logistics Practice Guide, page 15).
✔Facilitating Change Training (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation K, pages 91-130)
✔Language Line Procedures (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation B, pages 18-19)
✔Facilitation Training Pat Miles (Sycamores HFW Comprehensive Practice Guide, II.3 Engagement, Supporting Documentation P, pages 143-192)
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
Standard 4.1 requires that, prior to development of the Wraparound Plan of Care, the Child and Family Team completes and documents the following with each family:
✔Formal team agreements regarding engagement and decision-making
✔Identification and documentation of youth, family, team, and community strengths
✔Creation of a team mission statement aligned with the Family Vision
✔Ongoing documentation of newly identified strengths in the youth’s record
Sycamores’ current practice fully aligns with and operationalizes each component of this standard through structured facilitation, family-centered practice, and consistent documentation within the Electronic Health Record (Avatar NX).
Standard 4.1.1 & 4.1(a): Team Agreements Are Developed and Documented Prior to the Plan of Care & Before the HFW plan of care is developed, team agreements, a team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file.
Building upon engagement and relationship development, the Wraparound Facilitator leads the Child and Family Team in a collaborative process to establish team agreements (ground rules) prior to development of the initial Plan of Care. These agreements define how the team will work together and create a foundation of psychological safety, shared accountability, and respect. Team agreements are developed with the youth and family and are written in language that is meaningful, culturally responsive, and accessible to them. Agreements address:
✔How all voices will be heard and valued
✔How youth voice will be supported in developmentally appropriate ways
✔How the team will respond to strong emotions or challenging topics
✔How decisions will be made (e.g., consensus‐based decision‑making)
✔How disagreements or conflict will be addressed respectfully
✔Expectations regarding confidentiality
✔Team member accountability related to attendance and participation
The Facilitator ensures that youth and caregiver voice are centered in shaping agreements, that all team members clearly understand expectations, and that agreements are revisited and updated as team membership or dynamics change (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.1 Develop and Document Team Agreements, Additional Strengths and Team Mission Practice Guide, pages 1-3).
Standard 4.1.2 & 4.1(b): Strengths Identified During Engagement Are Updated and Expanded -The youth’s and family members’ strengths identified in engagement are updated to reflect any additionally discovered strengths as they are identified and are documented in the youth’s file.
Sycamores recognizes strengths discovery as a continuous and evolving process, not limited to initial engagement. As relationships deepen and team collaboration increases, Wraparound Facilitators and Parent Partners intentionally support the Child and Family Team in identifying additional strengths across multiple domains, including:
✔Youth strengths and interests
✔Caregiver and family strengths
✔Relational and cultural strengths
✔Strengths of team members (skills, expertise, influence, connections)
✔Strengths within extended family, natural supports, and the broader community
Newly identified strengths are consistently reflected back to the family, reinforcing resilience and progress, and are actively incorporated into planning and strategy development. Strengths are treated as functional tools that inform decision‑making and planning rather than static statements. All additional strengths are documented in real time and integrated into ongoing planning to ensure that the Wraparound Plan continues to build upon what is already working for the family (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.1 Develop and Document Team Agreements, Additional Strengths and Team Mission Practice Guide, pages 1-3).
Development and Documentation of Team Mission Statement
Standard 4.1.3: Creating a team mission statement that defines the overall purpose of the HFW team in alignment with the family vision.
With each youth and family, the Wraparound Facilitator supports the Child and Family Team in developing a team mission statement prior to completion of the initial Plan of Care. This mission statement clearly:
✔Defines the shared purpose of the team
✔Reflects the youth’s and family’s priorities, values, and voice
✔Aligns directly with the Family Vision established during Engagement
The mission statement is used as an ongoing guiding compass for the team. Facilitators intentionally reference the mission to:
✔Anchor discussions during team meetings
✔Guide decision‑making when challenges or disagreements arise
✔Maintain focus on long‑term family goals
✔Reinforce shared responsibility and collective commitment among team members
This practice ensures consistency between the family’s vision, team actions, and the strategies outlined in the Plan of Care (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.1 Develop and Document Team Agreements, Additional Strengths and Team Mission Practice Guide, pages 1-3).
Documentation and Record Maintenance
Standard: Prior to development of the initial Plan of Care, team agreements, a team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file.
Sycamores ensures that all required components are completed prior to development of the initial Plan of Care and are clearly documented in the Electronic Health Record (Avatar NX). Documentation is structured, identifiable, and consistently maintained within:
✔The Plan of Care
✔Progress Notes
✔Strengths Inventories
✔Child and Family Team documentation
Strengths identified during Engagement are updated as new strengths emerge and are reflected throughout ongoing documentation and Plan of Care revisions, ensuring alignment with HFW fidelity expectations and state certification requirements (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.1 Develop and Document Team Agreements, Additional Strengths and Team Mission Practice Guide, pages 1-3).
Sycamores’ current practice demonstrates full alignment with HFW Standard 4.1 by ensuring that:
✔Team agreements, strengths, and mission statements are developed before the Plan of Care
✔Youth and family voice are centered throughout the process
✔Strengths are continuously identified, documented, and used in planning
✔Documentation is consistent, timely, and clearly identifiable within the youth record
This integrated approach supports high‑quality, family‑driven, and culturally responsive Wraparound practice consistent with state HFW certification standards (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.1 Develop and Document Team Agreements, Additional Strengths and Team Mission Practice Guide, pages 1-3).
Supporting Documents:
✔4.1 Develop and Document Team Agreements, Additional Strengths and Team Mission Practice Guide (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.1 ✔Develop and Document Team Agreements, Additional Strengths and Team Mission Practice Guide, pages 1-3).
✔CFT meeting agenda (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, A, page 13).
✔Facilitation Training Pat Miles (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, B, pages 14-54).
✔Plan of Care- Team Agreements (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, C, pages 55-60).
✔LATC Facilitating Change (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, D, pages 61-100).
✔LATC Plan of Care Training (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, E, pages 101-108).
✔Plan of Care (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, F, pages 109-114).
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
Sycamores’ High Fidelity Wraparound (HFW) practice is fully aligned with Practice 4.2 standards. Through a structured, team‑based facilitation process, Wraparound Facilitators guide Child and Family Teams (CFTs) to identify and prioritize underlying needs, develop measurable goals and outcomes, and brainstorm multiple individualized strategies. This collaborative process ensures that Plans of Care are needs‑based, strengths‑driven, culturally responsive, and grounded in youth and family voice, consistent with HFW principles.
Standard 4.2(a): Identification and Prioritization of Underlying Needs
Before the HFW Plan of Care is developed, underlying needs are identified and prioritized for each family and documented in the youth’s file.
At Sycamores, Wraparound Facilitators build on discovery and engagement activities to lead the Child and Family Team in identifying the underlying unmet needs driving behaviors or challenges. Needs are intentionally framed in non‑blaming, strengths‑based language (e.g., safety, belonging, stability, connection, competence, autonomy), reinforcing a needs‑based rather than deficit‑based approach. Facilitators guide teams to review needs previously identified during engagement, add newly identified needs, and collaboratively prioritize needs based on family voice, urgency, and alignment with the Family Vision. Identified and prioritized needs are clearly documented in the youth’s record prior to Plan of Care development, ensuring transparency, continuity, and fidelity to HFW standards (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.2 Describe and Prioritize Needs, Develop Goals and Assign Strategies Practice Guide, pages 4-6).
Standard 4.2(b): Development of Measurable Goals and Outcomes
Measurable goals and outcomes are developed from identified needs rather than behaviors or deficits.
For each prioritized need, the Facilitator supports the CFT in developing specific, measurable goals and outcomes that directly stem from the underlying need rather than from surface behaviors or diagnoses. Goals are written in family‑friendly language and are explicitly connected to the Family Vision, reinforcing meaningful life changes identified by the youth and caregivers. This process ensures that planning remains focused on outcomes that matter most to the family, supporting sustainable change rather than compliance‑driven service activity (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.2 Describe and Prioritize Needs, Develop Goals and Assign Strategies Practice Guide, pages 4-6).
Standard 4.2(c): Collaborative Development with Youth, Family, and Team
Goals and outcomes are developed collaboratively with the youth, family, and the rest of the HFW team.
Sycamores ensures that all goals, outcomes, and strategies are developed through a collaborative, team‑based planning process. The youth (in developmentally appropriate ways), family members, formal service providers, natural supports, and tribal representatives (when applicable) are actively engaged in decision‑making. Facilitators and Parent Partners work intentionally to center youth and family voice, reinforce shared understanding of needs‑based planning, and promote power‑sharing rather than professional‑driven direction. This approach strengthens engagement, ownership, and accountability across the team (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.2 Describe and Prioritize Needs, Develop Goals and Assign Strategies Practice Guide, pages 4-6).
Standard 4.2 (d): Documentation of Multiple Individualized Strategies
Multiple individualized brainstormed strategies are documented and available for reference.
For each prioritized need and related goal, Wraparound Facilitators lead the CFT in brainstorming multiple creative and individualized strategies before selecting specific action steps. Brainstorming is intentionally strengths‑based, culturally responsive, and inclusive of both formal services and natural supports identified by the family. Multiple strategies are documented and maintained as reference points within the youth’s file, ensuring flexibility and responsiveness as needs evolve. Selected strategies are translated into clear action items with identified responsible parties and timelines when appropriate (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.2 Describe and Prioritize Needs, Develop Goals and Assign Strategies Practice Guide, pages 4-6).
Standard 4.2(e): Facilitator Training in Needs‑Based Planning
Facilitators are trained to lead teams in identifying, prioritizing needs, developing strategies, and assigning action items.
Sycamores provides comprehensive training to Wraparound Facilitators in needs‑based planning, prioritization of needs, collaborative goal development, brainstorming strategies, and translating team decisions into actionable plans. Facilitators are expected to consistently apply these skills across all phases of Wraparound when developing and updating Plans of Care. Ongoing coaching and supervision further support fidelity to HFW standards and reinforce high‑quality facilitation practice (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.2 Describe and Prioritize Needs, Develop Goals and Assign Strategies Practice Guide, pages 4-6).
Standard 4.2(f): Development of the Individualized HFW Plan of Care
These steps are utilized to develop the individualized HFW Plan of Care in a collaborative environment.
The identified needs, measurable goals, outcomes, and strategies developed through the collaborative CFT process form the foundation of the individualized HFW Plan of Care. The Plan of Care is not created separately from team discussions but directly reflects the family’s voice, strengths, prioritized needs, and shared vision. This integrated approach ensures that the Plan of Care remains a living document grounded in the Wraparound process and responsive to the evolving needs of the youth and family (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.2 Describe and Prioritize Needs, Develop Goals and Assign Strategies Practice Guide, pages 4-6).
Supporting Documents:
✔4.2 Describe and Prioritize Needs, Develop Goals and Assign Strategies Practice Guide (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.2 Describe and ✔Prioritize Needs, Develop Goals and Assign Strategies Practice Guide, pages 4-6)
✔Facilitation Training Pat Miles (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, B, pages 14-54).
✔Plan of Care- Team Agreements (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, C, pages 55-60).
✔LATC Facilitating Change (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, D, pages 61-100).
✔LATC Plan of Care Training (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, E, pages 101-108).
✔Plan of Care (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, F, pages 109-114).
✔Wraparound Needs vs. Goals Infographic (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, G, page 115).
4.3 Develop an Individualized Child or Youth and Family Plan
Standard 4.3: Development of an Individualized Plan of Care Through a High‑Quality Team Process
The HFW team develops a comprehensive, individualized Plan of Care based on prioritized family and youth needs through a high‑quality, collaborative team process that elicits multiple perspectives, builds trust, and demonstrates HFW principles.
Sycamores delivers High Fidelity Wraparound services using an individualized Plan of Care developed through a structured, team‑based planning process grounded in HFW principles. Wraparound Facilitators lead the Child and Family Team—including youth, caregivers, formal partners, natural supports, and Tribal representatives when applicable—in collaboratively developing the Plan of Care. The planning process prioritizes family and youth voice and choice, intentionally elicits multiple perspectives, and promotes trust, shared understanding, and alignment among team members. Plans are driven by prioritized needs, measurable goals, and brainstormed strategies that reflect the Family Vision and team mission statement.
Standard 4.3(a) & 4.3.1: Alignment with Family Vision, Strengths, Needs, and Culture
Plans must align with the family vision and team mission and be based on youth and family strengths, prioritized needs, and cultural context, including ICWA requirements for Indian children.
At Sycamores, each Plan of Care is explicitly aligned with the Family Vision, team mission, and identified strengths of the youth, family, and team. Underlying needs are prioritized collaboratively and addressed in a manner that honors the family’s culture, values, identity, and preferences. For Indian children, Sycamores incorporates ICWA considerations and includes the Tribe in the planning process in accordance with legal requirements and family wishes. This ensures culturally responsive, legally compliant, and family‑centered planning (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.3 Develop an Individualized Child or Youth and Family Plan Practice Guide, pages 7-10).
Standard 4.3(b) & Standard 4.3.2: Comprehensive, Cross‑System Planning Across Life Domains
The Plan of Care addresses needs across multiple life domains and integrates goals from all involved Children’s System of Care partners.
Sycamores ensures each Plan of Care addresses needs across relevant life domains, including home life, education, behavioral health, physical health, social relationships, community involvement, and legal system involvement. Facilitators actively incorporate input and goals from all involved system partners—such as Child Welfare, Juvenile Justice, schools, mental health providers, and the Regional Center—while maintaining alignment with youth and family priorities. This promotes coordinated, holistic service delivery across systems (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.3 Develop an Individualized Child or Youth and Family Plan Practice Guide, pages 7-10).
Standard 4.3.3: Clearly Documented Strategies, Action Items, and Roles
Plans must clearly document strategies, responsible parties, and timelines, ensuring clarity and accountability among team members.
Sycamores’ Plans of Care clearly document individualized strategies linked to each prioritized need and goal. Each strategy identifies responsible team members and timeframes when applicable. Strategies are strengths‑based, culturally relevant, and intentionally balanced across formal services, natural supports, and community resources. Over time, teams work toward reducing reliance on formal services while strengthening sustainable supports (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.3 Develop an Individualized Child or Youth and Family Plan Practice Guide, pages 7-10).
Standard 4.3.4: Coordinated, Accessible, and Community‑Based Services
Services must be well‑coordinated, community‑based, accessible, and responsive to family schedules, culture, trauma history, and equity considerations.
Sycamores prioritizes delivering services in the community where the youth and family live whenever possible. Planning considers family schedules, cultural factors, trauma history, and equitable access to ensure meaningful participation. Facilitators coordinate services across partners to minimize duplication and barriers while supporting engagement and continuity of care (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.3 Develop an Individualized Child or Youth and Family Plan Practice Guide, pages 7-10).
Standard 4.3.5: Inclusion and Development of Natural Supports
Natural supports and sustainable community resources are included in the Plan, or strategies are developed to build these supports prior to transition.
Sycamores actively includes natural supports—such as extended family, friends, mentors, faith and cultural organizations, and Tribal representatives—whenever possible.
When natural supports are limited, the Plan of Care includes intentional strategies to identify, develop, and strengthen community connections in alignment with family readiness and comfort, supporting long‑term sustainability (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.3 Develop an Individualized Child or Youth and Family Plan Practice Guide, pages 7-10).
Standard 4.3.6: Gradual Transition from Formal Services
Plans must include benchmarks for transitioning to less restrictive, less formal services, paced according to family readiness.
Sycamores incorporates transition planning throughout the Wraparound process. Plans address gradual movement toward increased independence and reduced reliance on formal services while recognizing that readiness and pace vary by family. Transition benchmarks are flexible, individualized, and responsive to evolving family needs, ensuring continuity and stability (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.3 Develop an Individualized Child or Youth and Family Plan Practice Guide, pages 7-10).
Standard 4.3(c): Documentation, Distribution, and Quality Review
Plans must be documented in the youth’s file, distributed to team members, and reviewed for quality improvement.
All Plans of Care are documented in Sycamores’ Electronic Health Record (Avatar NX) and shared with Child and Family Team members in accordance with signed Releases of Information. Plans clearly reflect all required components, supporting transparency, accountability, and continuity of care. Procedures are in place to review Plans of Care as part of ongoing quality improvement efforts (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.3 Develop an Individualized Child or Youth and Family Plan Practice Guide, pages 7-10).
Standard 4.3(d): Staff Training, Coaching, and Continuous Improvement
Facilitators receive ongoing training and coaching to ensure high‑quality planning and fidelity to HFW principles.
Sycamores provides ongoing training and coaching to Wraparound Facilitators focused on collaborative planning, eliciting multiple perspectives, building trust, and upholding HFW principles. Supervisors and coaches offer continuous support, feedback, and skill development to strengthen practice over time. Sycamores’ Practice 4.3 meets and operationalizes the HFW standards for developing an individualized Child or Youth and Family Plan through a high‑quality, team‑based, culturally responsive, and system‑coordinated process that prioritizes family voice, community integration, and sustainable outcomes (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.3 Develop an Individualized Child or Youth and Family Plan Practice Guide, pages 7-10).
Supporting Documents:
✔4.3 Develop an Individualized Child or Youth and Family Plan Practice Guide (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.3 Develop an Individualized Child or Youth and Family Plan Practice Guide, pages 7-10).
✔LATC Plan of Care Training (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, E, pages 101-108).
✔Plan of Care (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, F, pages 109-114).
✔Wraparound Needs vs Goals Infographic (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, G, page 115).
✔Authorization to Use and Disclose PHI (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, H, pages 116-118).
4.4 Develop a Crisis and Safety Plan
Sycamores meets and exceeds HFW State Certification Standard 4.4 Develop a Crisis and Safety Plan through the consistent use of a unified HFW Safety and Crisis Plan. This plan is developed collaboratively with youth, families, and the Child and Family Team and reflects High Fidelity Wraparound principles by centering youth and family voice and choice, cultural relevance, individualized strategies, and the intentional use of natural supports. The HFW Safety and Crisis Plan is treated as a living document that evolves in response to emerging needs, behaviors, and strengths.
Standard 4.4(a): An individualized crisis and safety plan is documented in the youth’s file, which identifies potential safety, high‑risk and crisis situations with proactive and reactive crisis management strategies chosen by the family members and including who should be called for support 24/7.
Sycamores ensures that every youth enrolled in HFW services has an individualized Safety and Crisis Plan documented in the Electronic Health Record (EHR), Avatar NX. The Wraparound Facilitator leads the Child and Family Team in identifying:
✔Current safety concerns
✔Potential high‑risk or crisis situations
✔Triggers and early warning signs (when applicable)
✔Proactive prevention strategies
✔Reactive strategies to be used during crisis
All strategies are developed collaboratively and selected by the youth and family, written in language that is meaningful and accessible to them, and grounded in family strengths, culture, and preferences. Each Safety and Crisis Plan clearly identifies 24/7 support options, including:
✔Family‑identified natural supports
✔Formal providers involved in the youth’s care
✔Sycamores’ program‑specific 24/7 crisis line, staffed by on‑call clinicians, supervisors, and/or LPS‑designated supervisors capable of assessing safety, supporting crisis planning, and initiating higher levels of care when clinically indicated.
Families are provided with crisis contact information in multiple formats, including written copies and access through myHealthPointe, ensuring timely access to support during emergencies (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.4 Develop a Crisis and Safety Plan Practice Guide, pages 11-12).
Standard 4.4(b): The development of the plan occurs in a team‑based, collaborative environment and facilitators receive training and coaching to this process.
The HFW Safety and Crisis Plan is developed within a team‑based, collaborative Child and Family Team (CFT) process facilitated by the Wraparound Facilitator. Team membership is determined by the youth and family and may include:
✔Youth and caregivers
✔Wraparound Facilitator
✔Parent Partner
✔Family Specialist
✔Involved clinician
✔County Social Worker and/or Probation Officer (when applicable)
✔Other formal and natural supports identified by the family
✔Tribal representatives for Indian children, when applicable
The involved clinician gathers relevant safety and crisis information and collaborates with the team to ensure that:
✔Youth and family voice remains central
✔There is a shared understanding of safety needs and risks
✔Each team member understands their role in supporting safety before, during, and after crisis events
Sycamores supports high‑quality implementation through ongoing staff training and coaching, which includes:
✔Collaborative and strengths‑based safety planning
✔Developing individualized, needs‑based crisis strategies
✔Centering youth and family voice and choice
✔Integrating natural supports into crisis response
Supervisors and coaches provide continuous guidance to ensure facilitators consistently apply HFW principles during Safety and Crisis Plan development (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.4 Develop a Crisis and Safety Plan Practice Guide, pages 11-12).
Standard 4.4(c): Crisis and safety plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.
Sycamores treats the Safety and Crisis Plan as a living document subject to continuous review and refinement. An initial plan is developed at the start of services and is reviewed and updated whenever clinically or situationally indicated, including:
✔Following crisis events, to identify strategies that were effective and eliminate those that were not
✔When new behaviors, triggers, or safety concerns emerge
✔As the team gains deeper insight into risk, protective factors, and family strengths
Supervisors and coaches routinely review Safety and Crisis Plans to assess:
✔The degree of individualization
✔The logical progression from proactive to reactive strategies
✔Cultural relevance and responsiveness
✔Appropriate and meaningful use of natural supports
Findings from these reviews are incorporated into continuous quality improvement (CQI) efforts, staff coaching, and targeted training, reinforcing fidelity to High Fidelity Wraparound practice (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.4 Develop a Crisis and Safety Plan Practice Guide, pages 11-12).
Through its structured yet individualized approach to Safety and Crisis Planning, Sycamores demonstrates full alignment with HFW State Certification Standard 4.4. Practices consistently reflect youth‑ and family‑driven decision‑making, cultural responsiveness, proactive and reactive planning, robust team collaboration, and ongoing quality review—ensuring safety planning remains effective, relevant, and responsive over time.
Supporting Documents:
✔4.4 Develop a Crisis and Safety Plan Practice Guide (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, 4.4 Develop a Crisis and Safety Plan Practice Guide, pages 11-12).
✔Safety Plan Training (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, I, pages 119-130).
✔Safety and Crisis Plan (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, J pages 131-132).
✔Sycamores EHR MyHealthPointe portal (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, K, page 133).
✔Quality Cup (Sycamores HFW Comprehensive Practice Guide, II.4 Planning, Supporting Documentation, L, pages 134-147).
Implementation
5.1 Implement The Plan of Care
Sycamores’ High‑Fidelity Wraparound (HFW) program implements the Plan of Care as a living, team‑driven document that actively guides service delivery and decision‑making. Implementation is viewed as an ongoing process of action, reflection, and adaptation, anchored in the family’s shared vision, strengths, prioritized needs, and goals. While core elements of the Plan of Care—vision, strengths, and needs—provide continuity, strategies and action steps are intentionally flexible and responsive to learning over time. As families’ circumstances evolve and new information emerges, the Child and Family Team (CFT) adjusts the Plan of Care in alignment with HFW principles. Throughout implementation, staff intentionally recognize effort, progress, and success—both large and small—to sustain hope, reinforce engagement, and strengthen team cohesion. All implementation practices are supported through training, coaching, and fidelity monitoring to ensure consistency with High‑Fidelity Wraparound expectations.
Standard 5.1(a): The facilitator leads the team to review strategies and action items at HFW team meetings, track individual assignments, support timelines and deliverables, and adjust strategies and action items as needed.
At Sycamores, HFW Facilitators lead the ongoing implementation of the Plan of Care through structured, accountable Child and Family Team (CFT) meetings. Each meeting follows a consistent Wraparound‑aligned agenda that ensures action items, assignments, and timelines are actively reviewed and documented. Facilitators guide the team in reviewing previously assigned action steps, identifying what was completed, what progress was observed, and what barriers may have impacted completion. This review is framed as shared learning and collaborative problem‑solving, rather than performance evaluation, reinforcing psychological safety and sustained engagement. Responsibility for action items is clearly assigned to specific team members, with timelines reviewed and adjusted as needed to reflect the family’s capacity, priorities, and changing circumstances (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, 5.1 Implement Plan of Care Practice Guide, pages 1-3).
Facilitators regularly “check in” with team members—during meetings and between meetings—to support follow‑through, troubleshoot barriers, and maintain momentum. When strategies are not producing the desired outcomes, Facilitators support the team in adapting strategies, generating new ideas, or shifting roles while remaining grounded in the family’s vision and HFW principles. This ensures implementation remains responsive, collaborative, and outcome‑focused. Documentation of implementation—including action item completion, adjustments made, and new assignments—is consistently captured in the ongoing Plan of Care and progress notes, creating transparency and accountability across the team (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, 5.1 Implement Plan of Care Practice Guide, pages 1-3).
Standard 5.1(b): Staff receive training and coaching on implementing the Plan of Care in alignment with HFW principles. Training and processes address celebrating successes as they occur.
Sycamores ensures that all staff are trained and coached to implement Plans of Care in alignment with High‑Fidelity Wraparound principles. As part of onboarding, all HFW staff complete the UC Davis Foundational High‑Fidelity Wraparound training, which establishes a shared understanding of Wraparound values, team‑based planning, and strengths‑driven implementation. Following foundational training, HFW Supervisors provide individualized coaching, with particular emphasis on Facilitators’ role in leading CFT meetings, tracking action steps, and supporting adaptive implementation. New staff receive enhanced support through shadowing, supervision, and case consultation, allowing skills to be reinforced in real‑world practice. Ongoing supervision focuses on:
✔Maintaining accountability without blame
✔Supporting meaningful team collaboration
✔Adjusting strategies based on progress and learning
✔Intentionally celebrating effort and success
(Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, 5.1 Implement Plan of Care Practice Guide, pages 1-3).
Celebration of progress is embedded into both practice and training expectations. Facilitators are coached to begin meetings by acknowledging “what’s working,” naming emerging strengths, and highlighting even small steps forward. This practice reinforces hope, resilience, and continued engagement, particularly for families experiencing high levels of stress or change. Fidelity monitoring further reinforces effective implementation. Supervisors review CFT documentation, observe meetings when appropriate, and utilize tools such as the WFI‑EZ to assess alignment with HFW principles, including strengths‑based practice, collaboration, and accountability (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, 5.1 Implement Plan of Care Practice Guide, pages 1-3).
Sycamores meets HFW Standard 5.1 by implementing Plans of Care through structured, collaborative team processes; maintaining accountability for action items; supporting ongoing adaptation; and ensuring staff are well‑trained and coached in High‑Fidelity Wraparound practice. Implementation is consistently documented, grounded in family voice and vision, and reinforced through supervision, fidelity monitoring, and intentional recognition of success.
Supporting Documents:
✔5.1 Implement Plan of Care Practice Guide (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, 5.1 Implement Plan of Care Practice Guide, pages 1-3).
✔POC Template (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, A, pages 9-14).
✔Facilitator Training II Pat Miles (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, B, pages 15-23).
✔Facilitator Tool Kit (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, C, pages 24-29).
✔Supervision Log (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, D, pages 30-31).
✔Case Consultation Template (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, page 32).
✔WFI-EZ (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, F, pages 33-36).
✔LATC Observation Coaching Form (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, G, pages 37-38).
5.2 Review and Update The Plan of Care
Sycamores’ current practice fully aligns with High‑Fidelity Wraparound (HFW) standards for the ongoing review, updating, documentation, and communication of the Plan of Care. Review and updates are embedded into routine Child and Family Team (CFT) meetings and supported by consistent documentation practices that ensure accountability, transparency, and fidelity to Wraparound principles, including family voice and choice.
Standard 5.2(a): Review of Strategies, Progress, and Action Items Occur in an HFW Team Meeting
At Sycamores, review of the Plan of Care occurs within the context of regularly scheduled HFW Child and Family Team meetings. Facilitators intentionally guide the team to review progress toward identified needs, discuss the effectiveness of current strategies, and assess completion of action items. Reviews are structured to ensure participation from youth, caregivers, formal providers, and natural supports, reinforcing collaboration and shared responsibility. Discussions focus on what is working well, barriers encountered, and whether action steps remain relevant and achievable. This ensures the Plan of Care remains a living document that reflects the team’s current understanding of the youth’s and family’s needs. Sycamores ensures that all review and updates to the Plan of Care occur during Child and Family Team meetings. Reviews consistently address:
✔Progress toward identified needs
✔Effectiveness of current strategies
✔Successes achieved
✔Newly identified strengths
✔New or evolving needs
✔Strategies or action steps that are no longer effective
✔New ideas proposed by the team
(Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, 5.2 Review and Update the Plan of Care Practice Guide, pages 4-5).
Standard 5.2(b): Facilitator Leads the Team to Adjust the Plan as Needs, Successes, or Strategies Change
Sycamores facilitators actively lead the Child and Family Team in adjusting the Plan of Care as successes are achieved, new needs are identified, or existing strategies prove ineffective. Changes to goals, strategies, or action steps are made collaboratively during team meetings, ensuring transparency and honoring family voice and choice. Updated Plans are documented in the youth’s file following the meeting. When changes are incremental, updates are reflected in progress notes and meeting minutes; when changes are substantial, the full Plan of Care is formally revised. This flexible approach allows the team to remain responsive while maintaining consistency with Wraparound standards. All changes to goals, strategies, and priorities are developed collaboratively with the team, reinforcing transparency, shared decision‑making, and family voice and choice (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, 5.2 Review and Update the Plan of Care Practice Guide, pages 4-5).
Standard 5.2(c): Documentation and Communication of Team Activity and Plan Updates
Sycamores maintains comprehensive documentation of all Child and Family Team activity. Changes and progress discussed during each Child and Family Team meeting are documented through progress notes and meeting minutes. These records capture ongoing team activity even when a full Plan of Care update is not required, ensuring continuity and a complete record of the team’s work over time. Following each meeting, facilitators document and communicate:
✔Completion of tasks and new assignments
✔Team member attendance
✔Participation of formal and natural supports
✔Use of flex funds when applicable
✔Adjustments to goals, strategies, and action steps
At a minimum, these updates are shared with all team members through written Child and Family Team meeting minutes. This practice ensures accountability, continuity of care, and shared understanding among all team members, including those unable to attend meetings (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, 5.2 Review and Update the Plan of Care Practice Guide, pages 4-5).
Standard 5.2(d): Ability to Update and Individualize Required Forms
Sycamores utilizes required HFW documentation tools in compliance with Los Angeles County contract standards while allowing for meaningful individualization. Facilitators tailor forms to reflect the family’s language, priorities, cultural context, and evolving needs. Documentation remains flexible so that goals, strategies, and supports can be updated without compromising fidelity. This balance of structure and flexibility ensures consistency across teams while honoring the individualized, family‑driven nature of High‑Fidelity Wraparound. Sycamores’ documentation practices support fidelity to HFW while allowing flexibility to meet each family’s unique needs. Facilitators ensure that all documentation accurately reflects the team’s decisions, the family’s voice, and the evolving nature of the work. The written Plan of Care is formally reviewed, updated, and distributed to all team members at least every 90 days, or more frequently when significant changes occur. These updates take place within Child and Family Team meetings and are used to confirm that the Plan continues to reflect current priorities, strategies, and the family’s direction. Updated Plans also support orientation of new team members (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, 5.2 Review and Update the Plan of Care Practice Guide, pages 4-5).
Through structured Child and Family Team meetings, facilitator leadership, comprehensive documentation, and individualized use of required tools, Sycamores demonstrates full alignment with HFW Standard 5.2. Current practice ensures that the Plan of Care is continuously reviewed, updated, documented, and communicated in a manner that reflects High‑Fidelity Wraparound values and certification requirements.
Supporting Documents:
✔5.2 Review and Update the Plan of Care Practice Guide (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, 5.2 Review and Update the Plan of Care Practice Guide, pages 4-5).
✔POC Template (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, A, pages 9-14).
✔Facilitator Training II Pat Miles (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, B, pages 15-23).
✔Facilitator Tool Kit (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, C, pages 24-29).
✔Supervision Log (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, D, pages 30-31).
✔Case Consultation Template (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, page 32).
✔WFI-EZ (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, F, pages 33-36).
✔LATC Observation Coaching Form (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, G, pages 37-38).
✔Flex Funds Request (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, H, page 39).
✔Relias Training Log (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, I, pages 40-44).
✔Connections Map (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, J, page 45).
✔Natural Support Training (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, K, pages 46-73).
✔Team Tool Kit (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, L, pages 74-79).
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
Sycamores’ High-Fidelity Wraparound (HFW) program recognizes that strong Child and Family Teams are the foundation of effective, sustainable Plans of Care. In alignment with HFW principles, Facilitation practice intentionally prioritizes emotional safety, trust, collaboration, and shared purpose throughout the life of the team. Facilitators continuously assess team functioning, support the inclusion of natural supports when appropriate, and ensure that both professional and natural team members are engaged in ways that honor family voice and promote cohesive teamwork.
Standard 5.3(a): Team agreements are utilized, reviewed regularly, and present at HFW Team Meetings
Consistent with HFW expectations, all Child and Family Teams supported by Sycamores develop team agreements (ground rules) collaboratively during the early stages of the Wraparound process. Facilitators guide families, youth, and team members in identifying shared expectations for communication, confidentiality, respect, accountability, and shared decision-making. These team agreements are:
✔Co-created with meaningful participation from caregivers and youth
✔Grounded in Wraparound values, particularly family voice and choice
✔Reviewed periodically and intentionally revisited when challenges, transitions, or conflicts arise
✔Actively referenced during Child and Family Team meetings to reinforce expectations and maintain psychological safety
(Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, 5.3 Build Supports While Maintaining Team Cohesiveness Practice Guide, pages 6-8).
Facilitators ensure that agreements are physically or visually available during meetings (e.g., printed, displayed, or included in meeting materials), reinforcing their role as a living framework rather than a one-time activity (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, 5.3 Build Supports While Maintaining Team Cohesiveness Practice Guide, pages 6-8).
Standard 5.3(b): Facilitators receive ongoing training and coaching on building, engaging, and maintaining effective teams
Sycamores ensures that HFW Facilitators receive ongoing training, coaching, and reflective supervision focused on sustaining effective team functioning. Training emphasizes skills related to:
✔Building trust and emotional safety
✔Managing group dynamics and power imbalances
✔Elevating and protecting family and youth voice
✔Supporting respectful communication across diverse team members
✔Recognizing and responding to cultural considerations
Supervisors and coaches provide regular feedback to Facilitators on their ability to monitor team cohesion, engage quieter voices, address conflict constructively, and reinforce shared purpose aligned with the Family Vision. Team functioning is viewed as a core practice competency, not an ancillary skill (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, 5.3 Build Supports While Maintaining Team Cohesiveness Practice Guide, pages 6-8).
Standard 5.3(c): Use of natural supports are monitored over time and teams are provided feedback through coaching and supervision
In alignment with HFW principles, Sycamores’ Facilitators thoughtfully support the identification, inclusion, and ongoing monitoring of natural supports as part of the Child and Family Team. Natural supports are engaged in ways that respect family preferences and enhance, not disrupt, team cohesion. Facilitators continually assess:
✔The role and effectiveness of natural supports over time
✔The comfort and engagement of the family and youth with each support
✔The impact of natural supports on team trust, communication, and shared ownership
Supervisors and coaches review the use of natural supports during case consultations and supervision, providing feedback to ensure that these relationships are strengths-based, sustainable, and aligned with the family’s goals (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, 5.3 Build Supports While Maintaining Team Cohesiveness Practice Guide, pages 6-8).
Standard 5.3(d): Processes for orienting new team members (including formal and natural supports) are in place
Sycamores utilizes intentional orientation processes when new members, both professional and natural supports, join the Child and Family Team. Facilitators ensure that new participants are welcomed and brought into the team in ways that preserve trust, honor family voice, and maintain continuity. Orientation includes:
✔An explanation of the Wraparound philosophy and HFW process
✔A review of the Family Vision, current goals, strategies, and team agreements
✔Clarification of roles and expectations
✔Opportunities for relationship-building and connection with existing team members
This approach supports seamless team integration while reinforcing shared purpose and emotional safety (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, 5.3 Build Supports While Maintaining Team Cohesiveness Practice Guide, pages 6-8).
Sycamores’ HFW practice fully aligns with Standard 5.3 by demonstrating consistent, intentional attention to team cohesion, trust, and engagement. Through the use of team agreements, ongoing Facilitator development, careful integration of natural supports, and structured orientation processes, Sycamores ensures that Child and Family Teams remain collaborative, respectful, and focused on achieving meaningful outcomes for youth and families.
Supporting Documents:
✔5.3 Build Supports While Maintaining Team Cohesiveness Practice Guide (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, 5.3 Build Supports While Maintaining Team Cohesiveness Practice Guide, pages 6-8).
✔POC Template (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, A, pages 9-14).
✔Facilitator Training II Pat Miles (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, B, pages 15-23).
✔Facilitator Tool Kit (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, C, pages 24-29).
✔Supervision Log (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, D, pages 30-31).
✔Case Consultation Template (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, page 32).
✔WFI-EZ (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, F, pages 33-36).
✔LATC Observation Coaching Form (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, G, pages 37-38).
✔Flex Funds Request (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, H, page 39).
✔Relias Training Log (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, I, pages 40-44).
✔Connections Map (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, J, page 45).
✔Natural Support Training (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, K, pages 46-73).
✔Team Tool Kit (Sycamores HFW Comprehensive Practice Guide, II.5 Implementation, Supporting Documentation, L, pages 74-79).
Transition
6.1 Develop a Transition Plan
When predetermined benchmarks indicate sufficient progress toward the team’s mission and goals, and the youth, family, and team agree the family is ready for transition, the HFW team develops a formal, individualized transition plan. The plan identifies ongoing needs, services, and supports that will persist beyond formal HFW involvement, including strategies for transferring responsibility from HFW staff to long-term formal and natural supports.
Standard 6.1(a): Readiness for Transition Is Identified Collaboratively
The facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators monitored and adapted throughout the HFW process.
At Sycamores, transition planning is introduced at the start of HFW services and reinforced throughout treatment. The Facilitator leads the Child and Family Team (CFT) in collaboratively determining readiness for transition using clearly defined benchmarks and qualitative indicators rather than service duration alone. Readiness is assessed through shared review of progress toward the family’s vision and goals, increased utilization of strengths and natural supports, reduced frequency and intensity of crises, stability across life domains (home, school, relationships, and safety), and the family’s confidence in independently managing challenges. Consideration is also given to the status of child welfare, probation, or other system involvement when applicable. Transition readiness is reached through collective agreement by the youth, caregivers, and team members (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, 6.1 Develop a Transition Plan Practice Guide, pages 1-2).
Standard 6.1(b): Individualized Transition Plan Is Developed, Documented, and Distributed
Once readiness is determined, the facilitator leads the team in creating an individualized transition plan, distributes it to all team members, and documents the plan in the youth’s file.
When readiness is identified, the Facilitator convenes a CFT meeting to develop a formal, individualized Transition Plan. The plan builds on the family’s vision, strengths, culture, and relationships and clearly identifies ongoing needs, services, and supports that will continue after HFW ends. The plan includes strategies for a gradual and purposeful transfer of responsibility from HFW staff to caregivers, youth, and natural supports. All team members receive copies of the finalized plan, ensuring shared understanding and accountability. The Transition Plan is documented in the youth’s Electronic Health Record (EHR) to ensure continuity and accessibility (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, 6.1 Develop a Transition Plan Practice Guide, pages 1-2).
Standard 6.1(c): Transition Planning Is Team-Based, Collaborative, and Supported by Training
Transition planning occurs in a team-based, collaborative environment, and facilitators receive training and coaching in this process.
Sycamores’ transition planning process is fully aligned with High-Fidelity Wraparound principles, emphasizing family voice and choice, shared decision-making, and team collaboration. The Facilitator guides the process while actively incorporating input from youth, caregivers, Parent Partners, Family Specialists, Clinicians, and other formal and natural supports. Facilitators receive ongoing training and coaching in transition planning to ensure consistency, fidelity, and responsiveness to family-defined needs. Transition discussions reinforce family self-efficacy and celebrate progress, ensuring the process is empowering rather than abrupt (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, 6.1 Develop a Transition Plan Practice Guide, pages 1-2).
Standard 6.1(d): Services and Supports Are Verified to Continue Beyond HFW
The team verifies that services and supports identified in the transition plan will persist beyond formal HFW and that the family can access them, including post-adoption services when applicable.
The HFW team ensures sustainability of supports through proactive verification and warm handoffs. Formal providers, natural supports, and community resources identified in the Transition Plan are contacted and confirmed prior to discharge. The team verifies that caregivers understand how to access services and what steps to take if needs escalate. For families receiving Adoption Assistance Program (AAP) funding, education and connection to post-adoptive services are provided to ensure continuity of care. Parent Partners provide individualized support to caregivers, reviewing learned skills, reinforcing progress, and completing any necessary linkages prior to discharge
(Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, 6.1 Develop a Transition Plan Practice Guide, pages 1-2).
All transition-related documentation—including the finalized Transition Plan and the Clinician’s Transition Instructions Form—is maintained in the youth’s Electronic Health Record (Avatar NX). These records serve as a reference for the family and future service providers and ensure accountability, compliance, and continuity of care following HFW discharge.
Supporting Documents:
✔6.1 Develop a Transition Plan Practice Guide (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, 6.1 Develop a Transition Plan Practice Guide, pages 1-2).
✔Transition Instructions (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, Supporting Documentation, A, page 7).
✔Parent Partner Practice Guide for Transition (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, Supporting Documentation, B, page 8-16).
✔Facilitator Tool Kit (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, Supporting Documentation, C, pages 17-22).
✔Parent Partner Tool Kit (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, Supporting Documentation, D, page 23-30).
✔Transition POC (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, Supporting Documentation, E, pages 31-36).
✔The Collaborative Tool kit- Pat Miles Training (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, Supporting Documentation, J, page 49-67).
6.2 Develop a Post-Transition Safety Plan
HFW Standard 6.2 requires that facilitators lead the Child and Family Team in developing or updating a crisis and safety plan that anticipates post‑transition risks and supports sustained safety after formal HFW involvement concludes. The plan must be individualized, family‑driven, culturally relevant, team‑based, and emphasize the use of natural and community supports, with clear documentation and quality review processes in place. Sycamores meets this standard through a structured Post‑Transition Safety Planning process that intentionally builds upon the existing Crisis and Safety Plan developed during HFW and prepares youth and families to manage safety independently.
Standard 6.2(a): Individualized Post‑Transition Crisis and Safety Plan Updated and Documented
The crisis and safety plan is updated or newly completed to reflect transition, identifies potential post‑transition crisis situations, outlines proactive and reactive strategies selected by the family, maximizes natural supports, and is documented in the youth’s file.
At Sycamores, the Post‑Transition Safety Plan is not a separate or generic document; rather, it is a deliberate update of the existing Crisis and Safety Plan, completed as part of transition planning from formal HFW services. As youth and families prepare to step down or close services, the team identifies anticipated post‑HFW crisis situations and reviews the effectiveness and ownership of existing strategies. The Facilitator supports the team in revising proactive strategies (e.g., early warning signs, preventive routines) and reactive strategies (e.g., de‑escalation steps, emergency contacts), explicitly shifting responsibility from HFW staff to the youth, caregiver, and identified formal and natural supports. Strategies are selected and affirmed by the family and youth, ensuring plans are personalized, culturally relevant, and practical within the family’s real‑life context. The finalized Post‑Transition Safety Plan is documented in the youth’s Electronic Health Record (Avatar NX) and maintained as part of the permanent clinical record to ensure continuity and accountability (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, 6.2 Develop a Post – Transition Safety Plan of Care Practice Guide, pages 3-4).
Standard 6.2(b): Team‑Based, Collaborative Planning Process with Trained Facilitators
The development of the post‑transition crisis and safety plan occurs in a team‑based, collaborative environment, and facilitators receive training and coaching in this process.
Sycamores ensures that Post‑Transition Safety Planning is completed within the Child and Family Team (CFT) structure, preserving fidelity to the High‑Fidelity Wraparound model. The Facilitator leads a collaborative discussion with the youth, caregiver, natural supports, and formal providers to review risks, clarify roles, and confirm readiness for transition. This process intentionally includes:
✔Identifying which strategies were staff‑led during HFW
✔Determining which strategies can be fully transitioned to the family or supports
✔Including ongoing formal system partners (e.g., school staff, clinicians, child welfare, probation) when applicable
Facilitators conducting these meetings are trained and coached in team facilitation, strengths‑based planning, and transition readiness, ensuring the process remains family‑driven, collaborative, and culturally responsive, rather than compliance‑focused (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, 6.2 Develop a Post – Transition Safety Plan of Care Practice Guide, pages 3-4).
Standard 6.2(c): Review Processes for Quality, Individualization, Cultural Relevance, and Natural Supports
Processes are in place to review crisis and safety plans to ensure individualized strategies, progression from proactive to reactive responses, cultural relevance, and the use of natural supports, for continuous quality improvement and coaching.
Sycamores embeds quality assurance into Post‑Transition Safety Planning by ensuring each plan reflects clear progression from proactive prevention to reactive crisis response, rather than reliance on emergency or system‑driven interventions alone. Supervisors and program leadership review Post‑Transition Safety Plans through:
✔Chart reviews in Avatar NX
✔Clinical supervision discussions
✔Fidelity support and coaching processes
These reviews assess whether plans:
✔Are individualized to the youth and family
✔Reflect family voice and cultural context
✔Actively incorporate natural and community supports
✔Demonstrate appropriate transfer of responsibility from HFW staff
Feedback from these reviews informs ongoing training, coaching, and continuous quality improvement, strengthening facilitator practice and sustaining model fidelity (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, 6.2 Develop a Post – Transition Safety Plan of Care Practice Guide, pages 3-4).
Through its structured Post‑Transition Safety Planning process, Sycamores fully meets HFW Standard 6.2 by ensuring that crisis and safety planning is individualized, family‑driven, culturally relevant, team‑based, well‑documented, and supported by quality review processes. This approach ensures youth and families exit High‑Fidelity Wraparound feeling prepared, supported, and confident in maintaining safety without ongoing HFW staff involvement.
Supporting Documents:
✔6.2 Develop a Post – Transition Safety Plan of Care Practice Guide (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, 6.2 Develop a Post – Transition Safety Plan of Care Practice Guide, pages 3-4)
✔Transition Instructions (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, Supporting Documentation, A, page 7).
✔Transition POC (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, Supporting Documentation, E, pages 31-36).
✔Safety and Crisis Plan (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, Supporting Documentation, F, page 37-38).
✔The Collaborative Tool kit- Pat Miles Training (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, Supporting Documentation, J, page 49-67).
6.3 Create a Commencement and Celebrate Success
Sycamores’ High‑Fidelity Wraparound (HFW) program intentionally recognizes the conclusion of formal services as a meaningful transition point for youth and families. Commencement is treated as an essential component of the Wraparound process, reinforcing strengths, celebrating growth, and affirming the family’s readiness to sustain progress beyond formal HFW involvement. Practices are designed to be family‑driven, culturally responsive, and consistent with Wraparound values.
Standard 6.3: The team ensures that the conclusion of formal HFW is celebrated in a manner that reflects a positive transition, is culturally relevant, and is meaningful to the youth and family.
At Sycamores, the conclusion of formal HFW services is recognized as a significant milestone rather than a termination of support. Commencement is intentionally designed to honor the youth’s and family’s journey, resilience, and accomplishments while supporting confidence and continuity following transition. Celebrations are family‑centered and strength‑based, emphasizing reflection on progress, acknowledgment of growth, and affirmation of the family as the leaders of their ongoing journey. Rather than relying on uniform or prescriptive activities, Sycamores prioritizes individualized recognition that reflects each family’s culture, values, and preferences. This approach aligns with High‑Fidelity Wraparound principles by reinforcing empowerment, cultural humility, and sustainability. Commencement activities are integrated into the Wraparound process and often occur in conjunction with Child and Family Team (CFT) meetings or community‑based gatherings, reinforcing connection, closure, and continuity of natural supports (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, 6.3 Create a Commencement a Celebrate Success Practice Guide, pgs. 5-6).
Standard 6.3(a): Transitions out of the Wraparound process are celebrated according to the family’s culture, values, and preferences.
Sycamores ensures that commencement activities are planned collaboratively with the youth and family. The Facilitator, Parent Partner, Family Specialist, and Clinician engage the family in conversations focused on how they naturally celebrate milestones, cultural traditions or values related to recognition, and activities that feel meaningful and realistic to continue independently. Celebrations are intentionally flexible and culturally responsive, allowing families to define what recognition looks like for them. Examples of family‑identified commencement activities include:
✔Small gatherings with food or snacks reflective of family traditions
✔Visits to meaningful community locations (e.g., parks, beaches, community spaces)
✔Inclusion of natural supports such as extended family members, friends, mentors, or community partners
✔Reflective activities embedded in CFT meetings that honor the family’s story and progress
By honoring family voice and choice, Sycamores reinforces Wraparound fidelity and ensures that celebration practices are authentic, respectful, and personally meaningful (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, 6.3 Create a Commencement a Celebrate Success Practice Guide, pgs. 5-6).
Standard 6.3(b): Administrative structures are supportive of engaging in celebration (e.g., access to flex funds, time for community resourcing, community partnerships, ensuring staff are available to attend celebrations).
Sycamores maintains administrative and programmatic structures that actively support meaningful commencement activities. Leadership recognizes celebration and closure as integral to High‑Fidelity Wraparound and ensures staff are equipped and encouraged to engage in these practices. Administrative support includes:
✔Reasonable access to flex funds, when appropriate, to support modest and meaningful celebration activities aligned with family preferences
✔Allocation of staff time to participate in commencement activities and reflective closure, including attendance by key team members when feasible
✔Encouragement of community‑based and sustainable practices that do not create financial or emotional burden for families
✔Ongoing emphasis on partnerships with natural supports and community resources that can continue beyond formal HFW services
These structures ensure that celebration practices are feasible, equitable, and consistent with Wraparound values without creating unrealistic or unsustainable expectations (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, 6.3 Create a Commencement a Celebrate Success Practice Guide, pgs. 5-6).
Consistent with HFW expectations, commencement activities are documented to ensure accountability and continuity:
✔The Facilitator records commencement activities in the youth’s EHR (Avatar NX) through a progress note.
✔The Clinician documents the family’s reflections on services, progress, and transition planning within Transition Instructions.
This documentation confirms that celebration and reflection are completed intentionally and in alignment with certification standards (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, 6.3 Create a Commencement a Celebrate Success Practice Guide, pgs. 5-6).
Sycamores’ approach to commencement aligns with HFW State Certification Standard 6.3 by ensuring that transitions out of Wraparound are positive, culturally responsive, family‑defined, and administratively supported. Through intentional planning, meaningful recognition, reflective closure, and strong program infrastructure, Sycamores embeds celebration as a core element of High‑Fidelity Wraparound practice.
Supporting Documents:
✔6.3 Create a Commencement a Celebrate Success Practice Guide (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, 6.3 Create a Commencement a Celebrate Success Practice Guide, pgs. 5-6).
✔Transition Instructions (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, Supporting Documentation, A, page 7).
✔Transition POC (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, Supporting Documentation, E, pages 31-36).
✔Sample Graduation Certificate (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, Supporting Documentation, G, page 39).
✔Enrollment/ Exit Form (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, Supporting Documentation, H, page 40).
✔Discharge OMA (Sycamores HFW Comprehensive Practice Guide, II.6 Transition from the Fourth Phase of HFW, Supporting Documentation, I, pages 41-48).
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
Sycamores operationalizes High‑Fidelity Wraparound (HFW) by positioning youth and families as essential decision‑makers at both the individual and system levels. Youth and caregiver voice is intentionally embedded into service planning, program implementation, workforce development, and quality improvement processes. Through formal structures, routine feedback mechanisms, and visible responsiveness, Sycamores ensures that lived experience meaningfully guides how HFW services are delivered, refined, and sustained across the agency.
Standard 7.1(a): Mechanisms for Family Participation in Local HFW Implementation
There are mechanisms in place for families to participate in decisions regarding local HFW implementation.
Sycamores maintains multiple, structured mechanisms that intentionally elevate youth and family participation in local HFW implementation decisions. At the individual practice level, youth and caregiver participation is foundational to the Child and Family Team (CFT) process. Facilitators, Parent Partners, Family Specialists, and Clinicians routinely solicit direct feedback during CFT meetings regarding what is working well, what needs adjustment, and whether strategies remain aligned with family‑defined goals. Youth and caregivers are actively encouraged to articulate their vision, priorities, and desired outcomes, and service strategies are collaboratively adjusted and documented in real time. This ensures service planning remains dynamic, responsive, and family‑driven rather than prescriptive (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.1 Youth and Family as Key Decision Makers Practice Guide, pages 1-3).
At the program implementation level, Sycamores sustains a Parent Partner (Peer) Practice Council that meets monthly and serves as a formal structure for family‑driven oversight of HFW implementation. The Council is comprised of veteran Parent Partners (including one Youth Peer Advocate) representing each service location and is co‑led by a veteran Parent Partner and an Assistant Vice President with over two decades of HFW experience. This structure is expressly designed to integrate lived experience into local implementation decisions rather than relying solely on administrative or clinical perspectives (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.1 Youth and Family as Key Decision Makers Practice Guide, pages 1-3).
The Parent Partner Practice Council provides input on implementation challenges, fidelity to the Wraparound model, emerging family needs, workforce supports, training, and opportunities for refinement and innovation. Recommendations are elevated to site and agency leadership for review and action, ensuring that family participation directly influences how HFW is implemented at the local level. In addition, Quarterly All‑Parent Partner convenings provide an agency‑wide forum for collective family voice. These gatherings promote peer learning, shared problem‑solving, and discussion of field‑based challenges. Themes and trends identified through these convenings are synthesized and communicated to leadership to inform local implementation adjustments across programs and sites (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.1 Youth and Family as Key Decision Makers Practice Guide, pages 1-3).
Standard 7.1(b): Use of Family Feedback in Decision‑Making Across Program Domains
Family feedback is used in decision‑making regarding service planning and implementation, policy and procedure development, workforce development, and quality improvement.
Sycamores integrates youth and family feedback across all key decision‑making domains at both programmatic and organizational levels in the following areas:
Service Planning and Implementation:
Feedback gathered through routine CFT processes directly informs ongoing service planning and implementation. Youth and caregivers participate as equal partners in evaluating team functioning, service effectiveness, and goal alignment. Adjustments are made collaboratively to ensure plans remain responsive to evolving family needs and preferences (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.1 Youth and Family as Key Decision Makers Practice Guide, pages 1-3).
Policy and Procedure Development:
The Parent Partner Practice Council serves as a formal conduit for family feedback on program policies and procedures. Council discussions routinely surface implementation barriers, fidelity concerns, and policy gaps from a lived‑experience perspective. Recommendations generated through this body are reviewed by program and agency leadership and used to guide revisions, enhancements, or clarifications to HFW policies and operating procedures (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.1 Youth and Family as Key Decision Makers Practice Guide, pages 1-3).
Workforce Development and Hiring Practices:
Sycamores intentionally embeds family perspective into workforce development. Veteran Parent Partners regularly participate in final‑stage interviews for HFW staff positions, providing direct input on candidates’ ability to engage respectfully with families, collaborate with peer support roles, and uphold family‑centered values. This practice reinforces that family partnership is central to workforce selection and organizational culture. Additionally, feedback from Parent Partners informs training priorities and professional development planning for HFW staff (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.1 Youth and Family as Key Decision Makers Practice Guide, pages 1-3).
Quality Improvement:
Youth and caregiver feedback obtained through CFT processes, Practice Council discussions, quarterly convenings, and annual satisfaction surveys is systematically integrated into Sycamores’ quality improvement framework. Survey data is reviewed by site and agency leadership, analyzed for patterns, and shared with staff to reinforce strengths and address areas for improvement. When trends emerge, leadership identifies action steps that may include training enhancements, policy refinements, or practice changes aimed at strengthening fidelity, responsiveness, and effectiveness (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.1 Youth and Family as Key Decision Makers Practice Guide, pages 1-3).
Across all domains, leadership examines trends across sites and incorporates family‑identified priorities into programmatic adjustments, ensuring continuous alignment with the High‑Fidelity Wraparound model and community needs. Through intentional structures, routine feedback mechanisms, workforce integration, and formal quality improvement processes, Sycamores ensures that youth and family voice meaningfully informs service planning, implementation, policy development, workforce practices, and organizational improvement. Youth and caregivers are positioned not only as decision‑makers within their own teams, but as active contributors to the ongoing evolution and sustainability of the High‑Fidelity Wraparound program.
Supporting Documents:
✔ 7.1 Youth and Family as Key Decision Makers Practice Guide (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.1 Youth and Family as Key Decision Makers Practice Guide, pages 1-3).
✔Parent Partner Practice Council Charter (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, Supporting Documentation, A, pages 8-14)
✔Satisfaction Survey Report (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, Supporting Documentation, B, pages 15-19)
7.2 Community Leadership Team
Sycamores’ High-Fidelity Wraparound (HFW) program actively supports county-led Community Leadership Teams (CLTs) as a core mechanism for system-level collaboration, shared decision-making, and continuous quality improvement. While counties are responsible for convening and overseeing CLTs, Sycamores ensures meaningful provider participation, leadership engagement, and internal structures that promote alignment with the California Wraparound Standards and the HFW model. Through designated leadership representation, internal practice councils, and structured communication pathways, Sycamores contributes to removing system barriers, strengthening interagency collaboration, and maintaining fidelity to Wraparound values and practices.
Standard 7.2(a): Community Leadership Team Structure and Shared Decision-Making
The county establishes a Community Leadership Team that engages in shared decision-making, includes tribal representation, ensures communication with Interagency Leadership Teams (ILTs), and provides opportunities for child-serving entities to participate.
Sycamores actively participates in county-led Community Leadership Teams as a contracted HFW provider, (i.e., DMH Service Area Leadership Teams (SALT), Wraparound Provider Meetings, Wraparound Service Area Provider Networks, Wraparound Steering Committee, etc.) ensuring that provider perspectives and practice-level insights inform shared decision-making processes. Sycamores’ participation supports alignment across child-serving systems and ensures that service delivery considerations impacting families are elevated within county leadership structures. Information and guidance emerging from CLT participation are communicated internally through established leadership and practice oversight forums to support consistent implementation across service areas (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.2 Community Leadership Team Practice Guide, pages 4-5).
Standard 7.2(b): Identification and Removal of Interagency and System Barriers
The Community Leadership Team actively identifies and removes interagency and system barriers that interfere with collaboration and effective service delivery to families.
Through active engagement in CLT meetings, Sycamores elevates system-level barriers, interagency challenges, and service access issues experienced by families receiving Wraparound services. These concerns are communicated both externally to county partners and internally through Sycamores’ leadership and practice structures to inform problem-solving, planning, and coordinated responses. This bidirectional feedback loop supports timely identification of barriers and alignment of organizational strategies with countywide system improvement efforts (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.2 Community Leadership Team Practice Guide, pages 4-5).
Standard 7.2(c): Cross-Agency Training and Community Collaboration
The Community Leadership Team identifies and supports cross-agency training and community collaboration to promote family-centered, culturally relevant practices and fidelity to the CA HFW model.
Sycamores uses information and guidance obtained through CLT participation to inform internal training priorities, practice alignment, and supervision strategies. The designated Vice President convenes an internal HFW Practice Council composed of leaders supervising Wraparound staff across service locations. This council promotes consistency in practice, disseminates system-level guidance, and supports fidelity to culturally responsive, family-centered Wraparound principles across the organization (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.2 Community Leadership Team Practice Guide, pages 4-5).
Standard 7.2(d): Review of Family Plans at the Community and Systems Level
The Community Leadership Team ensures processes are in place to review family plans at the community and systems level based on HFW values, principles, and activities.
While individual family plan reviews occur at the care coordination and supervisory levels, Sycamores supports system-level review processes by contributing practice-level insights and trends through Community Leadership Team participation. System-wide themes, practice challenges, and population-level needs identified through Wraparound implementation are elevated through CLTs to inform broader system planning, policy considerations, and continuous quality improvement efforts aligned with HFW values (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.2 Community Leadership Team Practice Guide, pages 4-5).
Standard 7.2(e): Review of Flex Funds Use and Procedures
The Community Leadership Team ensures there are processes to regularly review the use of, access to, and procedures around flex funds to ensure individualized family needs are met.
Sycamores participates in CLT discussions related to flex fund policies, procedures, and access as facilitated by counties. When flex fund challenges or barriers to individualized service provision are identified, Sycamores elevates these concerns through county leadership forums and integrates guidance received into internal practice oversight and staff support. This process promotes transparency, appropriate use of flexible resources, and responsiveness to family-identified needs (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.2 Community Leadership Team Practice Guide, pages 4-5).
Standard 7.2(f): Data Review and Continuous Quality Improvement (CQI)
The Community Leadership Team ensures regular review of HFW data at organizational, community, and systems levels to inform CQI efforts that reflect HFW values and standards.
Sycamores uses CLT participation as a mechanism to contribute to and respond to system-level data review and CQI discussions facilitated by counties. Data-informed guidance, performance expectations, and system priorities shared through CLTs are communicated internally through leadership and Practice Council structures. This ensures that Wraparound implementation, supervision, and quality improvement activities remain aligned with county expectations and statewide HFW standards (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.2 Community Leadership Team Practice Guide, pages 4-5).
Provider Procedure Requirement: Designated Community Leadership Team Representative
Provider procedures ensure there is an identified representative who actively participates on the Community Leadership Team.
Sycamores designates a Vice President, currently Charity Wang, as the process owner for High-Fidelity Wraparound practice and contractual oversight. This Vice President serves as Sycamores’ primary representative to countywide Community Leadership Teams and identifies qualified designees to ensure continuity of participation. For CLTs convened at the Service Planning Area (SPA) level, the corresponding SPA Director represents Sycamores and also serves on the internal Practice Council, ensuring seamless communication between county systems and site-level practice oversight (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.2 Community Leadership Team Practice Guide, pages 4-5).
Supporting Documents:
✔7.2 Community Leadership Team Practice Guide (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.2 Community Leadership Team Practice Guide, pages 4-5).
✔Parent Partner Practice Council Charter (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, Supporting Documentation, A, pages 8-14)
✔HFW Practice Council Charter (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, Supporting Documentation, C, pages 20-35)
7.3 Eligibility and Equal Access
Sycamores demonstrates full alignment with the HFW Eligibility and Equal Access standards by ensuring that High-Fidelity Wraparound (HFW) services are accessible, equitable, and responsive to the full range of youth and family needs. Eligibility, referral, staffing, and service delivery practices are intentionally designed to eliminate barriers to participation, support families with complex needs, and ensure continuity and adequacy of services, including 24/7 crisis response.
Standard 7.3(a): Eligibility and Non-Exclusion Based on Severity or Nature of Needs
Youth who meet established eligibility criteria are able to receive services and are not excluded based on the severity or nature of their needs.
Sycamores ensures equitable access to HFW services for all youth and families who meet established eligibility criteria. Youth are not excluded based on symptom severity, level of impairment, co-occurring conditions, or system involvement. Referral and enrollment processes prioritize appropriateness of need and potential benefit from HFW, ensuring services reach families with the most complex presentations. Staff actively engage families who may face access barriers, including families with prior system disengagement, cultural or linguistic differences, or distrust of service systems. Participation is guided by family voice and choice, ensuring services reflect each family’s identified strengths, priorities, and goals (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.3 Eligibility and Equal Access Practice Guide, pages 6-7).
Standard 7.3 (b): Staffing Capacity, Caseload Management, and Service Intensity
Staffing is planned to ensure appropriate caseload assignments that support the intensity and frequency of services necessary to meet families’ complex needs and enable staff to provide 24/7 support.
Sycamores intentionally plans staffing assignments based on the intensity and complexity of family needs rather than solely on enrollment numbers. Caseload size, acuity, and required service frequency are considered to ensure staff capacity aligns with HFW fidelity and family needs. Supervisors utilize Key Performance Indicator (KPI) dashboards during weekly supervision to monitor caseload distribution, service intensity, and delivered service hours. This real-time oversight ensures workloads remain manageable, supports staff effectiveness, and allows leadership to respond promptly to changes in family acuity (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.3 Eligibility and Equal Access Practice Guide, pages 6-7).
Standard 7.3(b): 24/7 Crisis Support and Continuity of Care
Programs ensure families have access to 24/7 support to meet complex needs and respond to crises.
Sycamores provides continuous access to crisis support through a rotating on-call system at each service site. Families have access to live support 24 hours a day, 7 days a week. Staff are scheduled for weekly crisis phone coverage, with structured backup support to ensure responsiveness during high-risk situations. Clinical supervisors provide secondary support, and when situations involve danger to self or others, hospitalizations, or other high-risk circumstances, LPS-designated supervisors are available to ensure appropriate clinical and legal response. This layered coverage model ensures continuity of care, staff support, and uninterrupted access for families regardless of staff leave or absences (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.3 Eligibility and Equal Access Practice Guide, pages 6-7).
Organizational Capacity to Support Equal Access:
Sycamores maintains the organizational infrastructure and experience necessary to provide equitable, high-intensity services across its HFW programs. With over 120 years of combined agency experience and continuous Wraparound implementation since 2000, the first DMH contracted provider in Los Angeles County, the organization is equipped to meet the needs of youth and families requiring individualized, comprehensive care. This capacity supports consistent service availability, ensures fidelity to the HFW model, and strengthens access for families who might otherwise be excluded due to system complexity or service intensity needs (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.3 Eligibility and Equal Access Practice Guide, pages 6-7).
Sycamores fully meets Practice 7.3 standards by ensuring inclusive eligibility practices, intentional staffing and caseload management, continuous crisis support, and organizational readiness to serve families with complex and high-intensity needs—without exclusion or access disparity.
Supporting Documents:
✔7.3 Eligibility and Equal Access Practice Guide (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, 7.3 Eligibility and Equal Access Practice Guide, pages 6-7).
✔KPI Dashboard of Service Delivery (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, Supporting Documentation, D, page 36)
✔Crisis Rotation (Sycamores HFW Comprehensive Practice Guide, III.7 HFW Program and Community Leadership, Supporting Documentation, E, page 37)
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
Funding practices ensure alignment with Wraparound values and principles and support fidelity to the California Wraparound Standards. Budgets and contracts allocate funding for essential Wraparound operations, including required staffing, workforce development, data collection, data management systems, and flexible resources to meet individualized youth and family needs.
Standard 8.1(a) Funding Supports High‑Fidelity Direct Services and Individualized Supports
Rates and budgets reflect funding for high‑fidelity, individualized services and supports that meet immediate youth and family needs.
Sycamores structures its fiscal practices to ensure that funding directly supports the delivery of high‑fidelity, individualized Wraparound services consistent with California HFW standards. Contracts and internal budgets intentionally include funding for all required Wraparound roles and functions, ensuring that youth and families receive comprehensive, team‑based, and culturally responsive services. Required High‑Fidelity Wraparound staff funded through contracts include:
✔Wraparound Facilitators
✔Parent Partners
✔Family Specialists
✔HFW Supervisors
✔Licensed Clinicians
(Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.1 Funding Supports the CA HFW Model Practice Guideline, pages 1-4).
In addition to required Wraparound roles, Sycamores integrates Specialty Mental Health Services (SMHS) at each Wraparound site. These services may include:
✔Individual therapy
✔Family therapy
✔Group therapy
✔Intensive Home‑Based Services (IHBS)
✔Medication support services
This integrated funding structure allows Child and Family Teams (CFTs) to incorporate clinical interventions directly into individualized plans of care when appropriate, supporting timely access to services while maintaining Wraparound principles. When a youth enters Wraparound with an existing therapist (e.g., through a managed care plan or a trusted community‑based provider), Sycamores ensures continuity by maintaining that provider as an active CFT member. In these cases, Sycamores assigns a licensed clinician to provide clinical oversight, coordination, and safety monitoring. This approach honors established therapeutic relationships while ensuring accountability, quality, and fidelity to the model (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.1 Funding Supports the CA HFW Model Practice Guideline, pages 1-4).
Standard 8.1(b) Funding Supports Workforce Development and Required Staffing Functions
Funding supports required staffing roles, workforce development, training, supervision, and fidelity monitoring as outlined in Workforce Development standards.
Sycamores allocates dedicated funding to support a comprehensive workforce development infrastructure aligned with High‑Fidelity Wraparound standards. Budgets are structured to ensure:
✔Required HFW staffing ratios and supervision structures
✔Initial and ongoing Wraparound‑specific training
✔Leadership oversight and coaching capacity
✔Fidelity monitoring and quality improvement supports
(Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.1 Funding Supports the CA HFW Model Practice Guideline, pages 1-4).
All new HFW staff are required to complete foundational Wraparound training as part of Sycamores’ Orientation Passport prior to the initial performance evaluation and completion of probation. Training requirements are clearly defined, monitored, and enforced to ensure readiness and competence in Wraparound practice. Ongoing training and compliance are tracked through the agency’s Learning Management System (Relias), which monitors required training hours, certifications, and continuing professional development. In addition, Sycamores leverages its long‑standing experience delivering HFW services by maintaining an internal library of Wraparound‑specific trainings developed over time. These trainings are delivered by site leadership and experienced HFW staff to address emerging practice needs and reinforce fidelity. Sycamores also operates an internal Center of Excellence, which is funded to provide:
✔Clinical skill development
✔Evidence‑Based Practice (EBP) training
✔Advanced practice and leadership development
Funding structures ensure that workforce development is embedded into agency operations and fully supports the staffing, training, and supervision requirements necessary for high‑fidelity implementation, meeting Standard 8.1(b) (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.1 Funding Supports the CA HFW Model Practice Guideline, pages 1-4).
Standard 8.1(c) Funding Supports Data Collection and Data Management Systems
Funding supports required data collection, tracking, and management systems to ensure accountability and continuous quality improvement.
Sycamores allocates funding to maintain robust data collection and data management systems that support compliance with contract requirements and fidelity to the California Wraparound Standards. The agency employs a dedicated Research and Evaluation (R&E) Team. A Research Analyst is assigned to support Wraparound programs with:
✔Data collection and validation
✔KPI dashboard development
✔Outcome tracking
✔Program performance monitoring
KPI dashboards are routinely used by program and executive leadership to:
✔Inform supervision and coaching
✔Identify service utilization and outcome trends
✔Monitor fidelity indicators
✔Support continuous quality improvement efforts
✔Ensure accountability to county and state requirements
This data infrastructure enables leadership to make informed, timely decisions that strengthen program quality, outcomes, and fidelity to the HFW model. Dedicated funding for data systems and evaluation infrastructure ensures ongoing monitoring, accountability, and data‑informed decision‑making consistent with Standard 8.1(c) (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.1 Funding Supports the CA HFW Model Practice Guideline, pages 1-4).
Additional Fidelity Support: Practice Council Oversight:
Although not explicitly required under 8.1 sub‑sections, Sycamores further strengthens funding alignment through a structured High‑Fidelity Wraparound Practice Council.
The HFW Practice Council:
✔Is led by a Vice President with extensive HFW expertise (over 25 years)
✔Includes leadership representation from all Wraparound sites
✔Meets at least quarterly (or more frequently as needed)
The Council monitors fidelity, reviews trends, identifies training needs, promotes consistency across sites, and supports shared learning. Funding supports the leadership and administrative capacity required to sustain this structure and reinforce fidelity statewide (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.1 Funding Supports the CA HFW Model Practice Guideline, pages 1-4).
Through intentional fiscal planning, integrated clinical services, comprehensive workforce development systems, structured practice oversight, and dedicated data infrastructure, Sycamores ensures that funding fully supports the California High‑Fidelity Wraparound model. Fiscal practices are designed not only to meet contract requirements but to sustain the relational, strengths‑based, individualized, and data‑informed approach that defines High‑Fidelity Wraparound (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.1 Funding Supports the CA HFW Model Practice Guideline, pages 1-4).
Supporting Documents:
✔8.1 Funding Supports the CA HFW Model Practice Guideline (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.1 Funding Supports the CA HFW Model Practice Guideline, pages 1-4).
✔LA County Case Rate Services and Support Policy and Supplemental Information Form (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, Supporting Documentation, A, pages 16-23).
✔HFW Practice Council Charter (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, Supporting Documentation, B, pages 24-39).
✔KPI Dashboard Service Delivery (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, Supporting Documentation, C, page 40).
✔Agency Organizational Chart (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, Supporting Documentation, D, page 41).
8.2 Equitable Funding Across System Partners
N/A
8.3 Cost Savings are Reinvested
N/A
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied., (c) N/A (AAP funded Wraparound)
Sycamores meets and exceeds High‑Fidelity Wraparound (HFW) Standard 8.4 by maintaining a clearly defined, values‑driven process that ensures timely access, appropriate approval, and responsible stewardship of flexible funds. Flex funds are embedded within the Child and Family Team (CFT) process and are used strategically to remove barriers that threaten youth stability, placement preservation, and successful outcomes in the home and community. Flex funds at Sycamores are explicitly tied to individualized care planning, Wraparound principles, and sustainability. They are never used as unilateral staff decisions or ongoing financial supports, but rather as a bridge while natural, community, and system‑based resources are strengthened.
Standard 8.4(a):
Flexible funds are available and included as part of the funding plan for HFW
Flexible funds are an established and integral component of Sycamores’ HFW funding structure. Funds are planned for and available to address urgent and individualized youth and family needs that cannot be immediately met through other resources. Leadership oversight ensures that flex funds are consistently accessible to teams while maintaining fiscal accountability and alignment with county contract requirements, including LA County DMH guidelines. Flex funds are framed within the program as a stabilization and engagement tool, supporting families in remaining safely together while teams concurrently work toward long‑term solutions and independence.
✔ Funds are formally incorporated into the HFW funding plan
✔ Funds are available to support individualized care plans
✔ Funds are aligned with Wraparound values and program mission
(Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.4 Availability, Access and Approval of Flex Funds Practice Guidelines, pages 5-9).
Standard 8.4(b): Processes to access and manage flexible funds are articulated
Standard (b)(1): Timely access for families that meet urgent needs
Sycamores maintains a flex fund request process designed to prioritize timeliness, particularly in situations involving youth safety, placement stability, or imminent crisis. When urgent needs arise outside of scheduled Child and Family Team meetings, facilitators may convene an emergency CFT or case consultation to obtain team input and approval prior to submission. Emergency requests are reviewed as promptly as possible—often same day—by designated leadership to ensure that families receive support without unnecessary delays.
✔ Procedures allow for rapid response to urgent needs
✔ Emergency decision‑making pathways are clearly identified
✔ Timeliness does not bypass Wraparound team involvement
(Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.4 Availability, Access and Approval of Flex Funds Practice Guidelines, pages 5-9).
Standard (b)(2): Defined approval process with evaluation criteria
All flex fund requests follow a structured internal approval process that evaluates each request against both Wraparound principles and county contract criteria. Requests must demonstrate that the proposed use of funds:
✔Adds value to the Child and Family Team mission
✔Supports identified treatment goals
✔Builds on family strengths
✔Meets clearly identified youth or family needs
✔Is culturally relevant and responsive
✔Strengthens natural or community supports when possible
✔Represents responsible stewardship of funds
✔Includes a realistic sustainability or transition plan
(Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.4 Availability, Access and Approval of Flex Funds Practice Guidelines, pages 5-9).
Requests are reviewed and approved by an Assistant Director or Director, with additional documentation and county review required for requests exceeding established thresholds (e.g., over $1,500).
✔ Approval criteria align directly with HFW Standard 8.4
✔ Leadership review ensures consistency and accountability
✔ Cultural relevance, sustainability, and value are required
(Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.4 Availability, Access and Approval of Flex Funds Practice Guidelines, pages 5-9).
Standard (b)(3): Process to appeal denied requests with communication
When a flex fund request cannot be approved, leadership provides clear, transparent feedback to the team outlining the rationale for the decision. Denials are approached as collaborative planning opportunities rather than punitive measures. Teams receive guidance on whether the request requires:
✔Clearer linkage to treatment goals
✔Additional sustainability planning
✔Further exploration of alternative resources
✔Completion of required documentation
Teams may revise and resubmit requests, provide supplemental information, or request escalation to program or county leadership when appropriate. All communication regarding denials and follow‑up planning is documented and shared with families in a strengths‑based, transparent manner.
✔ Clear communication regarding denial decisions
✔ Appeal and revision pathways are available
✔ Youth and family engagement is maintained
(Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.4 Availability, Access and Approval of Flex Funds Practice Guidelines, pages 5-9).
Standard 8.4(c):
N/A (AAP‑Funded Wraparound)
This standard does not apply.
Additional Compliance Areas Addressed by Sycamores Practice
Cultural Relevance and Responsiveness
Flex fund decisions intentionally consider cultural context, family identity, and community connections. In alignment with HFW expectations, funds may be used in culturally responsive ways, including coordination with tribal entities when applicable for Native/Indian children.
(Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.4 Availability, Access and Approval of Flex Funds Practice Guidelines, pages 5-9).
Sustainability and Long‑Term Planning
Sycamores emphasizes sustainability in all flex fund decisions, with enhanced planning requirements for housing assistance, large purchases, or recurring needs. Teams are required to document income stability, budgeting considerations, benefits access, and long‑term plans to prevent future crises.
(Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.4 Availability, Access and Approval of Flex Funds Practice Guidelines, pages 5-9).
Fiscal Controls and Documentation
Sycamores maintains strong fiscal controls over all flex fund expenditures. Funds are distributed through approved mechanisms (petty cash under $75, agency credit card, check request, or EFT) and are never provided as cash directly to families or youth. Receipts, acknowledgments, and proper coding are required and maintained within the Electronic Health Record.
(Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.4 Availability, Access and Approval of Flex Funds Practice Guidelines, pages 5-9).
Sycamores’ flex fund policies and practices demonstrate full alignment with HFW Standard 8.4. The agency ensures that flexible funds are available, accessible, carefully reviewed, and used responsibly within a team‑based, family‑driven planning process. Decisions prioritize urgency, cultural relevance, and sustainability while strengthening natural and community supports. Through this structured and values‑based approach, Sycamores uses flex funds not only to resolve immediate needs but to promote long‑term family stability, independence, and successful Wraparound outcomes.
Supporting Documents:
✔8.4 Availability, Access and Approval of Flex Funds Practice Guidelines (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.4 Availability, Access and Approval of Flex Funds Practice Guidelines, pages 5-9).
✔Flex Funds Request Form (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, Supporting Documentation, E, page 42).
✔Flex Funds Training (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, Supporting Documentation, F, pages 43-63).
✔Screen Shot from NX of Flex Funds in Chart (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, Supporting Documentation, G, page 64).
8.5 Collaborative Oversight of Flex Funds
Sycamores maintains collaborative oversight and transparent management of flexible funds in partnership with the Los Angeles County Department of Mental Health (DMH) and other funding entities, in alignment with applicable Statements of Work and Program Service Exhibits. Oversight practices are designed to ensure pooled, equitable, and accountable use of funds while preserving flexibility to meet individualized youth and family needs through the High Fidelity Wraparound (HFW) model. Flexible funds are pooled at the program level and managed collectively to support the full population of families served. Although funds are aggregated for management and fiscal monitoring purposes, all expenditures remain youth‑ and family‑specific and are determined through the Child and Family Team (CFT) process.
Standard 8.5: Collaborative oversight exists among funders and providers regarding the use and availability of flexible funds
Sycamores recognizes that responsible stewardship of flexible funds requires shared accountability between providers and funders. The agency maintains ongoing communication and coordination with DMH Wraparound administration to ensure allowable use of funds, compliance with evolving County guidance, and appropriate fiscal accountability. Program leadership communicates with funders regarding:
✔Allowable and non‑allowable expenditures;
✔Requests requiring clarification or additional documentation;
✔Expenditures exceeding standard thresholds or requiring County consultation;
✔Changes in Service Function Code (SFC) or reimbursement guidance.
When uncertainty exists, Sycamores seeks County consultation prior to expenditure. Final determinations by DMH regarding allowability are adhered to and incorporated into internal processes (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.5 Collaborative Oversight of Flex Funds Practice Guidelines, pages 10-12).
Standard 8.5: A process is in place to ensure flexible funds are pooled and held to meet the needs of all families served
Flexible funds are allocated to Sycamores through County contracts and managed using a pooled funding structure consistent with the County’s case rate and CRSS expenditure framework. Funds are not considered an entitlement and are managed to ensure availability across the fiscal year for all enrolled Wraparound families. Program leadership monitors expenditure trends to prevent disproportionate allocation to a small number of cases and to preserve access for all families. Pooled management supports equity, sustainability, and responsiveness across the Wraparound population (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.5 Collaborative Oversight of Flex Funds Practice Guidelines, pages 10-12).
Standard 8.5(a): Flex fund use and availability is documented and transparently communicated to funders and providers, including amount, purpose, and HFW team recommendation
Sycamores maintains internal tracking, documentation, and reporting systems to ensure transparency regarding flex fund requests, whether approved or denied. Documentation is maintained in alignment with County and audit requirements and reflects the decision‑making role of the CFT. For each request, internal records include:
✔Amount requested;
✔Purpose of the request;
✔Identified treatment goal or strategy;
✔Child and Family Team recommendation;
✔Approval or denial determination;
✔Applicable Service Function Code (SFC), when required.
All approved expenditures are entered into the Wraparound Tracking System (WTS) within required timelines, and supporting receipts and fiscal documentation are maintained in accordance with audit standards (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.5 Collaborative Oversight of Flex Funds Practice Guidelines, pages 10-12).
Standard 8.5(b): Tracking and accounting for flexible funds includes the amount, purpose, and HFW team recommendation whether approved or denied
Sycamores maintains internal tracking logs that document the status of each flex fund request (approved, denied, pending), ensuring accurate accounting and transparency. Both approved and denied requests are recorded to demonstrate consistent application of criteria and team‑based decision‑making. Leadership oversight includes:
✔Monitoring total expenditures across the fiscal year;
✔Verifying that all expenditures are youth‑ and family‑specific;
✔Ensuring funds are used within the fiscal year of allocation;
✔Maintaining documentation for potential DMH or Auditor‑Controller review.
Emergency expenditures occurring prior to a formal CFT meeting are reviewed and documented at the subsequent team meeting to ensure retrospective team approval and alignment with HFW principles (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.5 Collaborative Oversight of Flex Funds Practice Guidelines, pages 10-12).
All flexible fund expenditures are subject to review by DMH and/or the Los Angeles County Auditor‑Controller. Sycamores maintains audit‑ready documentation, including:
Supporting receipts;
✔WTS submission and invoicing records;
✔Internal request and approval documentation;
✔Evidence of CFT recommendation and discussion.
These processes ensure fiscal integrity while preserving the flexibility necessary to meet individualized family needs within the HFW framework (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.5 Collaborative Oversight of Flex Funds Practice Guidelines, pages 10-12).
Through pooled funding structures, structured tracking systems, transparent documentation practices, and ongoing collaboration with funders, Sycamores ensures that flexible funds are accessible, equitably managed, and fully accountable. Oversight practices balance fiscal responsibility with the High Fidelity Wraparound commitment to timely, individualized, and team‑driven support for youth and families.
Supporting Documents:
✔8.5 Collaborative Oversight of Flex Funds Practice Guidelines, (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.5 Collaborative Oversight of Flex Funds Practice Guidelines, pages 10-12).
✔LA County Case Rate Services and Support Policy and Supplemental Information Form (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, Supporting Documentation, A, pages 16-23).
✔Flex Funds Request Form (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, Supporting Documentation, E, page 42).
✔Flex Funds Training (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, Supporting Documentation, F, pages 43-63).
✔Screen Shot from NX of Flex Funds in Chart (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, Supporting Documentation, G, page 64).
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
Sycamores is fully committed to ensuring that funding source requirements do not limit access to flexible funds or restrict the individualized planning process required under the High‑Fidelity Wraparound (HFW) model. Consistent with Wraparound principles, flex funds are treated as a responsive, needs‑driven resource that supports youth and family voice, choice, and creativity in developing and implementing their Plan of Care. Sycamores operates within funding structures established by Los Angeles County and other System of Care partners. While each funding stream may have distinct requirements, Sycamores’ practice explicitly ensures that no single funding source dictates or constrains access to flexible funds. Instead, funding is managed through strategic braiding, collaboration, and problem‑solving, allowing teams to remain focused on outcomes rather than fiscal silos.
Standard 8.6(a): Flex funds and program resources are funded by braiding of available System of Care funding to ensure availability
Sycamores utilizes a braided funding approach, drawing upon multiple System of Care funding streams to ensure that flex funds remain available to meet individualized youth and family needs. Flex funds are not tied rigidly to a single funding source or categorical program requirement. Program leadership and supervisors work collaboratively to identify appropriate funding pathways that support timely access to resources identified through the Child and Family Team (CFT) process. This approach ensures that flex funds can be deployed creatively and responsively, even when a specific funding stream has limitations. By managing flex funds at a system level rather than a source‑specific level, Sycamores preserves the integrity of HFW practice and ensures continuity of support for families (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.6 Funding Sources and Program Requirements Practice Guidelines, pages 13-15).
Standard 8.6(b): When funding limitations exist in a single funding source, alternate funding options are explored or reliance on other funding sources is increased to fill gaps
When a funding limitation arises within a single funding source, Sycamores does not deny or delay access to flex funds based solely on that restriction. Instead, staff are guided to engage supervisors and leadership to explore alternate funding options. This may include shifting reliance to another eligible funding stream, identifying complementary resources within the System of Care, or collaborating with County partners to resolve funding barriers. Supervisory consultation ensures that funding challenges are addressed proactively and that solutions remain aligned with Wraparound principles. This practice reinforces that fiscal constraints should never override individualized, team‑based decision‑making or impede the family’s progress toward their goals (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.6 Funding Sources and Program Requirements Practice Guidelines, pages 13-15).
Standard 8.6(c): Requirements of any single funding source do not prohibit families from accessing flexible funds to meet their needs
Sycamores maintains a clear expectation that no family will be denied access to flex funds solely due to the requirements of a single funding source. Flex fund requests are evaluated based on their alignment with the youth and family’s vision, needs, and Plan of Care—not on categorical funding restrictions. Flex funds are not assigned a fixed dollar cap per family. All requests are reviewed holistically, with consideration given to:
✔Alignment with the Plan of Care and identified outcomes
✔Promotion of stability and long‑term success
✔Use of natural, community‑based, and culturally responsive supports
✔Sustainability and long‑term impact
Requests may be denied or modified only when they do not align with Wraparound principles or the Plan of Care—not because of funding source constraints. This ensures equitable access to resources and preserves fidelity to the HFW model (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.6 Funding Sources and Program Requirements Practice Guidelines, pages 13-15).
Additional Practice Considerations Supporting Standard 8.6
While maintaining flexibility, Sycamores also emphasizes responsible stewardship of resources. For requests with potential long‑term implications (e.g., housing‑related supports), teams evaluate sustainability, transition planning, and step‑down strategies to avoid creating dependency on time‑limited resources. Flex fund requests are reviewed at the appropriate authorization level based on size and complexity. Approvals may occur at the program level or, when required, involve Assistant Vice President or County review. This structure ensures both timely access and appropriate fiscal oversight without compromising family‑driven planning (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.6 Funding Sources and Program Requirements Practice Guidelines, pages 13-15).
Through braided funding, collaborative problem‑solving, and a consistent focus on individualized planning, Sycamores demonstrates full compliance with HFW State Certification Standard 8.6. Funding source requirements are actively managed to ensure they do not limit access to flex funds, allowing youth and families to receive responsive, culturally relevant, and sustainable supports aligned with their unique needs and goals.
Supporting Documents:
✔8.6 Funding Sources and Program Requirements Practice Guidelines (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, 8.6 Funding Sources and Program Requirements Practice Guidelines, pages 13-15).
✔LA County Case Rate Services and Support Policy and Supplemental Information Form (Sycamores HFW Comprehensive Practice Guide, III.8 Fiscal, Supporting Documentation, A, pages 16-23).
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
Sycamores is committed to maintaining a High-Fidelity Wraparound (HFW) workforce that is culturally responsive and capable of meeting the cultural, racial, and linguistic needs of the youth and families served. Consistent with HFW principles, staffing practices prioritize family voice and choice, cultural humility, and equitable access to services. When direct staff matching is not possible, Sycamores implements alternative strategies to ensure families’ needs are met without disruption to service quality or fidelity.
Standard 9.1(a): Monitoring Demographics and Recruiting Based on Population Needs
The demographic composition of the population served is monitored, and processes are in place to recruit and hire staff according to population needs.
Sycamores systematically monitors the demographic characteristics of youth and families served, including age, ethnicity, and primary language, as well as staff demographics across programs and locations. This data is collected and maintained by the Research and Evaluation Department and reviewed annually by leadership to assess alignment between staff composition and community needs. Findings inform targeted recruitment strategies and staffing decisions to enhance cultural, racial, and linguistic responsiveness within HFW programs. In addition, hiring managers are required to submit staffing requisitions that clearly identify required or preferred linguistic capabilities based on the needs of the population served. Recruitment efforts are intentionally targeted toward the communities Sycamores serves, strengthening cultural understanding and increasing the likelihood of hiring staff who reflect the lived experiences of youth and families. Hiring decisions emphasize both professional qualifications and demonstrated cultural sensitivity, including a strength-based and non-judgmental approach consistent with Wraparound values (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.1 Culturally Responsive Workforce Practice Guidelines, pages 1-2).
Standard 9.1(b): Alternative Strategies When Direct Cultural Matching Is Not Possible
When unable to recruit or hire staff according to cultural, racial, and linguistic needs, efforts are made to meet families’ needs for cultural representation through alternative means.
When direct cultural, racial, or linguistic staff matching is not feasible, Sycamores employs creative and family-centered strategies to ensure cultural responsiveness is maintained. Wraparound Facilitators, Parent Partners, and team members actively identify and invite natural or informal supports—such as extended family members, community elders, faith-based supports, or trusted cultural representatives—to participate on the Child and Family Team. These supports help ensure that services reflect the family’s cultural values, traditions, and belief systems. Additionally, teams may connect families to culturally aligned community-based resources or cultural brokers who can provide guidance and support consistent with the family’s identity and preferences. These practices reinforce family voice and choice while preserving fidelity to the HFW model (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.1 Culturally Responsive Workforce Practice Guidelines, pages 1-2).
Standard 9.1(c): Language Access and Translation Services
When unable to provide a staff member who can deliver services in the family’s language, a translator or natural support person is utilized.
Sycamores ensures meaningful language access for families with limited English proficiency through multiple layers of support. When program staff are not fluent in a family’s primary language, the agency utilizes its internal Interpretation and Translation Department (ITS) to support phone calls, clinical sessions, and Child and Family Team meetings. This department also translates key documents, including Plans of Care and Safety Plans, and coordinates with external professional translation services when internal capacity is insufficient. In addition, Sycamores uses a language line to provide real-time interpretation as needed. Families’ linguistic preferences and needs are clearly documented in the youth’s file to ensure consistency and continuity of services across providers and settings. These practices ensure that families can fully participate in decision-making and service planning, consistent with Wraparound principles (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.1 Culturally Responsive Workforce Practice Guidelines, pages 1-2).
Sycamores’ commitment to a culturally responsive HFW workforce is reinforced through ongoing evaluation and an agency-wide Diversity, Equity, and Inclusion (DEI) framework. As an equal employment opportunity employer, Sycamores is dedicated to fostering an inclusive, equitable, and respectful workplace, recognizing that staff diversity strengthens service quality and outcomes for youth and families. Feedback from families and consumers is incorporated into periodic reviews of staffing and service delivery, with adjustments made as needed to maintain equitable and culturally grounded Wraparound services.
Supporting Documents:
✔9.1 Culturally Responsive Workforce Practice Guidelines (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.1 Culturally Responsive Workforce Practice Guidelines, pages 1-2).
✔ Staff Requisition Dayforce (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, A, pages 22-32)
✔ Workforce Recruitment Policy and Procedure (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, B, pages 33-37)
✔ Candidate Assessment Form (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, C, page 38)
✔ Staff vs Client Demographics (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, D, pages 39-40)
9.2 Tribally Responsive Workforce
While Sycamores High Fidelity Wraparound (HFW) programs infrequently serve American Indian/Alaska Native youth, the program maintains policies, training expectations, and practice guidelines that ensure full compliance with tribally responsive standards whenever an Indian child is enrolled. Sycamores is committed to honoring tribal sovereignty, cultural traditions, and tribal values, and to engaging in respectful communication, collaboration, and advocacy with tribal representatives and families. This commitment aligns with the HFW principle of culturally responsive, family- and youth-driven care and supports positive outcomes grounded in each youth’s cultural identity.
Standard (a): Staff Training on Tribal Sovereignty, Traditions, and Values
Staff are trained on tribal sovereignty, traditions, and values, and on how to ensure respectful communication, collaboration, and advocacy when serving Indian children.
Sycamores ensures that all HFW staff receive foundational and ongoing training focused on cultural humility and cultural appreciation, including education on tribal sovereignty, traditions, and values. Training emphasizes respectful communication, partnership-building, and advocacy practices that honor tribal authority and family self-determination. This approach equips staff to engage thoughtfully and appropriately with American Indian youth and families when such cases arise. Staff are further encouraged to approach cultural engagement with openness, curiosity, and a commitment to learning directly from families and tribal representatives, recognizing that tribal nations are diverse and that families are the primary source of cultural knowledge. This stance supports individualized, culturally grounded care planning and strengthens trust between staff, families, and tribal partners (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.2 Tribally Responsive Workforces Practice Guidelines, page 3).
Standard (b): Partnership With Tribal Representatives and Support for Cultural Participation
When serving an Indian child, HFW teams build partnerships with tribal representatives, encourage participation in tribal traditions and ceremonies, and understand and utilize services and supports offered by the Tribe.
When an Indian child is enrolled in Sycamores HFW, the Wraparound team actively works to identify and engage relevant tribal representatives in collaboration with the youth and family. The team prioritizes respectful partnership with tribal entities to ensure that services are aligned with tribal practices, cultural expectations, and community resources. The HFW team encourages and supports participation in tribal traditions, ceremonies, and cultural practices as identified by the youth, family, and Tribe. Staff collaborate with tribal representatives to better understand the services, supports, and cultural resources available through the Tribe, and these resources are incorporated into the youth’s Wraparound plan when appropriate. This collaborative approach reinforces cultural identity, promotes family engagement, and enhances the effectiveness of services (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.2 Tribally Responsive Workforces Practice Guidelines, page 3).
Documentation and Continuity of Care:
In accordance with Practice 9.2 guidelines, all tribal engagement activities, cultural participation, and any related accommodations or supports are documented in the youth’s clinical record. This documentation ensures continuity of care, reinforces accountability to tribal and family preferences, and supports consistent, culturally respectful practice across the care team.
Through staff training, culturally respectful engagement practices, and intentional collaboration with tribal representatives, Sycamores HFW demonstrates alignment with Practice 9.2 – Tribally Responsive Workforce standards. Even when services to Indian children are infrequent, Sycamores maintains readiness and capacity to respond in a manner that honors tribal sovereignty, supports cultural participation, and upholds High Fidelity Wraparound principles.
Supporting Documents:
✔9.2 Tribally Responsive Workforces Practice Guidelines (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.2 Tribally Responsive Workforces Practice Guidelines, page 3).
✔ Relias Culturally Responsive Care for Tribal and Urban Indian Training (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, E, page 41)
9.3 Flexible and Creative Work Environment
Sycamores’ High-Fidelity Wraparound (HFW) program demonstrates a strong, intentional commitment to fostering a flexible and creative work environment that promotes shared responsibility for program quality and improvement, staff cohesion, open communication, and fidelity to HFW philosophy. Leadership at all levels actively implements structures and routines that elevate staff voice, encourage innovation, strengthen team relationships, and maintain consistent alignment with Wraparound principles, values, phases, and activities. Recognizing that Wraparound work is intensive, relational, and community-based, Sycamores balances flexibility with accountability by embedding creativity and adaptability within clearly defined supervisory, communication, and quality improvement systems. This approach supports staff engagement, professional growth, and work-life balance while ensuring high-quality, fidelity-driven services to youth and families.
Standard 9.3(a): Program Quality and Continuous Improvement -Leadership is committed to engaging staff in program quality and improvement.
Sycamores leadership actively engages staff in continuous quality improvement through reflective, strengths-based, and participatory processes that mirror High-Fidelity Wraparound practice. Staff meetings and group supervision consistently begin with “What’s Working” reflections and acknowledgements, reinforcing a strengths-based culture aligned with Child and Family Team (CFT) processes. Supervisors and managers intentionally solicit staff ideas, observations, and recommendations related to practice improvement, workflow efficiency, and service delivery during staff meetings, individual/group supervisions, suggestion boxes, or 1:1 skip meetings with senior leadership, etc. These contributions are treated as integral to program development and innovation rather than as top-down directives (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.3 Flexible and Creative Work Environment Practice Guidelines, pages 4-6).
On an annual basis, sites conduct structured SWOT discussions to collaboratively identify strengths, challenges, opportunities, and threats, promoting transparency and collective ownership of growth at both the site and agency levels. Additionally, annual staff satisfaction surveys are administered, reviewed by leadership, and translated into clear action plans focused on staff retention, workplace culture, and system responsiveness. Supervisors further support program quality through ongoing coaching, observation, and feedback. This includes direct observation of practice, reflective supervision, and targeted skill-building to maintain fidelity and promote professional development (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.3 Flexible and Creative Work Environment Practice Guidelines, pages 4-6).
Standard 9.3(b): Cohesion and Positive Team Environment – Leadership promotes cohesion and a positive team environment.
Sycamores intentionally cultivates a collaborative and affirming team culture that prioritizes connection, shared identity, and mutual support. Leadership integrates team-building activities within regular staff meetings and organizes dedicated team-building events, including off-site activities when appropriate, to strengthen relationships and morale. Informal connection-building practices—such as potlucks, holiday celebrations, self-care events, and shared meals—are encouraged as part of fostering a welcoming and inclusive culture. Strengths-based activities, including peer “roasts,” provide structured opportunities for staff to recognize and affirm each other’s skills, contributions, and Wraparound-aligned practice. Group supervision is routinely held by role (e.g., Facilitators, Parent Partners, Clinicians, Child and Family Specialists/Community Wellness Specialists), allowing staff to normalize shared challenges, deepen peer connection, and reinforce professional identity within the Wraparound model. Community-based team activities, such as resource scavenger hunts and shared learning experiences, simultaneously enhance local system knowledge and collaborative capacity (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.3 Flexible and Creative Work Environment Practice Guidelines, pages 4-6).
Standard 9.3(c): Open Communication and Conflict Resolution – Leadership promotes open communication across the program.
Sycamores leadership actively models and reinforces transparent, respectful, and solution-focused communication at all levels of the organization. Teams collaboratively establish office ground rules and team agreements that clarify expectations related to communication, feedback, and conflict resolution, creating psychological safety and shared accountability. Staff are consistently encouraged to raise concerns, share feedback, and participate in problem-solving without fear of retaliation. Conflict is addressed proactively through open discussions about communication styles, clearly defined resolution protocols, and supervisor facilitation when needed. Leadership also incorporates reflective and inspirational materials—such as TED Talks and guided exercises—into meetings and supervision to promote learning, motivation, and shared dialogue, further supporting open communication and critical reflection (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.3 Flexible and Creative Work Environment Practice Guidelines, pages 4-6).
Standard 9.3(d): Clear Sense of Mission and Compliance with HFW Philosophy -Leadership ensures a clear sense of mission and compliance with HFW philosophy.
Leadership at Sycamores consistently reinforces the HFW mission, values, principles, phases, and activities through staff meetings, group supervision, trainings, and reflective discussions. Supervisors model strengths-based, family-centered practice in their interactions with staff, intentionally aligning internal organizational culture with external practice delivered to families. Practice-based coaching is a core mechanism for reinforcing fidelity. Supervisors regularly shadow CFT meetings, observe one-on-one sessions with youth and caregivers, and participate in community-based or telehealth sessions. Following observations, supervisors highlight strengths, provide constructive feedback focused on growth and fidelity, and engage staff in reflective dialogue about their practice (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.3 Flexible and Creative Work Environment Practice Guidelines, pages 4-6).
To further strengthen mission alignment and shared responsibility for quality, Sycamores maintains a Wraparound Practice Council and a Parent Partner (Peer) Practice Council. These councils convene regularly to review data, identify trends and challenges, share creative strategies, and promote consistency across sites. Feedback from councils is integrated into supervision, training, and site-level implementation, reinforcing a learning culture grounded in collaboration and fidelity. Sycamores also operates within a flexible hybrid work structure that supports staff well-being while maintaining supervision, accountability, and fidelity to the HFW model. This structure reflects leadership’s commitment to balancing flexibility, connection, and quality service delivery (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.3 Flexible and Creative Work Environment Practice Guidelines, pages 4-6).
Supporting Documents :
✔9.3 Flexible and Creative Work Environment Practice Guidelines (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.3 Flexible and Creative Work Environment Practice Guidelines, pages 4-6).
✔ SWOT survey (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, F, page 42)
✔ Staff Satisfaction Survey (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, G, pages 43-47)
✔ HFW Practice Council (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, H, pages 48-63)
9.4 Hiring, Performance Evaluation, and Job Descriptions
Sycamores maintains a comprehensive and intentional workforce development approach that supports High Fidelity Wraparound (HFW) implementation. Hiring, job design, and performance evaluation practices are structured to ensure staff possess the lived experience, competencies, and professional skills necessary to implement Wraparound with fidelity. Expectations are clearly communicated, performance is regularly assessed, and staff receive ongoing coaching and support to promote continuous quality improvement.
Standard 9.4(a) Roles and Functions Are Fully Met Within the HFW Program
Each required HFW role or function is fulfilled either through distinct positions or through combined roles with clearly defined responsibilities.
Sycamores ensures that all required HFW roles and functions are consistently met across its Wraparound programs. Roles are structured to reflect program size, service intensity, and contract requirements. In some cases, functions may be combined into a single position; however, role integration is intentional and supported by clearly delineated job descriptions, supervision structures, and workload expectations. Key HFW roles supported by Sycamores include, but are not limited to:
✔Youth Partner
✔Parent Partner
✔HFW Facilitator
✔Family Specialist
✔Fidelity Coach
✔Licensed Clinical Supervisor
✔HFW Supervisor/Manager
Each role’s scope of practice is clearly defined to ensure that all essential Wraparound functions—family voice and choice, care coordination, strength-based planning, and fidelity monitoring—are fully implemented without role dilution (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.4 Hiring, Performance Evaluation & Job Descriptions Practice Guidelines, pages 7-10); (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Job Descriptions, pages 1-40).
Standard 9.4(b) Role Descriptions Include Purpose, Functions, Skills, and Attributes
Each role description minimally includes role purpose, functions, and required qualities, including skills, competencies, and attributes consistent with Wraparound best practices.
Sycamores’ job descriptions are specifically tailored to High Fidelity Wraparound and align with the principles and practices outlined in the California Wraparound Standards Toolkit. Each job description includes:
✔A clear statement of the role’s purpose within the Wraparound model
✔Core responsibilities and day-to-day functions
✔Required and preferred competencies, including cultural humility, family partnership, and strengths-based practice
✔Desired attributes such as empathy, flexibility, collaboration, and commitment to family-driven care
Youth Partner and Parent Partner positions explicitly prioritize lived experience alongside professional competencies to ensure meaningful partnership with families. Supervisory and coaching roles emphasize fidelity monitoring, staff development, and quality assurance (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Job Descriptions, pages 1-40).
Standard 9.4(c) Job Descriptions Reflect HFW-Specific Knowledge, Skills, and Experience
Job descriptions reflect the attitudes, skills, knowledge, and experience most likely to result in success in HFW positions.
All HFW job descriptions at Sycamores are designed to attract and select candidates who demonstrate alignment with Wraparound values, including unconditional care, family voice and choice, cultural responsiveness, and team-based collaboration. Required and preferred qualifications emphasize:
✔Experience working with youth and families involved in child-serving systems
✔Knowledge of trauma-informed and strengths-based approaches
✔Ability to engage families as equal partners in decision-making
✔Understanding of team facilitation and community-based service coordination
(Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Job Descriptions, pages 1-40).
Descriptions are regularly reviewed and updated to reflect evolving best practices, fidelity requirements, and lessons learned from program implementation and outcomes (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.4 Hiring, Performance Evaluation & Job Descriptions Practice Guidelines, pages 7-10).
Standard 9.4(d) Hiring Processes Allow Candidates to Demonstrate Essential Skills and Attitudes
The hiring process includes opportunities for candidates to demonstrate the specific skills and attitudes essential to the position.
Sycamores utilizes a structured, competency-based hiring process to assess both technical qualifications and alignment with Wraparound values. Hiring practices may include:
✔Behavioral-based interview questions focused on family engagement, cultural responsiveness, and teamwork
✔Scenario-based questions or role plays to assess problem-solving and facilitation skills
✔Panel interviews that include supervisory staff and, when appropriate, individuals with lived experience
For partner roles, particular attention is given to assessing candidates’ ability to share lived experience in a professional, supportive, and family-centered manner (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.4 Hiring, Performance Evaluation & Job Descriptions Practice Guidelines, pages 7-10).
Standards 9.4(e) Clear Performance Expectations, Ongoing Feedback, and Coaching
Employees receive clear performance expectations and frequent feedback and coaching to support success.
Sycamores establishes clear performance expectations for all HFW staff through onboarding, supervision, and ongoing performance management processes. Staff receive:
✔Role-specific onboarding and initial training in Wraparound principles and practices
✔Regular individual and group supervision focused on skill development and family outcomes
✔Ongoing coaching, including fidelity-informed feedback, to support continuous improvement
✔Formal performance evaluations that assess both competency development and alignment with Wraparound values
Fidelity Coaches and Supervisors work collaboratively with staff to address challenges, reinforce strengths, and ensure that practice remains aligned with High Fidelity Wraparound standards (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.4 Hiring, Performance Evaluation & Job Descriptions Practice Guidelines, pages 7-10).
Through intentional workforce design, competency-based hiring, and structured performance support, Sycamores demonstrates full alignment with Practice 9.4. These practices collectively ensure that High Fidelity Wraparound services are delivered by a skilled, supported, and values-driven workforce committed to achieving positive outcomes for youth and families.
Supporting Documents:
✔9.4 Hiring, Performance Evaluation & Job Descriptions Practice Guidelines (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.4 Hiring, Performance Evaluation & Job Descriptions Practice Guidelines, pages 7-10).
✔Job Descriptions (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Job Descriptions, pages 1-40).
✔ Facilitator Tool Kit (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, I, pages 64-69)
✔ Parent Partner Tool Kit (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, J, pages 70-77)
✔ Clinician Tool Kit (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, K, pages 78-82)
✔ Family Specialist Tool Kit (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, L, pages 83-87)
✔ Interview Questions (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, M, pages 88-89)
✔ New Hire Passport (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, N, pages 90-96)
✔ Performance Review (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, O, pages 97-103)
9.5 Workforce Stability
Sycamores is committed to maintaining a stable, skilled, and supported High‑Fidelity Wraparound (HFW) workforce. Workforce stability is essential to sustaining trusting relationships with youth and families, maintaining Wraparound model fidelity, and ensuring continuity of care throughout the service process. Sycamores implements integrated organizational and program‑level strategies to recruit, retain, and develop qualified staff by aligning compensation with community standards, supporting manageable workloads, creating accessible advancement pathways, and recognizing staff expertise through leadership and professional growth opportunities that do not require a formal position change. These workforce stability practices reflect the agency’s belief that consistent staff relationships and supported practitioners are foundational to successful Wraparound outcomes and family engagement.
Standard 9.5(a): Matching Wages to Cost of Living in the Community
Programs match wages to the cost of living in the location of the organization/service implementation area.
Sycamores maintains compensation practices intended to remain competitive within the communities served and comparable to other behavioral health providers. Human Resources routinely monitors local market conditions to assess wage alignment with the cost of living and prevailing compensation trends. These efforts ensure that staff wages remain responsive to economic conditions impacting recruitment and retention. To support this commitment, Sycamores:
✔Provides annual merit increases based on performance evaluations;
✔Conducts quarterly reviews of competitor job postings to monitor local salary trends; and
✔Participates in the Association of Community Human Services Agencies (ACHSA) annual salary survey within Los Angeles County to evaluate compensation relative to similar organizations.
When workforce trends indicate a need—such as prolonged vacancies, declined job offers, or emerging disparities—market adjustments are implemented when financially feasible. These practices allow Sycamores to proactively address regional wage pressures and support long‑term workforce stability (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.5 Workforce Stability Practice Guidelines, pages 11-14).
Standard 9.5(b): Maintaining Manageable Workloads for Staff
Programs maintain manageable workloads for staff.
Sycamores recognizes that sustainable workloads are critical to workforce retention, staff well‑being, and high‑quality Wraparound practice. Program leadership actively supports manageable workloads through ongoing monitoring, supervision, and responsive staffing adjustments. Workload management strategies include:
✔Monitoring caseload expectations aligned with contract requirements and service intensity, using KPI dashboards that track service delivery levels;
✔Regular supervisory oversight and case consultation to assess staff capacity and address service barriers;
✔A team‑based Wraparound model that distributes responsibilities across Facilitators, Parent Partners, family clinicians, and support staff;
✔Ongoing coaching focused on problem‑solving and fidelity support; and
✔Adjustments to workload assignments when staff or family needs indicate additional support is required.
Supervisors routinely review staff workload capacity to ensure assignments remain aligned with effective engagement, fidelity expectations, and staff sustainability (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.5 Workforce Stability Practice Guidelines, pages 11-14).
Standard 9.5 (c): Clearly Communicated and Accessible Promotion / Advancement Structures
Programs maintain accessible promotion and advancement structures that are not prohibitive for individuals with lived experience.
Sycamores maintains a strong organizational commitment to promoting from within and developing frontline staff into future leaders. Many agency leaders and supervisors began their careers in direct service roles, reinforcing an agency culture that values lived experience and practice‑based expertise. Historically, Sycamores implemented structured Wraparound career ladder pathways, including Facilitator II, Parent Partner II, and Field Coach roles, which allowed experienced staff to expand responsibilities while remaining connected to direct service work. These roles supported workforce development, fidelity coaching, and staff retention. Although the availability of formal career ladder roles is influenced by reimbursement structures, current advancement opportunities remain accessible and include:
✔Internal promotional pathways across programs;
✔Leadership development through supervision and special projects;
✔Mentorship and onboarding support for new staff; and
✔Advancement opportunities across Sycamores’ multiple programs and service locations.
Sycamores continues to evaluate opportunities to reinstate or expand differentiated advancement pathways as funding structures evolve, ensuring pathways remain inclusive and supportive of staff with lived experience (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.5 Workforce Stability Practice Guidelines, pages 11-14).
Standard 9.5 (d): Wage Increases or Leadership Opportunities Without Position Change
Programs provide wage increases or leadership opportunities that do not require a position change.
Sycamores recognizes staff expertise and leadership through opportunities that allow professional growth and recognition without requiring reclassification into a different position. These opportunities support retention, morale, and continuity of relationships with youth and families. Examples include:
✔Serving as training facilitators or subject matter experts;
✔Facilitating parent support groups or focus groups;
✔Mentoring newly hired staff;
✔Leading the Parent Partner Practice Council; and
✔Participating in agency committees or cross‑program workgroups.
These leadership and professional growth opportunities allow staff to expand skills, contribute to program development, and receive professional recognition while maintaining their primary Wraparound role (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.5 Workforce Stability Practice Guidelines, pages 11-14).
Sycamores’ workforce stability practices are grounded in the understanding that stable staffing directly supports stronger youth and family relationships, increased engagement and trust, sustained Wraparound fidelity, and improved long‑term outcomes. Human Resources and program leadership collaborate to monitor workforce trends and continuously adjust recruitment, compensation, workload, and retention strategies to maintain a stable, supported, and high‑quality HFW workforce.
Supporting Documents:
✔9.5 Workforce Stability Practice Guidelines (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.5 Workforce Stability Practice Guidelines, pages 11-14).
✔ Employee Retention Summary (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, P, pages 104-107)
✔ KPI Dashboard of Service Delivery (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, Q, page 108)
9.6 High Fidelity Training Plan
Sycamores has developed and implemented a formal, structured, and multi‑layered High Fidelity Wraparound (HFW) training plan to ensure that all staff are prepared to implement Wraparound with fidelity from onboarding through ongoing practice. The training plan incorporates initial, ongoing, annual, and booster trainings, and includes general Wraparound content, role‑specific instruction, supervisory and leadership development, ICWA and Tribal sovereignty training, and training to support populations with unique and specialized needs. Training is reinforced through shadowing, coaching, supervision, case consultation, fidelity monitoring, and data‑informed quality improvement processes, ensuring that learning is translated into practice over time.
Standard 9.6(a): Initial HFW Training for All Staff
All staff receive an initial HFW training using one of the approved options.
Sycamores ensures that all new HFW staff and supervisors receive comprehensive foundational HFW training during onboarding and prior to carrying an independent caseload. Initial training is anchored in the Statewide Standardized Foundational HFW Training provided through the UC Davis Center of Excellence (COE), which all newly hired HFW staff and supervisors are required to complete. Existing staff and new supervisors who have not previously completed standardized Wraparound training are also required to register and attend. Initial training includes instruction on:
✔Wraparound philosophy and values
✔The ten principles of Wraparound
✔The four phases of Wraparound
✔Team‑based planning and Child and Family Team (CFT) processes
✔Roles and responsibilities within the Wraparound team
(Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.6 HFW Training Plan Practice Guidelines, pages 15-18).
All new HFW staff are also trained in the Integrated Practice Child and Adolescent Needs and Strengths (IP CANS) and are required to maintain annual certification. A significant component of initial training includes structured onboarding and shadowing. New staff complete a role‑specific HFW onboarding passport aligned with the four phases of Wraparound. The onboarding passport requires a minimum of 20 hours of shadowing within the first 90 days, including at least five structured shadowing activities. Shadowing activities include:
✔Attendance at Child and Family Team (CFT) meetings
✔Observation of role‑specific duties
✔Observation of other HFW roles to promote team understanding
✔Participation in case consultations focused on identifying underlying needs
✔Observation of individual or family sessions (live or recorded)
✔Structured opportunities for cross‑role collaboration and clarification
(Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.6 HFW Training Plan Practice Guidelines, pages 15-18).
Staff may also be paired with mentors or “buddies” during onboarding to support engagement, professional development, and skill acquisition. Facilitators receive additional 1:1 review of the certification practice model with their supervisor to ensure readiness for independent facilitation. Initial training also includes orientation to key practice components such as Flex Funds, IP CANS use, and outcomes measurement tools, ensuring staff understand both clinical and operational expectations from the outset (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.6 HFW Training Plan Practice Guidelines, pages 15-18).
Standard 9.6(b): Ongoing Training in General Wraparound and Role‑Specific Competencies
All staff receive ongoing training in general Wraparound and in their specific role through trainings, meetings, coaching, peer shadowing, and/or supervision.
Sycamores provides ongoing and continuous training to reinforce Wraparound fidelity and role‑specific competencies. Training is delivered through a blended model that includes formal instruction, supervision, coaching, and peer learning opportunities. Key components include:
✔Regular group supervision by role, which supports peer learning, skills practice, problem‑solving, and discussion of Wraparound challenges
✔Monthly supervisor shadowing, in which HFW Supervisors observe staff in their role or during CFT meetings and provide structured feedback
✔Case consultation, used intentionally to strengthen key practice areas such as strengths discovery, identification of underlying needs, use of natural supports, and effective Plan of Care development.
Supervisors document coaching, feedback, and skill development in supervision logs, which serve as both a training record and a fidelity monitoring tool. Annual performance evaluations—completed by the end of Q2 of each fiscal year—include assessment of staff competencies, training participation, and adherence to Wraparound principles (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.6 HFW Training Plan Practice Guidelines, pages 15-18).
Standard 9.6(c): Annual and Booster Trainings
All staff receive booster trainings at least annually in general Wraparound and in their specific roles.
Sycamores provides structured annual and ongoing training opportunities to reinforce core competencies and deepen practice skills. Quarterly trainings are delivered through site staff meetings and are developed and implemented through the HFW Practice Council, ensuring alignment with fidelity trends and program priorities.
Core training topics include:
✔Overview of the HFW process, values, and phases
✔Role‑specific skill development (e.g., Facilitator, Parent Partner, Family Specialist, Clinician)
✔Advanced practice areas such as identifying underlying needs, strengthening natural supports, and Plan of Care development.
All staff also complete required agency trainings annually, including cultural competency, HIPAA, crisis and safety planning, workplace violence prevention, Flex Funds, OMAs, and CANS re‑certification. Booster trainings are interactive and responsive to program needs, incorporating fidelity data, quality improvement findings, and staff feedback to address advanced practice challenges (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.6 HFW Training Plan Practice Guidelines, pages 15-18).
Standard 9.6(d): Supervisor and Leadership‑Specific Training
Clinical Supervisors and HFW Supervisors/Managers receive Wraparound training and role‑specific supervisory and leadership training.
Supervisors and managers receive specialized leadership training designed to support high fidelity implementation. This includes LEAD and Manager 101 training, reflective supervision for Parent Partners, and specialized HFW supervision to fidelity that emphasizes coaching strategies and use of fidelity tools. Leadership training is provided at hire into a supervisory role and reinforced through ongoing supervisory forums, learning communities, and annual booster trainings, ensuring supervisors are equipped to guide staff effectively (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.6 HFW Training Plan Practice Guidelines, pages 15-18).
Standard 9.6(e): ICWA, Tribal Sovereignty, and Training on Unique Populations
All staff receive ICWA and Tribal sovereignty training and training supporting populations with unique needs.
Sycamores provides ICWA and Tribal sovereignty training to all Wraparound staff, emphasizing culturally responsive practice, respect for tribal authority, and collaboration with Native communities. Training also addresses cultural humility, linguistic responsiveness, and population‑specific considerations. Training needs related to unique populations are identified through data monitoring, supervision, case consultation, and fidelity trends, and targeted trainings are developed or accessed as needed to ensure staff are prepared to serve diverse families effectively (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.6 HFW Training Plan Practice Guidelines, pages 15-18).
Sycamores maintains systems to document and track all training activities. Online trainings completed in Relias are automatically logged, while additional trainings, shadowing, and coaching are tracked through the agency Learning Management System (LMS), supervision logs, certificates, and sign‑in sheets with attached materials (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.6 HFW Training Plan Practice Guidelines, pages 15-18).
Through its detailed and structured training plan, Sycamores demonstrates full compliance with HFW Practice 9.6, ensuring that all staff and supervisors receive comprehensive initial training, continuous role‑specific development, annual and booster trainings, leadership preparation, and culturally responsive education necessary to sustain high fidelity Wraparound implementation.
Supporting Documents:
✔9.6 HFW Training Plan Practice Guidelines (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.6 HFW Training Plan Practice Guidelines, pages 15-18).
✔ LATC Parent Partner Trainings (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, R, pages 109-110)
✔ PPTA (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, S, page 111)
✔ Flex Funds Training (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, T, pages 112-132)
✔ Training Logs (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, U, pages 133-139)
✔ Case Consult Template (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, V, page 140)
9.7 Community-based Training Program
The training plan is administered in collaboration with community members and families with High Fidelity Wraparound (HFW) experience as part of the training team, and is inclusive of system and community partners to ensure comprehensive support and shared understanding across the Children’s System of Care. Sycamores’ HFW Program fully meets this standard by intentionally integrating individuals with lived HFW experience into the planning, delivery, and continuous improvement of all internal Wraparound trainings. Training activities are designed to be inclusive, culturally responsive, and accessible to staff, families, and cross‑system partners, ensuring a shared framework for High Fidelity Wraparound implementation across the System of Care.
Standard 9.7(a): Family, Youth, and Peer Participation in Training
Youth, families, and peer partners with current or prior Wraparound experience are meaningfully incorporated into the delivery of required Wraparound trainings.
Sycamores ensures that family and peer voice is embedded in HFW training delivery through consistent co‑training and active participation by individuals with lived Wraparound experience. A Sycamores Veteran Parent Partner serves as a co‑trainer for all internal HFW trainings, ensuring that instruction reflects authentic family perspectives and aligns with Wraparound values of partnership, respect, and shared decision‑making.
Family and peer co‑trainers actively contribute to learning through:
✔Sharing real‑world experiences that illustrate Wraparound principles in practice
✔Participating in role‑plays and interactive activities
✔Facilitating reflective discussion around youth and family engagement, strengths‑based planning, and team collaboration
This approach ensures that staff gain a practical understanding of HFW that extends beyond theory and reflects the lived experience of families navigating the Wraparound process. To support continuous quality improvement, Sycamores formally incorporates feedback from family and peer trainers to refine training content, structure, and delivery methods. This feedback loop reinforces the meaningful role of lived‑experience partners and strengthens training relevance and effectiveness (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.7 Community Training Plan Practice Guidelines, page 19).
Standard 9.7(b): Community Partner Participation and System Integration
Community partners are invited to attend Wraparound trainings or are offered trainings on Wraparound to strengthen their participation on HFW teams or their role in supporting HFW within the System of Care.
Sycamores actively promotes collaboration and shared understanding by inviting community partners and system representatives to participate in internal HFW trainings. Participants may include professionals from education, juvenile justice, child welfare, and other allied systems whose involvement is critical to effective Wraparound implementation. In addition to open invitations to core HFW trainings, Sycamores offers optional Wraparound‑specific training sessions tailored for community partners. These sessions are designed to:
✔Strengthen community partners’ ability to meaningfully participate on HFW teams
✔Increase understanding of Wraparound principles, roles, and team processes
✔Support alignment across systems serving youth and families
This intentional outreach ensures that team members from other systems understand the context of HFW participation and can effectively support family‑driven, team‑based planning (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.7 Community Training Plan Practice Guidelines, page 19).
Training schedules, materials, and facilitation approaches are designed to be inclusive, culturally responsive, and accessible to all participants. Considerations include flexible scheduling, interactive learning methods, and incorporation of diverse community and family perspectives. The collaboration of community members and families with lived experience strengthens system capacity and reinforces a shared commitment to High Fidelity Wraparound across the Children’s System of Care.
Sycamores demonstrates full compliance with Practice 9.7 by:
✔Meaningfully incorporating youth, family, and peer partners in all required HFW trainings
✔Engaging community and system partners through invitations and targeted training opportunities
✔Ensuring inclusive, accessible, and family‑centered training design
✔Using lived‑experience feedback to inform continuous improvement
These practices collectively ensure that Wraparound training at Sycamores reflects High Fidelity standards and builds shared understanding and capacity across the System of Care (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.7 Community Training Plan Practice Guidelines, page 19).
Supporting Documents:
✔9.7 Community Training Plan Practice Guidelines (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.7 Community Training Plan Practice Guidelines, page 19).
9.8 Coaching and Supervision
Sycamores is committed to ensuring that all Wraparound team members receive comprehensive initial apprenticeship and ongoing coaching and supervision that reflect High Fidelity Wraparound (HFW) values, principles, phases, and activities. Coaching and supervision structures are intentionally designed to support staff skill development, ethical and effective use of flex funds, responsiveness to family‑driven needs, and the flexible, on‑call nature of Wraparound practice, including crisis response outside of traditional business hours. This approach directly aligns with the requirements outlined in Practice 9.8 for HFW certification.
Standard 9.8(a): Initial Apprenticeship Covering HFW Values, Skills, Knowledge, and Flex Funds
All staff are provided with an initial apprenticeship that covers values, skills, and knowledge related to HFW principles, phases, activities, and the effective use of flex funds to meet family needs.
Sycamores has established a structured initial apprenticeship for all new Wraparound staff that ensures full immersion in High Fidelity Wraparound principles prior to independent practice. This apprenticeship begins during onboarding and continues through a supervised learning period tailored to the staff member’s role and experience level. The apprenticeship curriculum includes comprehensive training on HFW core values (family‑driven, youth‑guided, strengths‑based, team‑based, culturally responsive, and outcome‑focused), Wraparound phases and activities, and the practical application of these principles in real‑world family situations. Training incorporates didactic instruction, case‑based learning, observation of experienced Wraparound facilitators, and reflective discussions to promote fidelity and consistency (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.8 Coaching and Supervision Practice Guidelines, pages 20-21).
A key component of the apprenticeship is focused instruction and coaching on the ethical, creative, and effective use of flex funds. Staff are trained to align flex fund expenditures with individualized family goals, identified needs, and team‑developed plans of care. Supervisors and coaches review flex fund requests with staff during apprenticeship to reinforce accountability, documentation expectations, and alignment with Wraparound principles. Throughout the apprenticeship period, staff receive regular feedback from supervisors or designated Wraparound coaches, ensuring that knowledge acquisition is translated into high‑quality practice consistent with HFW standards before moving to greater independence (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.8 Coaching and Supervision Practice Guidelines, pages 20-21).
Standard 9.8 (b): 24/7 Access to Supervision or Coaching; Staff have access to supervision or coaching 24/7 as needed.
Sycamores ensures that Wraparound staff have continuous access to supervision and coaching on a 24/7 basis, recognizing the nature of Wraparound work and the potential for family needs and crises to arise outside of standard business hours. Leadership has established clear protocols that allow staff to access on‑call supervisors, managers, or designated clinical leaders during evenings, weekends, and holidays. On‑call supervision structures are communicated to all Wraparound team members and integrated into program policies and procedures. Staff are trained on when and how to access supervisory support, including for crisis response, safety concerns, urgent family needs, and decision‑making related to service coordination or flex fund use after hours (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.8 Coaching and Supervision Practice Guidelines, pages 20-21).
In addition to crisis availability, Sycamores emphasizes reflective supervision and coaching as a continuous process. Supervisors and coaches use after‑hours contacts not only to address immediate concerns but also to reinforce HFW principles, model problem‑solving, and support staff well‑being. Follow‑up supervision is provided to ensure learning, documentation, and quality improvement after critical incidents or high‑intensity situations. This system supports staff effectiveness, promotes fidelity to Wraparound practice during high‑stress situations, and ensures families receive responsive, principled support at all times (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.8 Coaching and Supervision Practice Guidelines, pages 20-21).
Through its structured apprenticeship model and robust 24/7 supervision and coaching system, Sycamores demonstrates strong alignment with Practice 9.8 Coaching and Supervision requirements. These practices ensure staff competency, fidelity to High Fidelity Wraparound, ethical flex fund use, and responsive support to families consistent with California HFW certification standards.
Supporting Documents:
✔9.8 Coaching and Supervision Practice Guidelines (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, 9.8 Coaching and Supervision Practice Guidelines, pages 20-21).
✔Crisis Phone Orientation (Sycamores HFW Comprehensive Practice Guide, III.9 Workforce Development and Human Resources Management, Supporting Documentation, W, pages 141-174)
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
N/A
10.2 Evaluation Metrics & Outcomes
Sycamores utilizes data as a central component of program oversight, continuous quality improvement (CQI), and fidelity to the High‑Fidelity Wraparound (HFW) model. Data collection and analysis are intentionally embedded across practice, supervision, program management, and leadership decision‑making to improve outcomes for youth and families, strengthen workforce development, and address system‑level barriers that impact HFW implementation. Data is used not as a replacement for clinical judgment, but as a complementary tool that enhances reflective practice, relationship‑based services, and adherence to Wraparound values and principles.
Standard 10.2(a): Data is utilized to improve practice with youth and families, including giving staff timely feedback from data or reports relevant to their service provision and using data to identify staff training needs.
Sycamores uses data to directly support and strengthen individualized, high‑quality practice with youth and families. Staff have access to real‑time and ongoing data relevant to the families they serve, enabling them to actively monitor and adjust services in alignment with Wraparound principles. At the direct service level, staff use data to:
✔Monitor service frequency, type, and duration to ensure services align with individualized plans;
✔Track timeliness and completeness of required documentation;
✔Review assessment and outcome data, including CANS results, to inform service planning;
✔Identify emerging patterns that may indicate the need for plan adjustments, increased engagement strategies, or additional supports.
(Sycamores HFW Comprehensive Practice Guide, III.10 Utility Focused Data and Outcomes Processes, 10.2 Informed Program Practice Guidelines, pages 1-4).
At the supervisory level, data is integrated into regular reflective supervision. Supervisors use reports and dashboards during individual supervision sessions to:
✔Provide timely, specific, and actionable feedback related to service delivery;
✔Support staff in identifying strengths and areas for growth in practice;
✔Reinforce fidelity to Wraparound values, phases, and activities;
✔Identify when additional coaching, mentoring, or skill‑building is indicated.
(Sycamores HFW Comprehensive Practice Guide, III.10 Utility Focused Data and Outcomes Processes, 10.2 Informed Program Practice Guidelines, pages 1-4).
Data‑informed discussions are framed as supportive and developmental, promoting learning and continuous improvement rather than compliance alone. This approach ensures that feedback is relevant, timely, and directly connected to day‑to‑day practice with youth and families (Sycamores HFW Comprehensive Practice Guide, III.10 Utility Focused Data and Outcomes Processes, 10.2 Informed Program Practice Guidelines, pages 1-4).
Standard 10.2(b): Data is utilized to identify and address program needs to better serve families and improve overall program effectiveness.
Sycamores utilizes data systematically to monitor program performance, identify trends, and guide Continuous Quality Improvement (CQI) efforts. Key Performance Indicator (KPI) dashboards provide program leaders with real‑time and longitudinal insights into operations, service delivery, and outcomes. KPI dashboards track, but are not limited to:
✔Service delivery (date, service type, duration);
✔Timeliness of documentation;
✔Special Incident Reports (SIRs);
✔Staff caseload distribution;
✔Length of stay;
✔Referral sources and demographics;
✔Referral‑to‑intake timelines;
✔CANS completion and compliance.
(Sycamores HFW Comprehensive Practice Guide, III.10 Utility Focused Data and Outcomes Processes, 10.2 Informed Program Practice Guidelines, pages 1-4).
Data is accessible at multiple levels—individual client, staff, program, and agency‑wide—allowing each role within the organization to engage in data‑informed decision‑making appropriate to their responsibilities. Program leadership regularly reviews KPI and outcome data to:
✔Identify gaps or trends affecting service quality or access;
✔Address workflow inefficiencies or operational challenges;
✔Inform staffing models, workload distribution, and resource allocation;
✔Develop targeted improvement strategies and CQI action plans.
Data reviews occur routinely and are embedded into management, leadership, and operational meetings to ensure that program improvements are proactive, responsive, and aligned with the needs of youth and families (Sycamores HFW Comprehensive Practice Guide, III.10 Utility Focused Data and Outcomes Processes, 10.2 Informed Program Practice Guidelines, pages 1-4).
Standard 10.2(c): Data is utilized to identify and communicate system barriers to the Community Leadership Team which impacts the HFW implementation.
In addition to informing internal practice and program improvement, Sycamores uses data to identify system‑level barriers that impact timely engagement, service access, and effective implementation of High‑Fidelity Wraparound. Program leadership reviews aggregated data trends to identify:
✔Barriers to timely referral processing or engagement;
✔Challenges in referral flow and service authorization;
✔Gaps in available community‑based services or supports;
✔Disparities in access, engagement, or outcomes across populations.
These findings are elevated through internal leadership structures, including Practice Councils, program leadership forums, and executive leadership reviews. When appropriate, data‑informed concerns and trends are shared with external system partners, including Community Leadership Teams, County representatives, and collaborative bodies involved in Wraparound implementation. This structured feedback loop ensures that data is used not only to improve Sycamores’ internal operations, but also to inform advocacy efforts, strengthen cross‑system collaboration, and support broader system improvements that enhance outcomes for youth and families (Sycamores HFW Comprehensive Practice Guide, III.10 Utility Focused Data and Outcomes Processes, 10.2 Informed Program Practice Guidelines, pages 1-4).
Through intentional, layered, and transparent use of data, Sycamores demonstrates full alignment with Standard 10.2. Data is embedded across direct practice, supervision, program management, and system‑level engagement to support High‑Fidelity Wraparound implementation. This integrated approach ensures that evaluation metrics and outcomes meaningfully inform practice improvements, workforce development, program effectiveness, and system advocacy—while remaining grounded in the values and principles of Wraparound.
Supporting Documents:
✔10.2 Informed Program Practice Guidelines (Sycamores HFW Comprehensive Practice Guide, III.10 Utility Focused Data and Outcomes Processes, 10.2 Informed Program Practice Guidelines, pages 1-4).
✔KPI Dashboard Consumer Demographics (Sycamores HFW Comprehensive Practice Guide, III.10 Utility Focused Data and Outcomes Processes, Supporting Documentation, A, page 5).
✔KPI Dashboard Service Delivery (Sycamores HFW Comprehensive Practice Guide, III.10 Utility Focused Data and Outcomes Processes, Supporting Documentation, B, page 6).
✔Supervision Log (Sycamores HFW Comprehensive Practice Guide, III.10 Utility Focused Data and Outcomes Processes, Supporting Documentation, C, pages 7-8).
✔KPI Dashboard- CANS Compliance (Sycamores HFW Comprehensive Practice Guide, III.10 Utility Focused Data and Outcomes Processes, Supporting Documentation, D, page 9).
✔Quality Cup (Sycamores HFW Comprehensive Practice Guide, III.10 Utility Focused Data and Outcomes Processes, Supporting Documentation, E, pages 10-23).
✔Performance Evaluation (Sycamores HFW Comprehensive Practice Guide, III.10 Utility Focused Data and Outcomes Processes, Supporting Documentation, F, pages 24-30).
✔KPI Dashboard- Referral to Intake Timeliness (Sycamores HFW Comprehensive Practice Guide, III.10 Utility Focused Data and Outcomes Processes, Supporting Documentation, G, page 31).
✔KPI Dashboard- Length of Stay (Sycamores HFW Comprehensive Practice Guide, III.10 Utility Focused Data and Outcomes Processes, Supporting Documentation, H, page 32).
✔KPI Dashboard- SIR (Sycamores HFW Comprehensive Practice Guide, III.10 Utility Focused Data and Outcomes Processes, Supporting Documentation, I, page 33).
✔Practice Council Agenda (Sycamores HFW Comprehensive Practice Guide, III.10 Utility Focused Data and Outcomes Processes, Supporting Documentation, J, pages 34-36).
Fidelity Indicators
1.1 Timely Engagement and Planning
See HFW 1 for supporting documents
1.1 Timely Engagement and Planning:
a.) First contact with families referred to High Fidelity Wraparound is made by the Facilitator within 24 hours of receiving the referral by the Santa Clara County Inter-Agency Placement Committee (IPC) or a self-referral for AAP. The Facilitator shall hold the first session (intake appointment) with the youth and family within 3 days of receiving the referral. Engagement is tracked using our Provider Response Form (PRF), and data are analyzed using our Timeliness Tool.
Refer to Attachment 1: HFW Admission (Procedure Pg. 2)
b.) The Facilitator, in conjunction with Family Partner, Family Specialist, and Family, completes the initial Plan of Care within 30 days of the start date. The Service Planning and Monitoring Procedure outlines the timeline for completing our Plan of Care. In addition, timelines are tracked and monitored using our internal tracking system, MANGO.
Refer to Attachment 2: Service Planning and Monitoring Procedure (Procedure-E1 Pg.7)
c.) The Facilitator updates the Plan of Care during a Youth and Family Team (CFT) Meeting at least every 30 to 45 calendar days. Please see the Service Planning and Monitoring Procedure. Additionally, the completion and review of the Plan of Care is tracked and monitored using our internal tracking system, MANGO.
Refer to Attachment 2: Service Planning and Monitoring Procedure (Procedure-H Pg. 8)
d.) The Plan of Care is updated by the Facilitator at the 90-day mark, or if needed, sooner. The updated Plan of Care is distributed to the CFT by the facilitator and documented in our Electronic Health Record (EHR). The Plan of Care update process is monitored through our internal tracking system, MANGO.
Refer to Attachment 2: Service Planning and Monitoring Procedure (Procedure-E2 Pg.7)
e.) Timeliness is reviewed by the HFW Leadership Team (Director and Clinical Program Managers) each month using data from our Electronic Health Record (EHR) system, MANGO, as well as information provided by our County Partners. In addition, during our DART process, the reviewer will provide feedback on the Plan of Care and any other documents completed after the expected deadline. The Program Director provides individualized feedback to Clinical Program Managers and staff on their progress toward meeting monthly deadlines.
Refer to Attachment 2: Service Planning and Monitoring Procedure (Procedure-E3 Pg. 7)
f.) Regular booster training sessions will be provided to staff on a host of topics, including timely engagement, which discusses alternative strategies for engaging challenging families. In addition, timely engagement is explored during individual and group supervision, programmatic team meetings, and team consultations.
Refer to Attachment 3: Wraparound Training Grid (Pg. 10)
1.2 Led by Youth and Families
See HFW 1 for supporting documents
1.2 Led by Youth and Families
a.) Elicitation of the family’s perspective, including Tribes, begins from our first encounter with them and continues throughout the Wraparound services. As the initial phase of the Plan of Care is developed, the team works with the family to develop a Family Vision and Team Mission statement in their own words. The Family Vision and Team Mission Statement are documented by the Facilitator on the Family’s Plan of Care and in the clinical chart through a progress note.
Refer to Attachment 2: HFW Service Planning and Monitoring Procedure (Procedure-D Pg. 7)
b.) The Family’s values, culture, expertise, capabilities, interests, and skills are elicited and clearly documented on the youth’s mental health assessment, Plan of Care, and progress notes. The information is stored in the youth’s chart in our electronic health records. The clinical Program Manager reviews and approves all documentation before marking it complete through our internal documentation tracking system (MANGO). In addition, the DART will be used to ensure that all documents, including the Plan of Care and Mental Health Assessment, contain the required information.
Refer to Attachment 4: Assessment for HFW Services (Procedure-A Pg11-12)
c.) Clinical Program Managers attend (a minimum of 1 per quarter) CFT Meetings to observe and ensure the Wraparound Process is followed. Additionally, the CPMs regularly review documentation, including progress notes, plan of care, mental health assessments, safety plans, and meeting minutes, and will provide feedback through individual supervision and team consultation (case consultation). This is tracked using an internal tracking log, which is reviewed during our weekly Wraparound management meeting. RCS plans to implement the use of DART to review documentation and TOM to observe CFTs and ensure they are conducted with fidelity.
Refer to Attachment 5: Case Review Plan (Components of the Case Review Plan 1-7 Pg 19-25)
d.) RCS will use TOM 2.0 to gather feedback about the youth and family’s experience with the Wraparound process. A trained reviewer will observe a Youth and Family Team (CFT) meeting and document the findings in TOM, which will be stored in Wrap Stat. The results will be reviewed upon receiving the completed survey.
Refer to Attachment 6: HFW Data and Evaluation (HFW Tools F, Pg 28)
1.3 Strength-Based
See HFW 1 for supporting documents
1.3 Strength-Based
a.) A strengths inventory is developed concurrently with the Plan of Care. The Strengths inventory is reviewed and, if needed, updated by the Facilitator at every CFT Meeting. The Strengths inventory is posted alongside the local resources list at every CFT Meeting. Reviewing both the Strength Inventory and Community Resources is a standing agenda item for every CFT. This is documented in the minutes of every CFT Meeting, which will also include an updated strengths inventory and resource list.
Refer to Attachment 2: HFW Service Planning and Monitoring Procedure (Procedure-A Pg 6 &C Pg 7)
b.) The Facilitator utilizes the IP-CANS, Strengths Inventory, the Plan of Care, and observations to identify the strengths of the youth, caregivers, natural supports, and professional team members. Identified strengths are added to the strengths inventory and the plan of care.
Refer to Attachment 2: HFW Service Planning and Monitoring Procedure (Procedure-C Pg 7)
c.) All RCS Wraparound staff are expected to complete training in motivational interviewing, a strength-based approach, and solution-focused therapy. In addition, the RCS training team will conduct quarterly booster training on strength-based services. Training certificates will be included in the staff’s charts, and boosters will be documented using a sign-in sheet.
Refer to Attachment 3: Wraparound Training Grid Pg. 10)
d.) The RCS Wraparound Leadership Team, which consists of the Chief Clinical Officer, Director, Clinical Program Managers, Supervisor, and our Quality Improvement (QI) Department, will meet monthly to review data regarding families’ experience of strengths-based services from the WFI-EZ, TOM, and CSQ-8. Based on the information gleaned from the data, our Leadership team will offer feedback to staff and develop a coaching plan that will consist of observations of CFT Meetings and documentation using the DART by their Clinical Program Manager, and enroll staff in training that will enhance their ability to deliver Wraparound to fidelity and improve overall family engagement in strengths-based services. Monthly data review meetings will be tracked through the utilization of Meeting Minutes that include date, attendees, a summary of data points examined, and action items.
Refer to Attachment 6: HFW Data and Evaluation (Data Evaluation Pg 30-31 &PQI Pg 31)
1.4 Needs Driven
See HFW 1 for supporting documents
1.4 Needs Driven
a.) The Facilitator will begin assessing the needs of the youth and family right away, including during their initial meeting. Additionally, at the initial CFT Meeting, the team will hold an open discussion regarding the Needs the Child and Family Team believes Wraparound should prioritize/focus on to ensure the youth and family’s success.
Refer to Attachment 2: HFW Service Planning and Monitoring Procedure (Procedure-E Pg 7-8)
b.) RCS Wraparound Staff will be trained to identify the needs of the youth and family and develop a needs statement through the UC Davis Wraparound 101 curriculum. In addition, booster training and refreshers on the Needs-Driven Principle and identifying needs will be provided to HFW staff quarterly.
Refer to Attachment 3: Wraparound Training Grid (Pg 10)
c.) All RCS HFW Staff will be trained and certified in IP CANS through the Praed Foundation. In addition, HFW Staff will be trained to use the PSC-35. Staff will also receive training to utilize the IP-CANS and PSC-35 data to identify youth and family needs. Once an IP-CANS or PSC–35 is complete, it is submitted to our EHR. The Facilitator and Clinical Program Manager have access to an IP-CANS Summary Report that lists the youth and family’s strengths and areas of concern. The CANS Summary is reviewed in Team Consultation to ensure needs are identified. The Facilitator will discuss findings from the IP-CANS Summary at a CFT Meeting to elicit discussion on adding additional Needs to the Plan of Care that the Wraparound team can support the family in overcoming. In addition, we intend to use data from the WFI-EZ, TOM 2.0, and DART to gather data on Needs Driven.
Refer to Attachment 6: HFW Data and Evaluation (HFW Outcome Tools A, B, D, E, F Pg 26-28)
Refer to Attachment 2: HFW Service Planning and Monitoring Procedure (Procedure-E Pg 7)
d.) The Transition process is discussed from the moment the youth and family begin Wraparound. The youth and family, and the CFT at large, will understand that the Transition from Wraparound will occur once the Needs outlined in the Plan of Care have been sufficiently met. The Facilitator will discuss the topic of Transition and ensure the Plan of Care is updated or amended to reflect tasks or objectives to be completed prior to closing HFW, including links to and referrals to other services or resources. The HFW Facilitator will ensure that a “warm handoff” is established between the youth, family, and the new provider.
Refer to Attachment 7: Aftercare Planning and Case Closing (Procedure A, B &C Pg. 33)
1.5 Individualized
See HFW 1 for supporting documents
1.5 Individualized
a.) All HFW forms, documentation, and plans are designed to allow flexibility for updates and changes based on the individual needs of the youth and family. For instance, if the youth and family request a change to their Plan of Care, the facilitator will arrange a CFT meeting to modify the plan according to the family’s preferences. This process can occur even if the Plan of Care was recently updated or is outside the regular update timeframe.
Refer to Attachment 2: HFW Service Planning and Monitoring Procedure (Procedure-E 1 Pg 7)
b.) RCS HFW Management will offer quarterly booster training to all HFW staff on an Individualized approach from the UC Davis Wraparound 101 curriculum that includes flexible, creative, and highly individualized services and strategies. In addition, coaching will be provided to staff if data gleaned by the WFI-EZ or DART reflects challenges in meeting this principle (Individualized). Coaching may also include Clinical Program Managers observing a CFT Meeting and measuring Individualized through the administration of the TOM and providing direct feedback from the results of the tool.
Refer to Attachment 3: Wraparound Training Grid (Pg 10)
Refer to Attachment 6: HFW Data and Evaluation (Evaluation Pg 30-31)
c.) HFW Facilitators will receive ongoing and booster training in leading the HFW team to customize the process and Plan of Care according to the individualized needs of each youth and family, taking into consideration their strengths, values, culture, and preferences. Training, including boosters, will be developed based on the UC Davis Wraparound 101 curriculum. Individualized coaching will be offered to facilitators whose youth and families’ WFI-EZ and DART indicate that the Principle of Individualization is below HFW standards.
Refer to Attachment 3: Wraparound Training Grid (Pg 10)
d.) The Clinical Program Manager reviews the plan of care for the HFW Facilitator’s youth and family and completes the Plan of Care Checklist. The Checklist is provided to the Facilitator with feedback and discussed during their weekly individual supervision. Coaching is offered to Facilitators who experience challenges meeting HFW standards for the Plan of Care.
Refer to Attachment 2: HFW Service Planning and Monitoring Procedure (Procedure-E 3 Pg 7)
Refer to Attachment 8: Plan of Care Checklist (Pg 36-37)
e.) Youth and families enrolled in HFW are provided with various opportunities to give feedback regarding the Wraparound process. This includes surveys such as the WFI-EZ and the CSQ-8 (at 60 days and discharge). RCS intends to implement the DART and use it to gather information on the experiences of youth and caregivers in HFW. Data from these surveys are analyzed for PQI/CQI, which includes enhancing our staff’s ability to meet HFW standards through training, coaching, and individualized supervision and observation. In addition, youth and caregivers are encouraged to participate in the Advisory Boards, which provide additional space to give RCS feedback.
Refer to Attachment 6: HFW Data and Evaluation (HFW Outcome Tools D, E, G & Evaluation Pg 27-28))
Refer to Attachment 9: Advisory Board Procedure (Evaluating Feedback Pg 39)
1.6 Use of Natural and Community Based Supports
See HFW 1 for supporting documents
1.6 Use of Natural and Community-Based Supports
a.) RCS’ HFW Plan of Care will include a Natural and Community Supports Inventory, which is developed alongside/simultaneously with the Plan of Care. The Inventory includes all natural supports in the youth and family’s lives that are a part of the CFT, their relationship to the family, and their contact information. The Natural and Community Supports Inventory shall be updated when the family decides to include or remove a natural support for the list. The Inventory is reviewed by the Facilitator’s Clinical Program Manager when a change occurs, in addition through the utilization of the DART.
Refer to Attachment 2: HFW Service Planning and Monitoring Procedure (Procedure-A Pg 6)
Refer to Attachment 6: HFW Data and Evaluation (Evaluation Pg 30-31)
b.) RCS HFW Staff are provided quarterly training in identifying Natural and Community-Based Supports through booster training developed using the curriculum from the UC Davis Wraparound 101, in addition to the Natural Support Skills Lab. Individualized coaching will be offered to Facilitators experiencing challenges, including Natural Support CFTs, which may include observations using TOM and individual supervision.
Refer to Attachment 3: Wraparound Training Grid (Pg 10)
Refer to Attachment 6: HFW Data and Evaluation (Evaluation Pg 30-31)
c.) The HFW Clinical Program Managers review the Plan of Care for the HFW Facilitator’s youth and family and complete the Plan of Care Checklist. The Checklist is provided to the Facilitator with feedback and discussed during their weekly individual supervision. Coaching is offered to Facilitators who experience challenges meeting HFW standards for the Plan of Care.
Refer to Attachment 2: HFW Service Planning and Monitoring Procedure (Procedure E-3 Pg 7)
Refer to Attachment 8: Plan of Care Checklist (Pg 36-37)
d.) Youth and families enrolled in HFW are provided with various opportunities to give feedback regarding the Wraparound process. This includes surveys such as the WFI-EZ and conducting the TOM. Data from these surveys are analyzed for PQI/CQI, which includes enhancing our staff’s ability to meet HFW standards through training, coaching, and individualized supervision and observation. In addition, youth and caregivers are encouraged to participate in the Advisory Boards, which provide additional space to give RCS feedback.
Refer to Attachment 6: HFW Data and Evaluation (D, Pg 27-28, F, Pg 28, and Evaluation Pg 30-31)
Refer to Attachment 9: Advisory Board Procedure (Evaluating Feedback Pg. 39)
1.7 Culturally Respectful and Relevant
See HFW 1 for supporting documents
1.7 Culturally Respectful and Relevant
a.) Information about the youth and family’s strengths, needs, and cultural discovery will be gathered through a variety of means, including CANS, and synthesized in the youth Clinical Mental Health Assessment. The sections regarding strength, needs, and culture will be completed before the Plan of Care is developed.
Refer to Attachment 4: Assessment for HFW (A-C Pg 11-13)
b.) All assessments will be conducted in a manner that is culturally respectful, relevant, and responsive to the unique values, beliefs, and experiences of the youth and family. Service providers will engage youth and families as active participants in the assessment process to ensure that identified strengths, needs, and priorities reflect the family’s perspective and lived experience. Information gathered during the assessment will be presented and discussed using clear, understandable language and will avoid the use of unnecessary clinical or system-specific jargon that may limit meaningful participation.
Assessments will be conducted at times and in settings that are responsive to the needs, preferences, and circumstances of the youth and family, including consideration of scheduling, location, privacy, and safety. When appropriate, services may be provided in community-based or home settings to support engagement and reduce barriers to participation.
Where possible, efforts will be made to match youth and families with staff who are culturally and/or linguistically aligned with the family’s identified preferences. When such matching is not feasible, staff will demonstrate cultural humility and seek consultation, supervision, or additional resources to ensure that services remain respectful and responsive. Interpretation or translation services will be utilized as needed to support meaningful participation.
Assessments will incorporate consideration of cultural identity, language, family structure, community connections, and historical or systemic factors that may impact engagement, service planning, and outcomes. Strengths will be identified in partnership with the youth and family and will reflect cultural, familial, and community-based assets.
Assessment findings will be documented in a manner that reflects family voice and choice and will be used to inform individualized, strengths-based care planning consistent with High Fidelity Wraparound (HFW) principles.
Refer to Attachment 3: Wraparound Training Grid (Pg. 10)
c.) Feedback from families regarding their experiences with culturally relevant and respectful services is routinely collected through the DART, which is administered by a trained reviewer. Data gathered from the DART informs continuous quality improvement efforts, including providing actionable feedback to staff and their supervisors for targeted training and coaching.
Refer to Attachment 6: HFW Data and Evaluation (E Pg. 28 & Evaluation Pg 30-31)
1.8 High-Quality Team Planning and Problem Solving
See HFW 1 for supporting documents
1.8 High-Quality Team Planning and Problem Solving
a.) The HFW team agreement is embedded in the Plan of Care. Each team member will sign the agreement and Plan of Care, and, after finalization, they will be placed in the youth’s chart. The team agreement includes:
1) The youth and family’s mission and vision statement
2) Wraparound Principles and Phases
3) Team members, roles, and contact information
4) Family rules and understanding
5) Strategies and action items for each team member
Refer to Attachment 2: HFW Service Planning and Monitoring Procedure (Procedure B Pg 6-7)
b.) Youth and families enrolled in HFW have multiple opportunities to provide feedback on High-Quality Team Planning and Problem Solving. This feedback is collected through tools such as the WFI-EZ and observations conducted with the TOM 2.0. The Facilitator will ensure the WFI-EZ is complete, and a trained reviewer will complete the DART. In addition, youth and caregivers are encouraged to participate in the Advisory Boards, which provide additional space to give RCS feedback.
Refer to Attachment 6: HFW Data and Evaluation (D Pg 27-28, F Pg 28, and Evaluation Pg 30-31)
Refer to Attachment 9: Advisory Board Procedure (Evaluating Feedback Pg. 39)
c.) Data from surveys are analyzed for PQI/CQI, which includes enhancing our HFW staff’s ability to meet standards and fidelity through training, coaching, and individualized supervision and observation.
Refer to Attachment 6: HFW Data and Evaluation (Evaluation Pg 30-31)
d.) The Clinical Program Manager will review CFT Meeting minutes and the Plan of Care as part of their oversight responsibilities. In addition, all HFW documents are reviewed using the DART by an RCS-trained reviewer. These documents are also reviewed to monitor shared ownership within the HFW Team and follow through on strategies and action items.
Refer to Attachment 2: HFW Service Planning and Monitoring Procedure (Procedure E-3, Pg 7)
Refer to Attachment 6: HFW Data and Evaluation (E Pg 28 and Evaluation Pg 30-31)
Refer to Attachment 5: Case Review Plan (Components of the Case Review Plan 1-7 Pg 19-25)
1.9 Outcomes Based Process
See HFW 1 for supporting documents
1.9 Outcomes-Based Process
a.) The Plan of Care is completed by the HFW Facilitator, and they ensure the plan will specify measurable strategies and action items with timeframes for completion, and the individual on the CFT responsible for completing the action item.
Refer to Attachment 2: HFW Service Planning and Monitoring Procedure (Procedure E-4 Pg7-8)
b.) All completed actions will remain on the Plan of Care labeled as completed and crossed out. The HFW Facilitator is responsible for tracking and updating the Plan of Care strategies and action items at the Wraparound CFT Meetings.
Refer to Attachment 2: HFW Service Planning and Monitoring Procedure (Procedure G-2 Pg 8)
c.) The Plan of Care is designed in a format (Microsoft Word Document) that allows for updates, adjustments, and edits to be made as needed. Once a change is made to the Plan of Care, the HFW Facilitator sends the updated plan to all the team members, informing them of the change.
Refer to Attachment 2: HFW Service Planning and Monitoring Procedure (Procedure E-2 Pg 7 & H Pg 8)
d.) All HFW Staff are CANS trained and certified through the Praed Foundation. While all RCS staff contribute to collecting the information needed for the CANS, the HFW Facilitator is responsible for completing, presenting, and disseminating data from the IP-CANS to the HFW team.
Refer to Attachment 3: Wraparound Training Grid (Pg 10)
e.) IP-CANS data is used to identify strengths and needs, as well as to inform strategies and action items necessary for the success of the youth and family. Additionally, the IP-CANS are utilized to monitor progress effectively and team decision-making.
Refer to Attachment 6: HFW Data and Evaluation (A Pg 26-27 and Evaluation Pg 30-31)
1.10 Persistence
See HFW 1 for supporting documents
1.10 Persistence
a.) RCS HFW Staff are trained in Persistence through the UC Davis Wrap 101 training. Training includes strategies for navigating setbacks and limited progress, as well as reengagement strategies for youth and families. However, if the team agrees (with the family’s voice and choice at the center) to terminate Wraparound services, a CFT Meeting will be held to outline a respectful closure that addresses the youth’s and family’s needs.
Refer to Attachment 6: HFW Aftercare Planning and Case Closing (L Pg 35)
Refer to Attachment 3: Wraparound Training Grid (Pg 10)
b.) RCS HFW Staff will be offered a variety of opportunities to access help when facing challenges with Youth and Families enrolled in HFW Services. Opportunity includes Team Consultations, which are designed for team members to meet bi-weekly with the HFW Facilitator’s Clinical Program Manager (who holds the role/function as the HFW Fidelity Coach) to discuss the HFW Facilitator’s families on their caseload. Staff will also meet bi-weekly with their manager for supervision. Additionally, each staff member will participate in Group Supervision every week to discuss their caseload. Wraparound staff can also request a meeting with their manager by phone, text, or email.
Refer to Attachment 10: TS Supervision Expectations & Guidelines (Supervision and Accountability of Staff A-C Pg 41-42)
c.) All RCS HFW staff (Facilitators, Family Specialist, Therapist, and Family Partners) will receive ongoing training through booster and coaching through supervision or in vivo on post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revisions. This will be supported by the Clinical Program Manager, who holds the role/function as the HFW Fidelity Coach.
Refer to Attachment 3: Wraparound Training Grid (Pg 10)
1.11 Transitions as a part of the Fourth Phase of HFW
See HFW 1 for supporting documents
1.11 Transition as Part of the 4th Phase of HFW
a.) Through the HFW process and the utilization of the Plan of Care, Transition is outlined and defined with measurable tasks and goals required for the family to successfully transition/graduate from HFW Services. Once the CFT has acknowledged that the family is prepared to graduate from services, the Plan of Care is updated to include transitional or aftercare services to which the family will be connected. The HFW team will initiate a warm hand-off to all referred services to ensure that the family is successfully connected. The goal is to have the family connected to services before they graduate from HFW. In the event of a family disengaging from services and being required to close, the HFW Facilitator, in collaboration with the referring worker, will ensure that the family is sent information on ways to reengage in HFW services, including by certified letter (mail) or text message. If an abrupt closure occurs due to adverse events or administrative reasons, the HFW team will consult with our contract guarantor (Santa Clara County Social Services Administration) on ways to ensure continuity of care while maintaining fidelity to HFW standards.
Refer to Attachment 7: HFW Aftercare Planning and Case Closing (Procedure C Pg 33, L Pg 35, M Pg 35)
b.) All youth and families transitioning out of HFW Services will be celebrated in accordance with their family culture, values, and preferences. The HFW Facilitator will ensure that all CFT members are present and acknowledged for their support to the family. The HFW Facilitator, in collaboration with their clinical program manager, will ensure that flex funds are available to accommodate the celebration.
Refer to Attachment 7: HFW Aftercare Planning and Case Closing (Procedure F Pg 34)
Expected Outcomes
2.1 Youth and Family Satisfaction
See HFW 2 for supporting documents
RCS will employ a variety of tools to record and evaluate High Fidelity for its Wraparound program. The tools, including those to be implemented upon certification approval, are included in the following policies.
Refer to Attachment 1: HFW Data and Evaluation Procedure (HFW Outcome Tools Pg 2-4)
RCS’ process for evaluating data for fidelity, communication of data findings/results, and measures taken to ensure the program meets or exceeds fidelity standards. This is achieved by using PQI activities to monitor and evaluate HFW practice through data collection, case reviews, and standardized tools such as CANS/IP-CANS, PSC-35, ACEs, PEARLS screenings, WFI-EZ, TOM, WrapStat, and CSQ-8. These tools assess clinical outcomes, service effectiveness, and adherence to Wraparound principles, such as family involvement and strengths-based planning. RCS uses these data sources to establish performance measures and track trends in service delivery and outcomes, focusing on indicators such as assessment quality, CFT meeting effectiveness, inclusion of natural supports, cultural responsiveness, and goal progress. Data is regularly reviewed by PQI Committees and reported through established structures to guide decision-making and continuous quality improvement.
Refer to Attachment 1: HFW Data and Evaluation Procedure (Evaluation Pg 6, Reports & Analysis Pg 7, and Performance and Quality Improvement Pg 7)
Refer to Attachment 2: Performance and Quality Improvement Master Plan (Evaluation Methodology Pg 18, Communicating Data Pg 19-20, Using Data for Implementing Improvement Pg 20, Program and Service Delivery Effectiveness Pg 20-22, HFW Amendment for HFW Pg 22-23).
2.1 Youth Satisfaction:
Our Wraparound program measures and evaluates satisfaction by using two key tools: the WFI-EZ (particularly Section C, which focuses on satisfaction from the perspectives of youth and caregivers) and the CSQ-8. The Facilitator is responsible for completing and submitting both assessment tools. The Quality Improvement (QI) Department at RCS will input and retrieve data from Wrap Stat, and the Outcomes Committee will generate reports to assess satisfaction levels.
Refer to Attachment 1: HFW Data and Evaluation Procedure (HFW Outcome Tools A Pg 2 &G Pg 4 and Outcomes B.1 Pg 5)
2.2 Improved School Functioning
See HFW 2 for supporting documents
2.2 Improved School Functioning:
Our Wraparound program records and evaluates School Functioning by administering the WFI-EZ (Questions D4 and D7) and the DART (Questions I5 and I6). The Facilitator will ensure that all required members complete the WFI-EZ. The DART Evaluator reviews staff progress notes, HFW CFT Meeting Minutes, school attendance, IP-CANS, Individualized Education Plans (IEPs), and Plan of Cares to evaluate school functioning.
Refer to Attachment 1: HFW Data and Evaluation Procedure (HFW Outcome Tools D Pg 3-4 &E Pg 4 and Outcomes B.2 Pg 5)
2.3 Improved Functioning in the Community
See HFW 2 for supporting documents
2.3 Improved Functioning in Community:
Our Wraparound program records and evaluates engagement with community activities through the administration of WFI-EZ (Caregiver D1 and D9, and Youth and Caregiver B13 and B25) and the DART (Question I7). The Facilitator will ensure that all required members complete the WFI-EZ. The DART Evaluator reviews staff progress notes, CFT Meeting Minutes, IP-CANS, and Plans of Care to evaluate improvements in community functioning.
Refer to Attachment 1: HFW Data and Evaluation Procedure (HFW Outcome Tools DPg 3-4 &E Pg 4, and Outcomes B.3 Pg 5)
2.4 Improved Interpersonal Functioning
See HFW 2 for supporting documents
2.4 Improved Interpersonal Functioning:
Our Wraparound program records and evaluates the interpersonal functioning of youth and families through the administration of the WFI-EZ (Caregiver Question D8 and Youth and Caregiver B9 and B10) and the DART (Question I4). The Facilitator will ensure that all required members complete the WFI-EZ. The DART Evaluator reviews staff progress notes, CFT Meeting Minutes, IP-CANS, PSC-35, and Plans of Care to evaluate improvements in interpersonal functioning.
2.5 Increased Caregiver Confidence
See HFW 2 for supporting documents
2.5 Increased Caregiver Confidence:
Our Wraparound program records and evaluates the caregiver’s confidence in their abilities and connectedness to resources in their community through the administration of the WFI-EZ (Caregiver Questions B24 and C4). The Facilitator will ensure that all required members complete the WFI-EZ, and the QI will enter the information into Wrap Stat.
Refer to Attachment 1: HFW Data and Evaluation Procedure (HFW Outcome Tools D Pg 3-4 and Outcomes B.5 Pg 5-6)
2.6 Stable and Least Restrictive Living Environment
See HFW 2 for supporting documents
2.6 Stable and Least Restrictive Living Environment:
Our Wraparound program records and evaluates the frequency and types of placement changes by administering the DART, with a focus on Question I1. The DART Evaluator reviews the client’s chart, focusing on progress notes, HFW CFT Meeting Minutes, IP-CANS, PSC-35, Incident Reports/Critical Incidents, and Plans of Care to evaluate improvements in interpersonal functioning. The DART Evaluator ensures that the completed form is submitted to the QI department for entry into Wrap Stat.
Refer to Attachment 1: HFW Data and Evaluation Procedure (HFW Outcome Tools E Pg 4 and Outcomes B.6 Pg 6)
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
See HFW 2 for supporting documents
2.7 Reduction in Inpatient, Emergency Department Admission:
Our Wraparound program tracks and assesses the frequency of hospital visits using the WFI-EZ, specifically focusing on Caregiver Questions D1, D2, and DART (Question I2). The DART Evaluator reviews the client’s chart, focusing on progress notes, HFW CFT Meeting Minutes, IP-CANS, PSC-35, Incident Reports, Critical Incidents, and Plans of Care to evaluate the reduction in inpatient and emergency department admissions. The DART Evaluator is responsible for submitting the completed form to the QI department for entry into Wrap Stat. The HFW Facilitator will ensure that all required members complete the WFI-EZ, and the QI Department ensures that the information is entered into Wrap Stat.
Refer to Attachment 1: HFW Data and Evaluation Procedure (HFW Outcome Tools D &E Pg 3-4 and Outcomes B.7 Pg 6)
2.8 Reduction in Crisis Visits
See HFW 2 for supporting documents
2.8 Reduction in Crisis Visits:
Our Wraparound program records and evaluates the frequency of hospital visits by administering WFI-EZ (Caregiver Questions D1 and D2) and DART (Question I2). The HFW Facilitator will ensure that all required members complete the WFI-EZ, and the QI department ensures that the information is entered into Wrap Stat. The DART Evaluator reviews the client’s chart, focusing on progress notes, CFT Meeting Minutes, IP-CANS, Incident Reports, Critical Incidents, and Plans of Care to evaluate the reduction in crisis visits. The DART Evaluator is responsible for submitting the completed form to the QI department for entry into Wrap Stat.
Refer to Attachment 1: HFW Data and Evaluation Procedure (HFW Outcome Tools D &E Pg 3-4 and Outcomes B.8 Pg 6)
2.9 Positive Exit from HFW
See HFW 2 for supporting documents
2.9 Positive Exit from HFW:
Our Wraparound program records and evaluates when and why families exit through the administration of the DART and the CSQ-8. The DART Evaluator reviews the Discharge Score. The DART Evaluator is responsible for submitting the completed form to the QI department for entry into Wrap Stat. The Facilitator will ensure that the youth and family complete the CSQ-8 prior to transitioning out of Wraparound Services. Once complete, the Facilitator will upload the scores into the youth’s chart.
Refer to Attachment 1: HFW Data and Evaluation Procedure (HFW Outcome Tools E & G Pg 4 and Outcomes B.9 Pg 6)
Engagement
3.1 Orientation
See HFW 3 for supporting documents
3.1 Orientation:
The Facilitator and their Clinical Program Manager conduct the Orientation (intake) appointment. The following areas are covered during the Orientation appointment:
a.) An overview of the Wraparound principles and phases
b.) Legal and ethical consideration
c.) The role of each team member (Informal and natural supports and tribes)
In addition, the youth and family are provided with a copy of our Welcome packet, which includes an overview of Wraparound services and roles, as well as the signed consent, Medi-Cal beneficiary packet, and safety plan.
Refer to Attachment 1: HFW Admission Procedure (Intake Pg 3-4)
Refer to Attachment 2: HFW Welcome Packet (Pg 6-8)
3.2 Safety and Crisis stabilization
See HFW 3 for supporting documents
3.2 Safety and Crisis Stabilization:
During the Orientation meeting, the Facilitator begins assessing safety concerns and develops the Crisis Plan (Initial Safety Plan). The plan is created regardless of safety concerns to provide an overview of our crisis response services, along with information on crisis numbers the family can access if a crisis develops. Once complete, the Facilitator ensures the Crisis Plan (Initial Safety Plan) is included in the client’s chart. If there are urgent issues, the Facilitator contacts the Crisis Response team. They are notified of a potential crisis if it is immediate and provided with the crisis plan.
a.) The Crisis Plan is created during the intake process, regardless of any pressing concerns.
b.) The Safety Plan is completed during the Plan Development phase.
c.) The client and their family are provided with a 24/7 crisis response line, which is included in the Crisis Plan.
Refer to Attachment 1: HFW Admission Procedure (Safety Planning Pg 4-5)
Refer to Attachment 3: Safety Plan (Pg 9-11)
3.3 Strengths, Needs, Culture and Vision Discovery
See HFW 3 for supporting documents
3.3 Strengths, Needs, Culture, and Vision Discovery:
During the engagement phase, the HFW team, including the Facilitator, Family and Youth Partner, and Family Specialist, collaborates to complete a comprehensive assessment of the youth and their family’s strengths and needs, as well as their cultural background. Additionally, the HFW team (Facilitator, Family and Youth Partner, and Family Specialist) assists the family in developing their Family Vision. This information is compiled into the youth’s mental health assessment. Once the assessment is complete, the Facilitator reviews it with the family, providing an opportunity for them to give additional feedback. The identified strengths are also documented in the Youth and Family’s strength inventory, which is discussed during CFT Meetings. The Facilitator’s Clinical Program Manager reviews the assessment to ensure it complies with standards, and the assessment is subsequently added to the youth’s chart.
Refer to Attachment 4: Assessment for HFW Services (Procedure A. 2-4 Pg 12-13)
Refer to Attachment 5: CFT Strength Inventory (Pg 16-18)
3.4 Engage All Team Members
See HFW 3 for supporting documents
3.4 Engage All Team Members:
a) The Facilitator, Family and Youth Partner, and Family collaborates with the client and their family to create a Natural Supports Inventory. Once finalized, the Inventory is uploaded to the client’s records. The Inventory is revised when new natural support is added to the CFT.
Refer to Attachment 6: Natural Supports Inventory (Pg 19)
Refer to Attachment 7: Natural Supports Procedure (Procedure 5 & 6. Pg 21)
b) Children’s System of Care Partners, such as DFCS Social Workers or JPD Probation Officers, are included in the CFT process from the moment we receive the referral. The Facilitator invites them to the Orientation Meeting and all Meetings.
Refer to Attachment 1: HFW Admission Procedure (Referral 6. Pg 3)
Refer to Attachment 8: HFW Provision of ICWA (Procedure Pg 22-23)
c) During the intake process, the Facilitator converses with the client and their family to recognize individuals in the client’s life who could participate in the CFT as natural supports (such as extended family, coaches, teachers, neighbors, clergy members, etc.). The discussion on including informal and natural supports starts in the engagement phase and continues throughout the Wraparound process. Additionally, during intake and throughout the engagement phase—which includes completing the mental health assessment—the HFW Team (Facilitator, Family and Youth Partner, and Family Specialist) is trained to gather information on the youth’s tribal identification and involvement.
Refer to Attachment 7: Natural Supports Procedure (Procedure 1. Pg 20 & 6. Pg 21)
Refer to Attachment 8: HFW Provision of ICWA (Procedure Pg 22-23)
d) Engagement and team-building activities are documented through meeting minutes and progress notes, which are included in the youth’s chart. Additionally, releases to exchange information with natural and informal supports are also stored in the client’s chart.
Refer to Attachment 7: Natural Supports Procedure (Procedure 5. Pg 21
3.5 Arrange Meeting Logistics
See HFW 3 for supporting documents
3.5 Arrange Meeting Logistics:
a) The CFT will prioritize flexible scheduling for meetings, making sure they are held on a date, at a time, and in a location that is convenient for the family. During the engagement phase (assessment), the Facilitator will collect the meeting preferences of the youth and the family.
Refer to Attachment 1: HFW Admission Procedure (Intake Pg 3)
b) All RCS Wraparound staff are trained to collaborate with youth and families to provide them with a voice and choice in scheduling meetings that align with their preferences, encouraging participation in services.
Refer to Attachment 1: HFW Admission Procedure (Referral 6 Pg 3.)
Refer to Attachment 9: HFW Training Grid (Booster Pg 24)
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
See HFW 4 and Plan of Care for Supporting Documents
4.1: Develop and Document Team Agreements, Additional Strengths, and Team Mission.
a) During the CFT (Child Family Team) meeting, the HFW team, led by the HFW Facilitator, completes and documents several important items: Team Agreements, a Team Strengths Inventory, and a Team Mission Statement. The facilitator helps the team establish meeting expectations and outlines the decision-making process. The HFW Facilitator guides the drafting process using the Team Agreement, Team Strength Inventory, and Family Vision. The CFT actively supports the family’s engagement, ensuring that their voice, cultural preferences, and priorities are incorporated into the process. Finally, the Facilitator’s Clinical Program Manager, who serves as the Fidelity Coach, reviews all documentation to ensure it meets fidelity standards and is included in the client’s chart.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure B-D Pg 2-3)
b) The HFW Facilitator reviews the identified strengths from the engagement phases and updates them based on information from the IP-CANS and the mental health assessment. Newly discovered strengths are added to the strengths’ inventory and incorporated into the Plan of Care.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure C Pg 3)
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
See HFW 4 and Plan of Care for Supporting Documents
4.2: Describe and Prioritize Needs, Develop Goals, and Assign Strategies
a) During an HFW team meeting, the Facilitator leads a discussion focused on identifying and prioritizing the underlying needs of the client and family. The Facilitator will utilize data from assessment tools like IP-CANS, PCS-35, PEARLS, and ACES to pinpoint the areas that require attention for the family. With the team’s support, the client and their family will express their needs and establish priorities. These identified needs will be documented in the client’s chart through progress notes and meeting minutes.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure E Pg 3-4.)
b) The HFW Facilitator ensures that all goals are identified by the family based on their underlying needs. Additionally, needs, goals, and outcomes are developed using strength-based language.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure E. 4, d. Pg 3-4)
c) All goals and outcomes are created during an HFW CFT team meeting that includes the client, family, and natural and informal support, ensuring every team member has an equal voice in the process.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure E Pg 3.)
d) The facilitator leads a team brainstorming session to generate various individualized strategies and interventions. The family partner ensures that cultural relevance and family preferences are taken into account. The supervisor reviews these strategies to assess their clinical appropriateness. All interventions and strategies are documented in the HFW plan of care, the Mental Health Assessment, and the Meeting Minutes. The facilitator records each strategy in the meeting minutes and Electronic Health Record (EHR), detailing the assigned responsibilities, specific steps, and due dates. Team members take ownership of their action items.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure E. 3 Pg 3)
e) The HFW Director and Clinical Program Manager provide ongoing training and coaching for facilitators in leading teams to identify needs, prioritization, strategy development, and action planning. Training for Facilitators begins at hire and includes the Wraparound Foundations Training from UC Davis and booster training.
Refer to Attachment 2: HFW Training Grid (Pg 6)
Refer to Attachment 3: HFW Required Training (D. Wraparound 101 Pg 9)
f) Facilitators will ensure that the Plan of Care is created in a team-based environment with the CFT, prioritizing the youth and family’s voice and choice in needs and goal development.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure A-E Pg 2-4)
4.3 Develop an Individualized Child or Youth and Family Plan
See HFW 4 and Plan of Care for Supporting Documents
4.3 Develop an Individual Child or Youth and Family Plan
1) The HFW Facilitator is responsible for ensuring that the Plan of Care is aligned with the family’s vision and mission, and is informed by the unique strengths, needs, and cultural background of the youth and family.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure A-E& E.b Pg 2-4)
2) The Plan of Care must address the needs identified and prioritized by the HFW team across all relevant life domains of the youth and family, including those of Children’s Systems of Care partners (DFCS Social Worker or JPD Probation Officer).
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure E. 4.b Pg 3 & G Pg 3-4)
3) The HFW Facilitator documents strategies and action items, assigns responsibilities and due dates, and ensures all team members understand their roles. Strategies are culturally relevant, balance formal services with natural supports and community resources, and increasingly emphasize natural supports over time.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure E & E. 4 a-d Pg 3-4)
4) The HFW Facilitator develops the Plan of Care by actively coordinating a range of services among Children’s System of Care partners. These services are planned together to meet the unique needs of each youth and family and are delivered in the community where they live. The plan puts family needs and choices first, considers family schedules, culture, and past trauma, and ensures all youth and families can access help.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure E &E.a. Pg 3)
5) The Plan of Care includes natural supports and sustainable community resources. It also outlines strategies for identifying and developing these supports before the child, youth, and family transition out of the HFW Program.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure E. 4. B Pg 3)
6) The HFW team initiates a gradual transition from formal services. The Plan of Care sets benchmarks for transitioning to less restrictive, less formal services, allowing families to progress at their own pace.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure E. 4. B Pg 3)
a) The HFW Facilitators will receive training, including quarterly and booster, on engaging the HFW team in the planning process to ensure multiple perspectives are included in the process, build trust and cohesion, and a shared vision.
Refer to Attachment 2: HFW Training Grid (Pg 6)
b) The Plan of Care will incorporate goals and objectives identified by all Children’s System of Partners.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure G Pg 4)
c) Each Plan of Care—whether it is the initial, an update, or a discharge/graduation plan—is reviewed by the Clinical Program Manager (CPM) of the HFW Facilitator. This review uses the Plan of Care Checklist to ensure that the plan meets the fidelity standard and is signed by all members of the HFW team. Once the CPM approves the plan, it is added to the client’s chart.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure E. 3 Pg 3)
d) All documents, including the Plan of Care, go through various quality improvement reviews, including reviews from the CPM, the DART, and our Santa Clara County Children’s System Partners review (Community Oversight). Feedback is provided to the HFW team, including the Facilitator, and training and coaching are developed accordingly.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure G Pg 4)
4.4 Develop a Crisis and Safety Plan
See HFW 4 and Plan of Care for Supporting Documents
4.4 Develop a Crisis Plan:
a.) The Crisis Plan (initial safety plan) developed during the engagement phase is built upon during the planning phases to construct a Safety Plan. The Safety Plan includes safety concerns, risky behaviors, and strategies to prevent and decrease the behaviors. In addition, step-by-step instructions are provided for de-escalating and identifying HFW members, along with crisis lines to contact.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure K. 1. A Pg 5)
b.) The Safety Plan is developed in collaboration with the HFW team and reflects the voice and choice of the client and caregiver. All HFW staff receive ongoing training in de-escalation techniques and strategies, as well as safety planning.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure K. 1. C Pg 5)
c.) All documents, including the Safety Plan, go through various quality improvement reviews, including reviews from the CPM, the DART, and our Santa Clara County Children’s System Partners review (Community Oversight). Feedback is provided to the HFW team, including the Facilitator, and training and coaching are developed accordingly.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure K. 2 Pg 5)
Implementation
5.1 Implement The Plan of Care
See HFW 5 for Supporting Documents
5.1 Implement the Plan of Care
a) Upon approval of the initial Plan of Care, the HFW Facilitator leads the team in monitoring the completion of action items and strategies, assessing effectiveness in meeting identified needs, and ensuring implementation remains consistent with HFW principles. Successes and progress toward goals are acknowledged and celebrated during team meetings. The Facilitator conducts structured evaluations of the Plan of Care at each CFT meeting to track action steps and progress, ensure adherence to timelines and deliverables, and adjust strategies or action items as needed.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure H Pg 4)
b) All HFW staff receive training and ongoing coaching on implementing the Plan of Care in alignment with HFW principles. The HFW Director and Clinical Program Manager, who serves as the Fidelity Coach, provide ongoing training and coaching for all staff on the application of HFW principles in care planning and implementation; the use of IP CANS assessments, PSC-35, and the Strengths Inventory to guide strategy development and outcome monitoring; documentation practices; and CFT minutes. Fidelity is monitored through TOM and WFI-EZ data.
Refer to Attachment 2: HFW Training Grid (Pg 6)
5.2 Review and Update The Plan of Care
See HFW 5 for Supporting Documents
5.2 Review and Update the Plan of Care
The Facilitator guides the Child and Family Team in regularly reviewing and updating the Plan of Care to ensure it meets the youth’s and family’s changing needs. Progress towards goals, the effectiveness of strategies, and task completion are consistently evaluated using information gathered from team meetings, DART documentation, and reassessments of needs through the IP-CANS process. The Plan of Care is formally updated during Child and Family Team (CFT) meetings at least every 90 days or more frequently if significant changes occur.
a) Progress toward goals and strategies is reviewed during CFT meetings using the CFT meeting agenda and CFT meeting minutes. Team members provide updates regarding assigned action items and service delivery.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure H&I Pg 4)
b) The Facilitator is responsible for guiding the HFW team in updating the Plan of Care whenever goals are met, new needs emerge, or adjustments to strategies are necessary. These updates may involve revising goals, selecting new strategies, identifying additional supports, or modifying action items. All changes are documented in the youth’s file and reflected in the updated Plan of Care.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure H Pg 4)
c) The HFW facilitator documents and communicates during the CFT meeting the completion of action items and new assignments, team member attendance, participation of formal and natural supports, use of flex funds, updates to strategies and goals within the Plan of Care. These updates are shared with all team members through CFT meeting minutes, updated Plan of Care documents, and follow-up communication as needed.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure H Pg 4)
d) Plan of Care templates, CFT agenda, CFT meeting minutes, and progress notes are designed to be adaptable and individualized to meet the evolving needs of the youth, family, and team. These tools allow the team to adjust goals, strategies, and supports as circumstances change.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure H Pg 4)
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
See HFW 5 for Supporting Documents
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
The Facilitator actively supports the development of strong, collaborative Child and Family Teams by fostering trust, maintaining team cohesion, and identifying opportunities to build natural supports. The Family Partner, Youth Partner, and Family Specialist all share the responsibility for supporting the youth and family while maintaining alignment with HFW principles.
a) Team agreements are established early in the Wraparound process with contributions from the youth, family, and team members. These agreements define expectations for communication, confidentiality, collaboration, and respect. They are reviewed regularly and referenced during CFT meetings to ensure a collaborative environment is maintained.
Refer to Attachment 1: HFW Service Planning and Monitoring Procedure (Procedure B Pg 2-3)
b) HFW Facilitators receive ongoing training and coaching focused on building and maintaining effective teams, managing group dynamics, and resolving conflicts. Supervisors provide coaching through team consultations, in supervision, and by observing team facilitation practices (TOM 2.0).
Refer to Attachment 2: RCS HFW Training Grid (Pg 6)
c) Natural supports are identified during the strengths discovery process and throughout the Wraparound process. The Family Partner and Youth Partner leverage their lived experience to support the exploration of Natural Supports specific to the youth and caregivers to include on the HFW CFT. RCS tracks the involvement of these supports by monitoring attendance at CFT meetings and documenting it in meeting minutes. Supervisors review cases to ensure that natural supports are actively engaged and strengthened. Additionally, coaching and supervision provide facilitators with feedback on strategies to expand and sustain these natural supports.
Refer to Attachment 3: Natural Supports Procedure (Procedure 1 Pg 7 &5 Pg 8)
Refer to Attachment 2: RCS HFW Training Grid (Pg 6)
d) The HFW team has a structured process for orienting new members, including both service providers and natural supports. The orientation, led by the Facilitator, introduces new members to the HFW process and principles. It includes a review of the current Plan of Care, team strategies, and an explanation of team roles and expectations. This process ensures that new members are well prepared to contribute effectively and to maintain continuity in supporting the youth and their families.
Refer to Attachment 3: Natural Supports Procedure (Procedure 3 Pg 7)
Transition
6.1 Develop a Transition Plan
See HFW 6 for Supporting Documents
6.1 Develop a Transition Plan
Our HFW program ensures that transition planning is a structured, team-driven, and individualized process that begins when the youth and family demonstrate progress toward established benchmarks and HFW goals. The HFW facilitator leads the Child and Family Team (CFT) in reviewing indicators that have been monitored throughout the HFW process and supports the team in determining readiness for transition.
a) As progress is made and reflected in data from the IP CANS, PSC 35, and the reported advancements in the Plan of Care, formal services will be gradually reduced. The HFW facilitator will update the Plan of Care to include transition strategies that promote long-term stability and independence for the youth and their family. As the youth and family near the transition from formal HFW services, the team will ensure that natural supports and community connections are sufficiently strengthened and included in the HFW team to maintain stability and support ongoing progress.
Refer to Attachment 1: HFW After Care Planning and Care Closing (Responsibilities, All Direct care staff Pg 2-3)
b) Once the youth, family, and team agree that it is time to transition out of HFW services, the HFW facilitator will guide the development of a formal, individualized transition plan. This plan outlines ongoing needs, services, and supports that will continue after formal HFW services end. Additionally, it includes strategies for transitioning any remaining support from HFW staff to natural supports, community-based services, and other sustainable resources.
Refer to Attachment 1: HFW After Care Planning and Care Closing (Procedure B Pg 3)
c) The individualized transition plan is developed during CFT Meetings, and the process is a collaborative, team-based process that prioritizes youth and family voice and choice. HFW facilitators receive boosters, annual training, and ongoing coaching, including individual supervision and team consultation, to effectively lead this process. The completed transition plan is distributed to all team members and documented in the youth’s file.
Refer to Attachment 1: HFW After Care Planning and Care Closing (Procedure Pg 3)
Refer to Attachment 2: HFW Training Grid (Pg 6)
d) The CFT ensures that all identified services and supports will continue beyond the formal wraparound framework (HFW) and that the family has the knowledge and skills to access them. For adoptive families using Adoption Assistance Program (AAP) funding, we provide information about available post-adoptive services to facilitate a successful transition. Any additional services implemented to support youth and families transitioning out of HFW will include a “warm handoff” to ensure a smooth connection is made.
Refer to Attachment 1: HFW After Care Planning and Care Closing (Procedure C&D Pg 3)
6.2 Develop a Post-Transition Safety Plan
See HFW 6 for Supporting Documents
6.2 Develop a Post-Transition Safety Plan
As part of the transition away from formal HFW, the HFW facilitator guides the CFT in creating or updating an individualized crisis and safety plan that addresses needs after the transition. The team identifies potential crises that might arise after the conclusion of HFW and develops both proactive and reactive strategies to address them effectively.
a) The Post- Transition Safety Plan is individualized, culturally relevant, and emphasizes the use of natural and community supports that will remain in place after HFW. Youth and family voice and choice are central to identifying strategies that are meaningful, practical, and sustainable.
Refer to Attachment 1: HFW After Care Planning and Care Closing (Procedure E Pg 4)
b) The safety plan is recorded in the youth’s electronic health record (EHR) and outlines a series of strategies aimed at preventing, de-escalating, and responding to crises. Development of the plan occurs in a collaborative team environment, and HFW facilitators receive training and coaching to maintain consistency in this process.
Refer to Attachment 1: HFW After Care Planning and Care Closing (Procedure E 1-4 Pg 4)
Refer to Attachment 2: HFW Training Grid (Pg 6)
c) The HFW program implements quality assurance processes to review crisis and safety plans, ensuring they contain: Individualized, strengths-based strategies; Inclusion of both proactive and reactive interventions; Cultural relevance and effective use of natural supports. Post-transition safety plans are presented to the family and the CPM for approval. Additionally, these plans undergo multiple quality-improvement reviews, including evaluations by the CPM and DART. Together, these processes promote continuous quality improvement and facilitate ongoing training and coaching for HFW staff.
Refer to Attachment 1: HFW After Care Planning and Case Closing (Procedure G Pg 4)
Refer to Attachment 2: HFW Training Grid (Pg 6)
6.3 Create a Commencement and Celebrate Success
See HFW 6 for Supporting Documents
6.3 Create a Commencement and Celebrate Success
The HFW program ensures that the transition from formal HFW is recognized and celebrated in a meaningful and culturally relevant way. The CFT works with the youth and their families to plan a commencement or celebration that reflects their values, culture, and preferences.
a) The Facilitator must ensure that the celebrations are individualized and designed to acknowledge the progress, strengths, and accomplishments achieved throughout the HFW process. This may include family gatherings, community-based celebrations, or other culturally meaningful activities.
b) Access to flexible funding, when necessary, is essential for staff to participate in celebrations, as well as for facilitating planning and coordination. Engagement with community partners and natural supports is also a crucial component of the transition planning process. This intentional graduation process highlights achievements, strengthens ongoing supports, and signifies a successful transition from HFW. Both youth and caregivers receive a certificate and recognition for their progress and commitment.
Refer to Attachment 1: HFW After Care Planning and Case Closing (Procedure F Pg 4)
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
See HFW 7 for Supporting Documents
7.1 Youth and Family as Key Decision-Makers
a) RCS offers clients and families enrolled in HFW services multiple opportunities to provide feedback on the Wraparound process. This includes surveys such as the WFI-EZ, the Santa Clara County consumer perception surveys, and the Client Satisfaction Questionnaire (CSQ-8). Additionally, the HFW Facilitator encourages participation in both the Youth Advisory Board and the Caregiver Advisory Board, enabling clients and families to share their perspectives on the Wraparound process. During the intake process, this information is communicated to youth and families, and they are given relevant literature. The Advisory Board meetings are held monthly, providing youth and families with opportunities to learn about the Wraparound process, build social networks, and discover community resources available to their families. These meetings also offer initial insights into HFW implementations, highlighting strengths and areas for improvement.
Refer to Attachment 1: HFW Advisory Board (Procedure Feedback Pg 2 & Advisory Boards Pg 3)
b) The feedback collected from surveys and advisory boards is reviewed by RCS’ Outcomes Committee and the HFW Leadership Team. This feedback is utilized to inform service planning and implementation for HFW, update policies and procedures, and enhance workforce development and quality improvement.
Refer to Attachment 1: HFW Advisory Board (Procedure Feedback Pg 2, Advisory Boards Pg 3, and Evaluating Feedback Pg 3)
7.2 Community Leadership Team
See HFW 7 for Supporting Documents
7.2 Community Leadership Team
a) Once established by Santa Clara County, the RCS HFW Chief Clinical Officer and Director will represent RCS on the county’s Community Leadership Team. RCS will be ready to share key data points and feedback from youths and families enrolled in services to inform improvements to HFW. Additionally, RCS will ensure that clients and caregivers participating in the advisory boards can attend the Community Leadership Team meetings.
Refer to Attachment 1: HFW Advisory Board (Community Leadership Team, Pg 3)
7.3 Eligibility and Equal Access
See HFW 7 for Supporting Documents
7.3 Eligibility and Equal Access
a) Santa Clara County has established eligibility criteria for HFW services. All referrals received are eligible for services and will not be rejected based on the severity or nature of their needs.
Refer to Attachment 2: HFW Admission Procedure (Procedure, Referrals Pg 5)
b) HFW employee workloads are regularly assessed to ensure optimal client outcomes. Workloads are determined by factors such as staff qualifications, experience, required tasks, and the level of client need, including crisis support. HFW cases are assigned to promote prompt engagement and a good match between staff expertise and client needs.
Refer to Attachment 3: HFW Assigning and Evaluating Workloads Procedure (Pg 9-11)
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
See HFW 8 for Supporting Documents
8.1 Funding Supports the CA High Fidelity Wraparound Model:
a) RCS’ Wraparound contract with Santa Clara County involves blended funding from the Social Services Administration (SSA), the Behavioral Health Services Department (BHSD), and the Juvenile Probation Department (JPD). This funding ensures that services are tailored to meet the unique and immediate needs of the children and families referred to the Wraparound program. The contract specifies the services required to administer Wraparound in Santa Clara County. Wraparound services include the following:
“These services include intensive care coordination, crisis support, individual, family, and group therapy, or referrals for therapeutic intervention, substance use treatment, social skills building, independent living skills, school support, supporting the family environment, advocacy, and ongoing service coordination/case management.”
Refer to Attachment 1: RCS’ Wraparound Contract with Santa Clara County (Program Description B1g Pg 5)
b) RCS’s Wraparound Contract with Santa Clara County outlines the training requirements for staff, specifying their individual roles and responsibilities within the Wraparound program. The contract provides flexibility, allowing RCS to allocate funds for training that improves the program’s workforce development.
Refer to Attachment 1: RCS’ Wraparound Contract with Santa Clara County (X: Training Pg 14)
Refer to Attachment 2: HFW Training Grid (Pg 18)
Refer to Attachment 3: HFW Required Training (Pg 19-25)
c) RCS’ Wraparound Contract with Santa Clara County offers flexibility for RCS to select vendors for an Electronic Health Record (EHR) and other systems required to capture data essential for meeting high fidelity standards. Currently, RCS utilizes Wrap Stat to collect data from the WFI-EZ. Once the HFW plan is approved, we will begin the integration of TOM 2.0 and DART.
Refer to Attachment 1: RCS’ Wraparound Contract with Santa Clara County (IX Data Reporting Requirements B 1-5 Pg 13-14)
8.2 Equitable Funding Across System Partners
N/.A
8.3 Cost Savings are Reinvested
N/A
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
See HFW 8 for Supporting Documents
8.4 Availability, Access, and Approval of Flex Funds
a) Our contract with Santa Clara County includes access to Flex Funds for youth and families enrolled in Wraparound Services.
Refer to Attachment 4: RCS’ Wraparound Flex Fund Procedure (Purpose Pg 26)
b) Our procedure to access Flex Funds is developed to streamline the timely access to funds.
1) RCS will ensure that funds are made available in a timely manner based on the family’s needs. In emergency situations, the process requiring a credit card can be completed within 4 hours. However, if a check is needed, the process may take up to 24 hours.
Refer to Attachment 4: RCS’ Wraparound Flex Fund Procedure (Processing Pg 27-28)
2) RCS’s approval process includes the Facilitator completing the Flex Fund Approval Form with the CFT and then reviewing it with their Clinical Program Manager. The form is developed to ensure it meets the evaluation criteria 1-7.
Refer to Attachment 4: RCS’ Wraparound Flex Fund Procedure (Identification of Need & Submission of Request and Manager Review Pg 26-27)
3) RCS has established an appeals process that enables youths and their families to reach out to the Clinical Program Manager either in writing or by phone. Additionally, if the family desires, the Clinical Program Manager can attend a CFT meeting to present their reasoning.
Refer to Attachment 4: RCS’ Wraparound Flex Fund Procedure (Denials and Appeals Pg 27)
8.5 Collaborative Oversight of Flex Funds
See HFW 8 for Supporting Documents
8.5 Collaborating Oversight of Flex Funds
a) The RCS Finance Department will provide monthly reconciliation reports that outline the total expenses and flex funds used during the month. Additionally, the reports will include itemized details for flex fund requests, specifying the client’s name, the reason for the request, and the amount used.
b) RCS’ Wraparound program ensures that all flex funds are pooled together to meet the needs of all families.
Refer to Attachment 4: RCS’ Wraparound Flex Fund Procedure (Monitoring and Accountability Pg 28)
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
See HFW 8 for Supporting Documents
8.6 Funding Sources and Program Requirements Do Not Limit Flex Funds
a) The Wraparound Program, provided by RCS, is supported through a collaboration of various resources by combining funding from the Santa Clara County Social Services Administration, Behavioral Health Services Department, and Juvenile Probation Department. The goal of the Wraparound Program is to guarantee that Flex Funds are available to all families in need. Consequently, there are no restrictions or limits on the funding that can be accessed by each family participating in Wraparound.
b) RCS will not restrict or stop the use of flex funds even if the Wraparound Program surpasses the limits outlined in the contract. If the Wraparound Program has reached or exceeded its contractual thresholds, RCS will inform SSA and collaborate to begin a process for Santa Clara County to accommodate any additional usage.
c) Additionally, individual funding dollars will not hinder families from accessing flexible funds (AAP Wraparound).
Refer to Attachment 4: RCS’ Wraparound Flex Fund Procedure (Funding Source Pg 28)
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
See HFW 9 for Supporting Documents
9.1 Culturally Responsive Workforce.
a) RCS’s hiring practices ensure that our staff reflects the cultural and linguistic needs of the specific programs we operate. We achieve this by having each program assess the demographics of the youth and families it serves. For RCS’s Wraparound program, we monitor client demographics through the quarterly report provided by Santa Clara County’s Social Services Administration (SSA) Office of Contracts Management (OCM). This report includes demographic information such as gender, primary language, and race and ethnicity. Wraparound Leadership reviews the OCM report’s outcomes and uses this information to guide our hiring and training practices.
Refer to Attachment 1: HR Recruitment and Selection Practices (Procedure A, section b. Pg 2)
Refer to Attachment 2: SSA OCM Quarterly Report (B. Demographics Section Pg 8)
b) If the HFW team is unable to hire or use internal RCS staffing to meet the individualized cultural, racial, and linguistic needs of the youth and family, the CFT must seek out natural or informal supports to ensure the family has cultural representation.
Refer to Attachment 3: Natural Support Procedure (Purpose Pg. 14)
c) RCS and its Wraparound Program follow a “No eject or reject” philosophy for all youth and families referred to services. While RCS may at times receive referrals for which we are unable to meet the family’s linguistic needs, RCS will ensure that alternative options are explored, including informal support (translator) or through the Santa Clara County-approved Language Line.
Refer to Attachment 4: CR Clients with Special Communication Needs or Language Barriers (Procedure B 1-4 Pg. 16-17)
9.2 Tribally Responsive Workforce
See HFW 9 for Supporting Documents
9.2 Tribally Responsive Workforce:
a) Once the program receives a referral for Wraparound Services, the referring worker must disclose whether the youth is eligible for the Indian Child Welfare Act (ICWA). Additionally, during the intake process and throughout the engagement phase—which includes completing the mental health assessment—the Facilitator is trained to gather information about the youth’s tribal identification and involvement. The referring worker, whether a social worker or probation officer, is responsible for providing the Wraparound team with information regarding cultural norms, practices, and tribal connections. The Clinical Program Manager will arrange training for the HFW Team (Facilitator, Family Specialist, Youth and Family Partner) related to the specific tribe associated with the youth and family, to be completed. If such training is not available, the Child and Family Team (CFT) will request guidance from the tribe while also allowing the youth and family to express their own cultural norms and practices. All Wraparound staff members receive annual training on Cultural Awareness and Humility that aligns with RCS’ Cultural Humility Plan.
Refer to Attachment 5: HFW Provision of ICWA (Procedure Pg. 19-20)
Refer to Attachment 6: RCS’ Cultural Humility Plan (Criterion 4 Pg. 52-56)
b) Throughout the service delivery process, the RCS HFW Team Members including, the Facilitator, Youth Partner, Family Partner, and Family Specialist works together with the youth’s family members and tribe or Indian organization to incorporate them into the service planning and implementation phases. This collaboration occurs through the Child and Family Team (CFT) process, in which a team is formed that includes family members and other natural support team members, which may include representatives from the youth’s tribe or Indian organization. CFT meetings serve as a platform for the HFW Facilitator and the team to work collaboratively with the youth and their family’s tribe or Indian organization to (1) involve representatives from the tribe or local Indian organization in assessment, service planning, and monitoring, as well as aftercare planning, to the maximum extent possible and appropriate; (2) promote participation in Tribal transitions and ceremonies; (3) take into account and prioritize culturally relevant resources offered by or suggested by the tribe or local Indian organization, as much as possible and appropriate (recognizing the importance and support that the tribe can provide); (4) reserve connections between the family and tribe when the family wishes for this connection.
Refer to Attachment 5: HFW Provision of ICWA (Procedure Pg. 19-20)
9.3 Flexible and Creative Work Environment
See HFW 9 for Supporting Documents
9.3 Flexible and Creative Work Environment
a) The RCS Wraparound program involves staff in improving program quality through transparency. This includes sharing data related to program outcomes, information collected from assessment tools, and the WFI-EZ. Additionally, staff participate in activities to ensure compliance by auditing documents in client charts, such as progress notes and evaluations of tools and care plans through peer reviews. Staff will participate in implementing corrective action plans to enhance fidelity to and compliance with the Wraparound standards.
Refer to Attachment 7: HFW Flexible and Creative Work Environment (Program Quality and Continuous Improvement Pg.67)
b) Wraparound Leadership will provide staff activities designed to strengthen cohesion within the Wraparound program, including staff meetings and PODs centered on team-building initiatives. The program will also recognize staff achievements through Peer Awards and Employee of the Month, celebrate individual team successes, and foster inclusive decision-making in organizing team-building events. Additionally, staff are encouraged to join agency committees, including IDEA, Staff Retention, and Safety. These committees provide staff with a voice in developing processes to ensure that RCS is a trauma-informed agency that values its workforce.
Refer to Attachment 7: HFW Flexible and Creative Work Environment (Team Cohesion and Positive Work Environment Pg. 67-68)
c) RCS offers staff various ways to communicate with leadership and provide feedback, including: team meetings for all staff and PODS; individual meetings with supervisors; and anonymous feedback through the my2cents portal, managed by the Quality Improvement (QI) department. Wraparound Leadership will share meeting minutes and information promptly and provide additional opportunities for feedback. Responses to my2cents submissions will be addressed within one week by the relevant department.
Refer to Attachment 7: HFW Flexible and Creative Work Environment (Open Communication Pg. 68)
d) Wraparound Leadership ensures that all staff understand the Wraparound principles and their alignment with RCS’s mission through a thorough onboarding process that includes UC Davis’s Wraparound 101 training, orientation, shadowing, coaching, and ongoing training. Leadership will also present data from the OCM quarterly report and results from WERT tools (WFI-EZ, DART, TOM) to monitor adherence to Wraparound standards and gather feedback. Wraparound values should be integrated into all activities, including All Staff Meetings, PODS, and Team Consultations, as well as in clinical supervision and staff evaluations. Leadership must provide individualized training and coaching to staff who are struggling to apply these principles.
Refer to Attachment 7: HFW Flexible and Creative Work Environment (Mission Alignment and HFW Compliance Pg. 68-69)
9.4 Hiring, Performance Evaluation, and Job Descriptions
See HFW 9 for Supporting Documents
9.4 Hiring, Performance Evaluation, and Job Descriptions
RCS employs strict hiring practices, clearly defined job descriptions, and effective performance evaluation processes to ensure all staff are qualified to deliver High-Fidelity Wraparound services.
a-c) RCS’ program design will ensure all necessary HFW functions are fulfilled through the use of the following roles :
1) Youth Partner: Refer to Attachment 8 (Pg. 70-72)
2) Family Partner: Refer to Attachment 9 (Pg. 73-75)
3) HFW Facilitator I&II (Non-Licensed and Licensed): Refer to Attachment 10 (Pg. 76-79)
4) Family Specialist: Refer to Attachment 11 (Pg. 80-82)
5) Clinical Program Manager (also fulfills function of Fidelity Coach): Refer to Attachment 12 (Pg 83-86)
6) HFW Supervisor of Community Services: (also fulfills function of Fidelity Coach) Refer to Attachment 13 (Pg. 87-90)
Refer to Attachment 14: Employee Handbook (2.10.1 Performance Evaluation Process Pg. 110-111) )
d) RCS’ hiring process is structured to assess both qualifications and practical competencies. Procedures include:
1.) Standardized interview questions aligned with HFW values and role expectations.
2.) Scenario-based and/or role-play exercises that allow candidates to demonstrate engagement skills, teamwork, and critical thinking.
3.) Use of interview panels and scoring rubrics to ensure consistency and equity.
4.) Verification of education, experience, and references prior to hire.
Refer to Attachment 1: HR Recruitment & Selection Practices (Requirements A-E Pg. 3-4)
Refer to Attachment 15: Interview Questions (Pg. 166-179)
e) Employees are provided with clear and measurable expectations from the moment they are hired and throughout their employment. The program ensures that staff receive the following:
1. Regular supervision that includes case consultation, coaching, and support aligned with HFW principles. This supervision employs a reflective format that offers staff feedback delivered in a strengths-based manner.
2. Annual performance evaluations that assess both job responsibilities and adherence to the Wraparound process.
3. Corrective actions and performance improvement plans when necessary, to support staff success.
Refer to Attachment 16: TS Supervision and Expectations Guidelines (A-G Pg. 181-182)
9.5 Workforce Stability
See HFW 9 for Supporting Documents
9.5 Workforce Stability
a) RCS has a structured compensation policy aimed at attracting and retaining qualified staff. RCS regularly reviews compensation ranges by considering both internal and external market factors to ensure they remain competitive and equitable. Wage increases can result from various factors, including market adjustments, internal equity assessments, reclassifications, union negotiations for paraprofessionals, and the attainment of advanced degrees or licenses.
Refer to Attachment 14: Employee Handbook (2.8 Compensation Pg. 108-109 and 2.11 Pay Increases Pg. 111-112)
b) In the HFW program, staff typically carry an average of 8 to 10 cases, although this number may vary based on each individual’s ability to meet the agency’s productivity expectations. Staff members review their caseloads and weekly schedules during supervision with their assigned managers. This is an opportunity for staff to discuss any challenges they may face in managing their caseloads and to receive strategies for maintaining productivity while effectively meeting the needs of children and families, all while preventing burnout.
Refer to Attachment 17: HFW Assigning and Evaluating Workload (Procedure Pg. 184-186)
Refer to Attachment 18: HFW Staff Work Schedule (Procedure E and F Pg. 188)
Refer to Attachment 16: TS Supervision and Expectations Guidelines (Supervisory Function Pg. 182, Administrative Functions Pg. 182-182, Educational Functions Pg. 183, Supportive Functions Pg. 183, Supervision Prioritization Pg. 183)
c) RCS prioritizes internal promotions and career advancement for its employees. All job openings are posted internally, and employees are encouraged to apply. Each position within the HFW program has three levels; for example, there are Family Partner I, II, and III. To advance to the next level, employees must meet specific requirements, which include having a certain number of years of experience in the position or obtaining a degree in a relevant field. All positions are posted, and staff must fulfill the specified requirements before submitting their applications. RCS promotes career advancement through flexible work schedules and our internal internship program, which allows employees to pursue further education while remaining in their current role.
Refer to Attachment 14: Employee Handbook (2.9 Promotion Pg. 109)
d) Wage increases can be achieved through several methods: cost-of-living adjustments, union pay increases for our para-professional employees, obtaining a degree or licensure, or through promotions. Leadership positions are regularly available to employees in the HFW program, allowing them to advance through various levels, such as Family Partner I, II, and III. To progress through these levels, employees must have several years of experience or possess a degree relevant to their specific job role.
Refer to Attachment 14: Employee Handbook (2.11 Pay Increases Pg. 111-112)
9.6 High Fidelity Training Plan
See HFW 9 for Supporting Documents
9.6 High Fidelity Training Plan
RCS will maintain a comprehensive and high-fidelity training plan that includes initial, annual, and booster training sessions, along with ongoing professional development. All RCS staff will receive orientation training tailored to both the agency and their specific roles. The training plan details the agency-wide and contractually mandated training requirements for HFW staff. This includes both general HFW training and role-specific training for every position. Additionally, specialized training will be provided for Clinical Supervisors and Managers, including reflective supervision.
RCS staff have access to a wide range of training opportunities offered internally as well as by the UC Davis Resource Center for Family Focused Practice (RCFFP), Santa Clara County agencies—including the Behavioral Health Department, Department of Family and Children’s Services, and Juvenile Probation Department—and community-based agencies. The RCS Human Resources (HR) Department supports compliance with required training by tracking completion in RELIAS and coordinating with external entities to schedule and facilitate internal agency training to support work with populations with unique needs.
a) All HFW staff will receive initial HFW training. Staff complete this initial external training by attending the Statewide Standardized Foundational HFW Training provided through the UC Davis Resource Center for Family Focused Practice (RCFFP).
Refer to Attachment 19: HFW Required Training (D. Wraparound 101 Pg. 191)
Refer to Attachment 20: HFW Training Grid (Pg. 196)
b) All HFW staff will receive ongoing training in both general Wraparound practices and in their specific roles. Ongoing training is provided through formal and informal methods, including training, webinars, meetings, coaching, peer shadowing, reverse shadowing, and supervision. Staff may also request to attend, or be required by the agency to attend conferences, seminars, and/or educational meetings to enhance job-related skills.
Refer to Attachment 19: HFW Required Training (D. Wraparound 101 Pg. 191)
Refer to Attachment 20: HFW Training Grid (Pg. 196)
Refer to Attachment 14: Employee Handbook (3.8 EDUCATION AND PROFESSIONAL DEVELOPMENT Pg. 120)
c) RCS maintains a Staff Development and Training Department that can provide annual internal booster trainings utilizing the Statewide Standardized Foundational HFW curriculum. These booster trainings are delivered either by RCS staff who have completed the Wraparound 101: Foundations for Fidelity Training for Trainers or by using an internal curriculum aligned with the Statewide Standardized Foundational HFW curriculum.
Refer to Attachment 19: HFW Required Training (D. Wraparound 101 Pg. 191)
Refer to Attachment 20: HFW Training Grid (Pg. 196)
d) Clinical Supervisors and HFW Supervisors/Managers attend general Wraparound training and receive initial, ongoing, and booster trainings specific to their roles. Clinical Supervisors and HFW Supervisors/Managers must maintain active status and good standing with the California Board of Behavioral Sciences (BBS) and complete all continuing education requirements associated with their respective license types.
Refer to Attachment 19: HFW Required Training (D. Wraparound 101 Pg. 191)
Refer to Attachment 20: HFW Training Grid (Pg. 196)
e) Mechanisms are in place to identify and provide training that supports populations with specific and unique needs as needed. All HFW staff will receive annual cultural competency and humility training; client culture training; CSEC, SOGIE, and LGBTQ training; an introduction to ICWA; and Tribal engagement. All RCS staff are required to complete two (2) trainings on evidence-based practices each year.
Refer to Attachment 19: HFW Required Training (I. Cultural Awareness and Humility Pg. 192)
Refer to Attachment 5: HFW Provision of ICWA (Procedure Pg. 19-20)
Refer to Attachment 20: HFW Training Grid (Pg. 196)
9.7 Community-based Training Program
See HFW 9 for Supporting Documents
9.7 Community- Based Training Program
a) HFW Leadership will engage youth and caregivers from the Youth and Parent Advisory Boards to share their personal experiences with the Wraparound process during training sessions, including annual booster meetings. The goal is for HFW staff to hear directly from the youth and families we serve about the impact our services have had on their lives and to discuss ways to improve our service delivery. Participants may also include youth and families who have transitioned from our services.
Refer to Attachment 21: HFW Advisory Board (Youth and Parent Advisory Board Pg 198)
b) RCS, in collaboration with Santa Clara County, will develop training for our community partners, including the System of Care, to improve their understanding of the Wraparound process and enhance their participation in services. RCS plans to make this topic a regular agenda item at the Community Leadership Team meetings once they are established.
Refer to Attachment 21: HFW Advisory Board (Community Leadership Team Pg 198)
9.8 Coaching and Supervision
See HFW 9 for Supporting Documents
9.8 Coaching and Supervision
Our program is committed to maintaining a comprehensive coaching and supervision structure that ensures all staff are trained, supported, and accountable in delivering HFW services. Our approach emphasizes adherence to Wraparound values, principles, phases, and activities, while promoting family-driven, team-based, and culturally responsive practices.
a) All newly hired staff members go through a structured onboarding process and must complete Wraparound 101 training through UC Davis. They also participate in both formal and informal training to build their skills in HFW delivery before taking on independent caseloads. This includes a minimum of 16 hours of shadowing. The initial apprenticeship provides comprehensive training in Wraparound values, principles, phases, and documentation standards. It focuses on skill development in areas such as family engagement, CFT facilitation, crisis and safety planning, and individualized service coordination. Additionally, staff receive training on the proper use of flexible funds, covering relevant policies, alignment with family needs, and fiscal accountability. Applied learning is incorporated throughout the training process, involving job shadowing, field observation, supervised practice, and ongoing coaching to ensure that staff are fully prepared for independent work.
Refer to Attachment 19: HFW Required Training (Wraparound 101 Pg. 191)
Refer to Attachment 22: Onboarding Schedule (Pg. 200)
Refer to Attachment 23: HFW Flex Funds Procedure (Purpose Pg. 202)
b) The RCS HFW program ensures that all staff receive continuous coaching and reflective supervision to maintain fidelity to the Wraparound model and promote ongoing professional development. The program offers comprehensive coaching and supervision through various methods to ensure alignment with Wraparound principles. Staff members participate in weekly individual supervision sessions that focus on case review, skill development, and reflective practice. Additionally, biweekly group supervision and multidisciplinary team consultations provide structured opportunities for case discussions, peer learning, and collaborative problem-solving. Community-based coaching includes direct observation of staff during CFT meetings and family interactions, offering immediate feedback to enhance their skills. Furthermore, HFW supervisors and Fidelity Coaches conduct ongoing fidelity monitoring using established tools, performance indicators, and documentation reviews.
To support the flexible and crisis-responsive nature of services, staff have access to coaching and supervision 24/7, including a CPM on call to provide immediate crisis support and intervention guidance. Designated supervisors and the program Director are available after hours, on weekends, and during holidays to offer real-time consultation for urgent family needs. Staff receive immediate coaching to ensure appropriate, family-centered responses and to support the implementation of crisis and safety plans. Supervisory support is also flexible, aligning with staff schedules and family availability, including coverage for non-traditional, community-based service hours.
Refer to Attachment 16: TS Supervision and Expectations Guidelines (Supervision Pg 181, Performance Review Pg. 182, and Administrative Functions Pg. 182-183)
Refer to Attachment 22: Onboarding Schedule (Pg 200-201)
Refer to Attachment 18: HFW Staff Work Schedule (Procedure C Pg 187and E Pg. 188)
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
N/A
10.2 Evaluation Metrics & Outcomes
See HFW 10 for Supporting Documents
10.2 Improved Program Practice:
RCS conducts data analysis for all its programs, including HFW, through multiple levels, starting with the Outcomes and Evaluation Committee. This committee, chaired by the Director of Quality Improvement (QI), is responsible for aggregating HFW data and reporting the outcomes to the HFW Leadership Team. Along with their findings, the Chair of the committee provides insights into areas of both strength and improvement. Based on this information, the HFW Leadership Team will develop an Action Plan, which will be reviewed monthly to ensure that the outlined steps are properly followed. The Action Plan will include strategies and tasks that address both programmatic needs (such as booster training) and staff-specific items (such as coaching and training).
a) RCS will use the data to provide timely feedback to the HFW Leadership Team on how to enhance overall service delivery. Additionally, the data will help identify training needs for both the program as a whole and for individual staff members.
Refer to Attachment 1: HFW Data and Evaluation (Evaluation Pg 6, Report & Analysis Pg 7, and Performance and Quality Improvement (CQI/PQI) Pg. 7).
b) Data obtained from the Outcome Committee’s analysis will be used to inform best practices to better serve families, while also improving the overall effectiveness of RCS’ HFW program. This will be achieved by developing an Action Plan and monitoring the strategies monthly until completion.
Refer to Attachment 1: HFW Data and Evaluation (Evaluation Pg 6, Report & Analysis, and Performance Pg. 7, and Quality Improvement (CQI/PQI) Pg. 7).
c) Additionally, if any barriers in the system are identified, particularly regarding implementation and service delivery, the RCS HFW Leadership will promptly communicate those challenges to the established Santa Clara County Community Leadership Team.
Refer to Attachment 1: HFW Data and Evaluation (Evaluation Pg 6 and Report & Analysis Pg 7).
Refer to Attachment 2: Performance and Quality Improvement Master Plan (Sections: Evaluation Methodology, Pg. 19-20, Using Data for Implementing Improvements, Pg. 20, Program and Service Delivery Effectiveness, Pg. 20, and Amendment for HFW, Pg. 22-23).
Fidelity Indicators
1.1 Timely Engagement and Planning
a) The HFW Facilitator initiates contact with the family or client as promptly as possible, via phone and/or email, and no later than ten (10) calendar days. See Program Statement SF Wraparound 04.2026, Page 3 Admissions Process, Bullet Points 2, 3, and 4.
b) The HFW Facilitator and Clinician collaboratively convene the initial Child and Family Team (CFT) meeting within thirty (30) days of service engagement. This meeting is held in partnership with the client and identified team members, including parents or caregivers, natural supports, and involved service providers. During this initial CFT meeting, the HFW team works collectively to develop the initial Wraparound Plan of Care, ensuring that services are individualized, family-driven, and responsive to the identified needs and strengths of the youth and family. See Program Statement SF Wraparound 04.2026, Page 5, Paragraph 2 and 3, Bullet Point B.
c) The HFW Facilitator coordinates and convenes the Child and Family Team (CFT) meeting no less than every 30–45 days, or as determined by the needs of the youth and family. See Program Statement SF Wraparound 04.2026, Page 5, Paragraph 3, Bullet Point D.
d) Following each CFT meeting, the HFW Facilitator is responsible for updating the Plan of Care to reflect decisions, goals, and action steps discussed during the meeting. The updated Plan of Care is distributed via email to all CFT participants and filed in the youth’s case record in a timely manner. See Program Statement SF Wraparound 04.2026, Page 5, Paragraph 3, Bullet Point D.
e) Program Leadership provides each staff member with timely feedback regarding adherence to documentation and service delivery timelines through weekly or biweekly scheduled supervision and coaching meetings. When a staff member is not meeting expected timelines, the supervisor identifies the gap, discusses contributing factors, and collaboratively develops a plan to address the area of concern. Compliance with expected timelines is monitored on an ongoing basis through case file reviews, documentation audits, and the coaching and supervision form, ensuring that accountability is structured, transparent, and tied to measurable performance expectations. See Edgewood QI Work Plan 2025-2026, Pages 6 and 7 Utilization Review. See Edgewood Wraparound High Fidelity Training Plan, Page 19 Coaching/Supervision Form.
f) When a client or family becomes unresponsive or difficult to engage, the Wraparound staff follows a multi-modal outreach strategy designed to exhaust all reasonable efforts to re-establish contact prior to considering disenrollment. Wraparound staff receive training on timely engagement strategies, including the use of alternate and creative outreach approaches when standard methods of contact are unsuccessful, ensuring that staff are equipped to respond flexibly and persistently when engagement challenges arise. Program Leadership monitors compliance with this protocol through case file documentation reviews and weekly supervision meetings, where outreach attempts and timelines are tracked, and staff receive targeted feedback and coaching to support continued engagement efforts. See FY 2025-2027 SMBHRS FSP Contract, Exhibit B, Page 23.
1.2 Led by Youth and Families
a) The HFW treatment team, including HFW Facilitators, Clinicians, Youth Specialists, Family Partners, and Leadership, centers the perspective of the youth and family at every stage of service delivery, from initial assessment through transition and discharge. This commitment to family voice and choice is embedded in all aspects of practice, including CFT meetings, Plan of Care development, and ongoing service coordination. See Program Statement SF Wraparound, Page 4 Treatment Approach, Paragraph 1.
b) Wraparound staff members, including HFW Facilitator, Clinician, Youth Specialists, and Family Partners gather comprehensive information about each family’s values, culture, strengths, and interests beginning at the point of initial assessment. See CFT Plan of Care, Page 1.
c) Leadership routinely observes weekly team meetings and reviews whether family-driven practices are consistently reflected in staff’s direct service work. Leadership provides weekly coaching and/or supervision to support meeting practice expectations, build skills, and increase confidence in staff. See Edgewood Wraparound High Fidelity Training Plan Page 19 Coaching/Supervision Form.
d) Our Wraparound staff routinely gathers feedback from the client and/or the family on an annual basis using the WFI. See WFI All Surveys.
1.3 Strength-Based
a) At each HFW team meeting, HFW Facilitators elicit identified strengths with the HFW team which is documented on their Plan of Care, distributed to all HFW team members, and added to the client chart. See CFT Plan of Care, Page 1.
b) At each CFT meeting, the HFW Facilitator encourages all HFW team members to review and provide strengths, including but is not limited to the IP-CANS, which is added to the Plan of Care. See CFT Plan of Care, Page 1.
c) Staff receive ongoing training, weekly supervision, and coaching in providing strengths-based, solution-focused services. Staff complete mandatory strengths-based training during on-boarding and are also provided with ongoing trainings and access to booster trainings specific to HFW through UC Davis. See Edgewood Wraparound High Fidelity Training Plan, Appendix A, Page 8-10 and Page 19 Coaching/Supervision Form.
d) Our Wraparound staff routinely gathers feedback from the client and/or the family on an annual basis using the WFI. See WFI All Surveys.
1.4 Needs Driven
a) During the assessment phase, first 30 days of engagement, the HFW Facilitator and Wraparound staff elicit client and/or family feedback to identify and review the client/family’s needs and are documented on the Plan of Care. See CFT Plan of Care, Page 1.
b) Staff receive ongoing training, weekly supervision, and coaching to support client and family need identification. Staff training during on-boarding and are also provided with ongoing trainings and access to booster training specific to HFW through UC Davis. See Edgewood Wraparound High Fidelity Training Plan, Appendix A, Page 8-10 and Page 19 Coaching/Supervision Form.
c) During CFT meetings, the HFW Facilitator actively encourages all HFW team to share needs, including but not limited to the IP-CANS, which is documented in the CFT Plan of Care. See CFT Plan of Care, Page 1
d) When the full HFW team reaches consensus that goals and needs have been met and transition is appropriate, the HFW Facilitator coordinates the development of a discharge Safety Plan, updates the Plan of Care, and the HFW Clinician presents a formal step-down plan to county partners prior to discharge to ensure alignment, continuity of care, and a supported transition out of the program. See CFT Plan of Care. See Wrap CFT Completed Action Steps. See Youth Transfer Discharge Note DSM 5.
1.5 Individualized
a) Client/Family resources and plans of care are individualized based on client/family voice and choice. The plan of care serves as a living document that is reviewed prior to each CFT and updated after each CFT in collaboration with the client, family, natural supports, external providers, and the HFW treatment team, which allows for flexibility to create an individualized and curated plan for each client and/or family. See CFT Plan of Care.
b) Staff receive ongoing support through weekly supervision, group supervision, and participate in provider meetings to brainstorm individualized services and strategies. Staff also complete annual training courses that encourage flexibility and creative solutions to individualize services for each of their clients. See Edgewood Wraparound High Fidelity Training Plan, Page 8-10 Appendix A and Page 19 Coaching/Supervision Form.
c) HFW Facilitators and staff will receive annual training internally and through the UC Davis Wraparound training offerings to support the HFW team to customize the HFW process and the HFW plan of care. See Edgewood Wraparound High Fidelity Training Plan, Page 7 2026 Training Implementation Plan, Phase 5.
d) The Wraparound Facilitator reviews the Plan of Care with internal Wraparound staff in preparation for each Child and Family Team (CFT) meeting, which is convened no less than every 30–45 days. During the CFT meeting, the Plan of Care is reviewed and updated collaboratively with the youth, family, external service providers, and natural supports to ensure that goals, strategies, and action steps remain current, relevant, and reflective of the family’s evolving needs and priorities. See CFT Plan of Care.
e) Our Wraparound staff routinely gathers feedback from the client and/or the family on an annual basis using the WFI. Results are reviewed as a team for continuous quality improvement. See WFI All Surveys.
1.6 Use of Natural and Community Based Supports
a) During the intake process, the HFW Facilitator develops a comprehensive provider contact list by actively eliciting information from the youth and family regarding their existing external service providers, natural supports, and community connections. Concurrently, the HFW treatment team, constructs a genogram to systematically identify and map additional natural supports within the client’s family and broader community network. See Provider Contact List. See Genogram Template
b) Staff receive ongoing support through weekly supervision, group supervision, and participate in biweekly provider meetings to brainstorm the integration of natural and community supports. Staff also complete annual training courses that the identification, engagement, and integration of natural supports to create sustainable practices and decrease reliance on formal supports. See Edgewood Wraparound High Fidelity Training Plan, Appendix A, Page. 8-10.
c) Prior to each CFT meeting, Wraparound staff review the Plan of Care to assess whether natural and community-based supports are actively engaged and whether opportunities to expand the family’s support network exist. During the CFT meeting, strategies are collaboratively developed with the youth, family, and natural supports with deliberate emphasis on sustainable, community-centered resources. See Genogram Template. See CFT Plan of Care.
d) Our Wraparound staff routinely gathers feedback from the client and/or the family on an annual basis using the WFI. Results are reviewed as a team for continuous quality improvement. See WFI All Surveys.
1.7 Culturally Respectful and Relevant
a) Upon intake, the HFW treatment team is provided with a completed IP-CANS and/or CANS 50, which includes the youth and family’s strengths, needs, and culture inventory. See CANS Assessment 5-20. Strengths, needs, and culture are further assessed by the HFW treatment team, HFW Facilitator, Family Partner, Family Support Specialist, and Clinician and the Clinician consolidates and integrates the information into the initial clinical assessment and treatment plan, while the HFW Facilitator incorporates the information into the client’s Plan of Care. See Youth Assessment Redacted.
b) All HFW treatment staff receive ongoing support through weekly supervision, participate in biweekly provider meetings, and mandated annual training to integrate culturally respectful and relevant strategies in their work with their clients and meet the county standards for diversity, equity, and inclusion. See Edgewood Wraparound High Fidelity Training Plan, Appendix A, Page 8-10 and Page 19 Coaching/Supervision Form.
c) Our Wraparound staff routinely gathers feedback from the client and/or the family on an annual basis using the WFI. Results are reviewed as a team for continuous quality improvement. See WFI All Surveys.
1.8 High-Quality Team Planning and Problem Solving
a) The HFW Facilitator establishes and upholds group agreements as a standard expectation for each HFW team, consistent with agency-wide practice standards. CFT team agreements are reviewed collaboratively with the HFW team, youth, and family at the outset of every CFT. See TIS Edgewood Group Agreements. See CFT Team Agreements and Agenda.
b) Our Wraparound staff routinely gathers feedback from the client and/or the family on an annual basis using the WFI. Results are reviewed as a team for continuous quality improvement. See WFI All Surveys.
c) Each team designates time to review the results in their regularly scheduled weekly team meetings. Together the team and supervisors address strengths in service delivery and areas for improvement. Then, the team develops a plan of how to implement change, which is discussed ongoing in weekly individual and group supervisions. See Edgewood QI Work Plan 2025-2026, Page 17, Paragraphs 2-4 Consumer Satisfaction and Feedback Mechanisms.
d) The HFW Facilitator distributes the CFT Plan of Care prior to the CFT meeting to allow all team members to review the Plan of Care individually. At the CFT, the HFW treatment team reviews the HFW plans of care, develops, and evaluates the completion of action items and strategies. All updates are recorded by the HFW Facilitator on the Plan of Care and Completed Action Steps document, distributed to the team, and added to the youth chart. See CFT Plan of Care. See WRAP CFT Completed Action Steps.
1.9 Outcomes Based Process
a) In the HFW Plan of Care, the goal and need of the client/family is sectioned into behavioral action steps, an identified responsible party, and a date to be completed to create specific, measurable, and timely strategies. See CFT Plan of Care, Page 1. See WRAP CFT Completed Action Steps.
b) All completed action items are recorded by the HFW Facilitator on the Plan of Care and Completed Action Steps document, distributed to the team, and added to the youth chart. See CFT Plan of Care, Page 1. See WRAP CFT Completed Action Steps
c) The HFW Plan of Care is continuously edited based on the needs of the client and family and the unique barriers that they may face. Action items undergo a progress review every 30-45 days during the CFT with the HFW team to explore potential barriers and challenges to adjust the plan and make changes as needed. See CFT Plan of Care, Page 1.
d) IP-CANS are created and completed by the referent and provided to the Clinical Intake Coordinator in the referral packet. The IP-CANS is then distributed to the internal HFW treatment team and reviewed at least every 90 days during regularly scheduled CFT meetings with all HFW team members. If needed, the IP CANS is updated by the county referent or HFW team to reflect changes in presentation and treatment. See Client Paperwork Procedures, Page 1 Intake: Referral Period 1, and Page 3 Quarterly 8.
e) The HFW Facilitator and HFW treatment team utilize the IP-CANS as a foundational tool to assess needs, strengths, and progress. The IP-CANS does not function in isolation but rather works in conjunction with the Plan of Care and Completed Action Items document which is developed collaboratively with the active involvement of HFW team. The Plan of Care and Completed Action Items documents are reviewed every 30-45 days during the CFT to track client and family progress towards needs and goal completion. See CFT Plan of Care. See WRAP CFT Completed Action Steps.
1.10 Persistence
a) HFW teams are encouraged to keep working with youth and family when faced with setbacks or limited progress and will use trainings, individual and group supervision, bi-weekly provider meetings, CFTs, or IPRC Case Consultations to brainstorm new ways to engage with the family in collaboration with their system partners or HFW team. See Edgewood QI Work Plan 2025-2026, Page 9 Training and Education, Paragraph 3 and 4.
b) Wraparound staff receive structured support through weekly individual supervision, group supervision, provider meetings, and CFT participation. When additional support is needed between scheduled touchpoints, staff are encouraged to contact their supervisor, manager on call, or leadership team via text, call, or email. For complex cases requiring a higher level of consultation, staff may present cases during IPRC (Interagency Placement Review Committee) meetings to collaboratively identify additional services and community supports. Weekly program staff meetings provide regular updates, including information on Flex Funds requests, training opportunities, and additional support pathways, which are distributed via email by the Program Manager. See Edgewood Wraparound High Fidelity Training Plan, Page 19 Coaching/Supervision Form. See Edgewood QI Work Plan 2025-2026, Page 9 Training and Education, Paragraphs 3 and 4.
c) Annually, Wraparound staff receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision. See Edgewood Wraparound High Fidelity Training Plan, Plan 9 Review with Supervisor and Appendix A, Pages 8-10.
1.11 Transitions as a part of the Fourth Phase of HFW
a) The HFW team collaboratively create an adequate transition plan of services, which can include warm hand-offs with new service providers and successful “connectors” have been made. See Program Statement SF Wraparound 04.2026, Page 5, Paragraph 5. For system-involved youth whose eligibility may be disrupted due to dismissal of their case by the county, Wraparound Savings may be utilized to extend services for up to three months to ensure continuity of care. Approval for the use of Wraparound Savings is obtained through the MAST or IPRC process. See CFT Plan of Care. See FSP Discharge Safety Plan.
b) As discharge approaches, the HFW Facilitator coordinates closely with all parties to ensure that meaningful connections to aftercare services are established prior to discharge, providing continuity of care and reducing the risk of service gaps. These connectors may include, but are not limited to, Therapeutic Behavioral Services (TBS), outpatient mental health services, and other community-based supports tailored to the ongoing needs of the youth and family. In addition to securing formal aftercare linkages, Wraparound staff work diligently to honor the rituals, traditions, and transition activities that have proven meaningful and successful for each client and family, which may include goodbye parties, graduation ceremonies, transition scrapbooks chronicling the client’s journey through pictures and quotes, and other personalized celebratory milestones. The HFW Facilitator gathers the youth and/or family’s preferences of ways to celebrate their progress, in conjunction with Edgewood’s core belief to serve in the context of their unique family system, culture, and community. See Program Statement SF Wraparound 04.2026, Page 5, Paragraph 5 and Page 6, Paragraph 1 and 2.
Expected Outcomes
2.1 Youth and Family Satisfaction
The Wraparound Fidelity Index (WFI) Satisfaction Survey for both Youth and Caregivers is administered by Wraparound staff and is completed annually to assess the youth and family’s experience with the wraparound process. The WFI is taken by all natural supports including Tribe member participation. HFW Facilitators administer the FC-CFT Evaluation following each CFT meetings to gather real-time feedback on the quality and effectiveness of the team meeting. See WFI-EZ Youth Form 5-2-22, Pages 2-4. See FC-CFT Evaluation-11.2025.
2.2 Improved School Functioning
The HFW Facilitator completes a Partnership Assessment Form (PAF) at the start of the youth’s care in the program and a Key Event Tracking Form (KET) to record significant changes during the Youth’s care in the program and at the point of Discharge. These evaluations are estimated by the HFW Facilitator from the last 12 months, prior to admission into the program, and for current, at the point of admission into the program. See Full Service Partnership (FSP) Child PAF Form, Page 4.
2.3 Improved Functioning in the Community
Key Event Tracking (KET)TAY and Child forms are completed by the HFW Facilitator to document significant changes in a client’s status across key life domains. This provides an ongoing record of progress and any justice involvement over the course of the client’s participation in HFW. Additionally, the WFI Satisfaction Survey is administered annually by Wraparound staff and captures elements of the client’s broader experience in the program, including community engagement. See Full Service Partnership (FSP) Child KET Form, Pages 4-7. See WFI-EZ Youth Form 5-2-22, Questions B14 and B19.
2.4 Improved Interpersonal Functioning
The WFI Satisfaction Survey for Caregivers and youth is administered annually by Wraparound staff, including specific questions addressing family relationships, stress at home, and the impact of HFW services on interpersonal functioning. The Annual Consumer Perception Survey administered by Wraparound staff similarly includes family functioning questions that capture changes in relationships and home environment over the course of the client’s enrollment. See WFI-EZ Caregiver Form 5-2-22, Pages 2-4. See Annual Consumer Perception Survey Outcome Results 2024, Questions 16-26.
2.5 Increased Caregiver Confidence
The annual WFI-EZ Caregiver Form is administered by Wraparound staff, includes caregiver-specific sections that assess satisfaction with services received, the impact of those services on the family, the quality of care coordination, and caregivers’ confidence in their ability to manage future problems and access support. The Annual Consumer Perception Survey similarly includes caregiver-specific questions that evaluate the caregiver’s sense of empowerment and connectedness to community resources. See WFI-EZ Caregiver Form 5-2-22, Questions B13, B18-B25. See Annual Consumer Perception Survey Outcome Results 2024, Questions 16-26.
2.6 Stable and Least Restrictive Living Environment
Placement stability is evaluated through the KET Form for both TAY and Child, which is completed by the HFW Facilitator any time there is a disruption in service or a change in a client’s living situation. Edgewood plans to integrate KET forms into our EHR, currently we receive an external report from our contracts to evaluate client trends. See Full Service Partnership (FSP) Child KET Form, Pages 2-3.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
The Partnership Assessment Form (PAF) for TAY and youth is completed by the HFW Facilitator during intake to establish a baseline of the client’s status. TAY and Child KET forms, as well as SIRs are completed by Wraparound staff document hospitalizations and emergency interventions as they occur throughout enrollment. Data is reviewed through quarterly reports discussed in the Directors’ team meetings and within HFW team meetings to address identified trends. See Full Service Partnership (FSP) TAY PAF Form, Questions 12-14. See Full Service Partnership (FSP) Child KET Form, Page 3, Questions 8-9. See Redacted SIR Welligent.
2.8 Reduction in Crisis Visits
Serious Incident Reports (SIRs) are completed in Edgewood’s EHR by Wraparound staff any time an event threatens the health or safety of a client, capturing a detailed account of the incident. TAY and Child KET forms are completed alongside SIRs to document any resulting changes in service or program involvement, maintaining an updated record of the client’s status following a crisis event. See Redacted SIR Welligent. See Full Service Partnership (FSP) Child KET Form.
2.9 Positive Exit from HFW
The Discharge Information of a client is completed in the EHR at the close of each case. A Discharge Survey is administered by the HFW Facilitator to gather structured feedback at the point of discharge. See Discharge Summary Note. See Discharge Survey 08.2021, Page 1. Progress towards treatment and stabilized discharge is monitored at each CFT meeting by all Wraparound team members and takes place at least every 30-45 days or as often as needed. See CFT Plan of Care.
Engagement
3.1 Orientation
a) Upon intake into the program, the HFW Facilitator leads a structured orientation with the client, family, and natural supports to introduce the Wraparound model, establish expectations, and ensure that all participants have a clear understanding of the program’s purpose, processes, and their role within the CFT. The HFW Facilitator gathers the youth and/or family’s preferences of ways to celebrate their progress, in conjunction with Edgewood’s core belief to serve in the context of their unique family system, culture, and community. Program Leadership monitors adherence to this standard through case file reviews and supervision meetings, where documentation of the intake orientation is reviewed to verify that it is completed consistently and in alignment with program expectations. See Wraparound Orientation, Pages 1-3. See Program Statement SF Wraparound 04.2026, Page 6, Paragraph 2 Program Service Components. See ECCF Privacy Notice, Pages 1-5.
3.2 Safety and Crisis stabilization
a) During the Orientation, the Clinician assesses safety and crisis using the Initial Screen. See Initial Screen, Pages 3-8. When the evaluation of risk is completed, the corresponding Plan Intervention is completed. See SM MH Risk Assessment, Pages 1 and 2, Step 7. In conjunction, the HFW Facilitator leads the initial Safety Plan in development with the client and/or family with the support of the Wraparound staff. The Safety Plan is then distributed to the family, the team, the crisis support team, and added to the client chart. See Safety Plan.
b) The HFW team member present during a crisis, will collaborate with the youth and family to develop a crisis plan that addresses the immediate safety concerns and needs of the youth and family. In conjunction, a safety plan is developed separately with the HFW team and serves as a living document, which is updated any time a safety concern is expressed, ensuring that it remains current, relevant, and responsive to the evolving circumstances of the youth and family. See SM MH Risk Assessment. See Safety Plan.
c) During the Orientation process, the HFW Facilitator provides information to the client and family regarding how to access the after-hours support team and their contact information. The HFW treatment team also reviews the process of accessing after-hours support with the client and/or family as needed. See Crisis Line Brochure.
3.3 Strengths, Needs, Culture and Vision Discovery
a) During the Child and Family Team meeting, the HFW Facilitator guides conversation and discussion with the HFW team to identify strengths, needs, culture, and signs of success for a better future and is documented on the client’s Plan of Care and added to the youth’s chart. Some information is gathered from the IP-CANS or CANS-50 to identify potential strengths, needs and aspects of culture that may be impacting the client and/or family and is brought into the conversation during the CFT. See CFT Plan of Care. See CANS Assessment 5-20, Pages 1-5.
b) The HFW Facilitator reviews and updates the Plan of Care every 30-45 days or as often as needed during the CFT with the input from the HFW team and client and/or family, which includes the identified strengths, needs, and cultural implications. See CFT Plan of Care, Page 1 Strengths and Worries.
3.4 Engage All Team Members
a) Beginning at the onset of HFW services, the HFW Facilitator and Wraparound staff gather information of all natural and community supports and formal providers from (school, physical health, mental health providers, etc.) and the HFW facilitator compiles the information on a Provider Contact List. See Provider Contact List, Rows 3 and 6 Family Members and Community Contacts. In conjunction, a genogram is created by Wraparound Staff that serves as a living document and is updated throughout the course of treatment when new natural support systems are identified by Wraparound staff. See Genogram Template.
b) Beginning at the onset of HFW services, the HFW Facilitator and Wraparound staff gather information of all natural and community supports and formal providers from (school, physical health, mental health providers, etc.) and compiles the information on a Provider Contact List. All formal providers, family members, and natural supports are invited by the HFW facilitator to each CFT with preference given to the client and family’s voice and choice of inclusion. See Provider Contact List, Rows 4, 5, 7, and 8.
c) During the Orientation and CFTs, Wraparound staff begins to identify natural and formal supports with the client and their family and continues to engage in conversations throughout the phases of Wraparound to identify and engage new natural supports and their role on the team. All natural supports and formal providers are added to the Provider Contact List and Genogram, which are added to the client chart. See Program Statement SAYFE 04.2026, Page 5, Paragraph 3.
d) The HFW Facilitator and Wraparound staff actively engage all members of the HFW team by inviting them to collaborate through CFT meetings, provider meetings, and individually scheduled meetings designed to strengthen participation and team cohesion. During these meetings, staff utilize targeted interventions to encourage the meaningful inclusion of all team members, ensuring that each participant has an opportunity to contribute to planning and decision-making in alignment with the collaborative principles of the Wraparound model. The Wraparound staff documents engagement and team building activities in case documentation and attendance sheets, ensuring that participation and the content of these activities are accurately recorded as part of the youth and family’s case record. See CFT Plan of Care.
3.5 Arrange Meeting Logistics
a) HFW Edgewood staff maintain flexible working hours to ensure that services are accessible and responsive to the scheduling needs of the clients and families they serve. This flexibility allows staff to conduct CFT meetings, home visits, and other service activities at times and places that are most convenient and feasible for the youth and family, reducing barriers to engagement and supporting consistent participation in the program. See Program Statement SAYFE 04.2026, Page 4, Paragraph 6 Service Delivery.
b) HFW Edgewood staff work collaboratively with the client, family, natural supports, and external system providers to schedule CFT meetings and other service activities at times that are accessible, convenient, and aligned with the preferences and needs of the youth and family. This collaborative scheduling process reinforces the program’s commitment to family voice and choice and reduces barriers to consistent engagement across all CFT participants. See Program Statement SAYFE 04.2026, Page 5, Paragraphs 1 and 2 Treatment Approach.
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
a) Prior to the development of the Plan of Care, the HFW Facilitator reviews Edgewood’s TIS Group Agreements with the team to establish shared meeting values and principles, which are documented in the youth’s chart. HFW Facilitators elicit identified strengths with the HFW team which is then documented on their Plan of Care. See CFT Plan of Care. See TIS Edgewood Group Agreements.
b) Before the Plan of Care is developed, the HFW Facilitator encourages all HFW team members to review and provide strengths, including but is not limited to the IP-CANS, which is added to the Plan of Care. See CFT Plan of Care. Moving forward at each CFT meeting, the HFW Facilitator reviews and updates the Plan of Care to reflect any additionally discovered strengths and current client needs, with the updated document added to the youth’s chart. The CANS is used to assess and inform the client’s strengths and needs. See Edgewood QI Work Plan 2025-2026, Page 7, Evaluation and Outcomes. See CANS Assessment 5-20, Pages 3 and 4.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
a) During the first phase of Wraparound, the HFW Facilitator guides the team in identifying and prioritizing urgent needs. Upon intake, the HFW Facilitator completes the CANS to assess client needs and strengths prior to plan development. See Edgewood QI Work Plan 2025-2026, Page 7 Evaluation and Outcomes. See CANS Assessment 5-20, Pages 3 and 4.
b) In phase two of Wraparound, the HFW Facilitator collaboratively develops goals with the team, establishing measurable markers of successful outcomes and the steps to achieve them, including HFW team and natural support involvement. See CFT Plan of Care. See Edgewood QI Work Plan 2025-2026, Pages 11 and 12 Coordination with Other Providers.
c) The HFW Team develops goals, included in the Plan of Care, collaboratively with the youth and family during CFT meetings. The document describes a Family Conference (FC) the equivalent of a CFT. See Edgewood QI Work Plan 2025-2026, Pages 11 and 12 Coordination with Other Providers.
d) The HFW team documents multiple individualized strategies in the client’s chart through the CFT Action Plan. See CFT Plan of Care.
e) HFW Facilitator internal and external training, weekly individual supervision, group supervision including training on their role within team and treatment planning. See Edgewood Wraparound High Fidelity Training Plan, Page 4, Row 1, Bullet Points 3, 4, 8, and 12.
f) The HFW Team carries out these steps collaboratively during CFT meetings in development of each client’s individualized Plan of Care. All program statements detail CFT meeting intentions to individualize plans based on HFW principles. See Program Statement SF Wraparound 04.2026, p.5 section D. See Program Statement SAYFE 04.2026, p.5. See Program Statement TAY FSP 04.2026, p.5 paragraph 3. See Program Statement Turning Point CY 04.2026, p. 6.
4.3 Develop an Individualized Child or Youth and Family Plan
a) HFW Facilitators receive quarterly and annual mandated training on facilitator development. Additionally, HFW Facilitators receive weekly individual supervision for specialized support and group supervision for collaborative support. See Edgewood Wraparound High Fidelity Training Plan, Pages 2, 3 and 4 Section 3 and Page 7, Rows 1 and 3.
b) The Plan of Care includes comprehensive documentation of needs, strategies and goals, markers of success, strengths, satisfactory progress, documentation of responsible parties, and action items. Action items can vary across multiple life domains including housing, education, safety, and, if applicable, System of Care Partners for system involved youth. Action items addressing needs within varying life domains can include funding such as Flex Funds. See CFT Plan of Care. See Flex Funds Policy and Request Form, Page 1.
c) The HFW Facilitator documents the Plan of Care in the youth’s chart as often as CFT meetings are held, making it available to all HFW team members. The plan is created following CFT principles and practices, included in all Wraparound program statements. See Program Statement SAYFE 04.2026, Page 5, Paragraphs 2-6 Treatment Approach.
d) During the Plan of Care approval process, HFW Staff receive feedback through individual supervision with the Fidelity Coach and collaboratively in group supervision. To ensure continuous quality improvement and facilitator development, Edgewood’s QM department conducts internal monitoring and auditing, as well as chart reviews. See Edgewood Wraparound High Fidelity Training Plan Page 5, Section 4 Coaching and Supervision. See Edgewood QI Work Plan 2025-2026 Page 13, Paragraph 5 Conducting Internal Monitoring and Auditing, Page 15, Paragraph 2.
4.4 Develop a Crisis and Safety Plan
a) The HFW Facilitator collaboratively develops an individualized plan with the client and team during the intake process, which is then uploaded to our EHR and shared with the crisis response team. See TPCY Safety Plan. See Client Paperwork Procedures.
b) The Plan of Care is developed by the HFW Facilitator during intake with the client and present natural supports. The plan is a living document throughout the duration of services. Facilitators are trained in leading the crisis and safety planning process through supervision and in collaboration with our Crisis Team. See Edgewood Wraparound High Fidelity Training Plan, Page 4, Row 1, Bullet Point 9 and Page 5, Bullet Point 2. See Program Statement TAY FSP 04.2026, Page 5 Treatment Approach.
c) The HFW Facilitator reviews and updates safety plans with natural support input during CFT meetings. Safety plans are regularly reviewed by supervisors and evaluated in alignment with program values to ensure individualization, cultural relevancy, and proactive and reactive strategy progression. See Program Statement TAY FSP 04.2026, Page 5 Treatment Approach. See Edgewood QI Work Plan 2025-2026, Pages 11 and 12 Coordination with Providers.
Implementation
5.1 Implement The Plan of Care
a) The HFW facilitator leads the team in reviewing and implementing the Plan of Care at each CFT meeting at least every 30-45 days or as often as needed. They assist the team in establishing an agenda at the start of each meeting, starting with the family first and allowing the family to guide the priorities of the meeting topics. When needs or action items are identified, they are assigned to the most appropriate member of the HFW team while utilizing natural supports to the family as often as possible. In review of the Plan of Care, updates are provided for each action item and when completed they are celebrated and documented on the teams completed action steps. When barriers or adjustments to the plan arise or are needed, the team works collaboratively to problem-solve and find alternative solutions. See CFT Plan of Care.
b) HFW Staff receive internal and external training and coaching on implementing the Plan of Care and respectful celebrations. See Edgewood Wraparound High Fidelity Training Plan, Page 2, Section 2 Initial Training and Orientation, Paragraph 3 and Page 4, Row 1 Wraparound Care Coordinators, Bullet Points 4 and 6.
5.2 Review and Update The Plan of Care
a) The HFW Facilitator reviews the Plan of Care within the HFW team meeting, using the Plan of Care and CFT Team Agreements in establishing the agenda. This review includes needs, strategies and goals, markers of success, strengths, satisfactory progress, and action items or revisions to action items, with forms updated as client needs evolve. See CFT Plan of Care. See CFT Team Agreements and Agenda.
b) The HFW Facilitator leads the HFW team in reviewing and updating the Plan of Care including documentation of new needs, successes, and new strategies. Changes are documented in the Youth’s file within Edgewood’s EHR. See CFT Plan of Care.
c) The HFW Facilitator utilizes the Plan of Care to document attendance and responsible parties for identified needs and strategies. Identified needs and strategies may include, but are not limited to, use of formal and natural supports, funding streams such as flex funds, and additional information/topics related to the treatment progress. The HFW Facilitator is responsible for the documentation of these changes within the Plan of Care and for uploading the updated Plan of Care to the Youth’s chart within Edgewood’s EHR. This chart is available to the HFW Team, including those not present at the meeting. If flex funds are identified as a need or strategy, the HFW Team will submit a Flex Funds Request Form to HFW Program Leadership for approval. See CFT Plan of Care. See Flex Fund Policy and Request Form Page 2.
d) The HFW Team reviews the Plan of Care at the beginning of each CFT meeting at least every 30-45 days or as often as needed, serving as a living document and is individualized to the client’s needs and culture throughout the course of treatment. Additional living documents such as the Safety Plan are reviewed at this time. See Edgewood QI Work Plan 2025-2026, Page 12, Paragraph 1.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
a) The HFW Facilitator presents the CFT Team Agreements at the onset of the HFW process and reviews the team agreements at the start of every HFW team meeting. See CFT Team Agreements and Agenda. Additionally, Edgewood utilizes Trauma Informed System (TIS) Group Agreements during all internal HFW staff meetings. See TIS Edgewood Group Agreements.
b) HFW Facilitators receive quarterly and annual internal and external booster trainings. These ongoing trainings include team planning on eliciting multiple perspectives, building trust and vision, and demonstration of HFW principles. See Edgewood Wraparound High Fidelity Training Plan, Page 3 Booster and Ongoing Trainings, and Page 4, Row 1, Bullet Points 4 and 8.
c) The HFW Team identifies natural supports and monitors needs for development over time, documenting changes to natural supports in the Plan of Care. Group and Individual supervision address the use of natural supports in the treatment process. See CFT Plan of Care. See Edgewood Wraparound High Fidelity Training Plan, Page 5 Group and Individual Supervision.
d) The HFW Facilitator orients the new member to the client and team, providing background and meeting direction. See CFT Team Agreements. See CFT Plan of Care. New HFW team members undergo onboarding and ongoing training. See Edgewood High Fidelity Training Plan, Pages 2 and 4.
Transition
6.1 Develop a Transition Plan
a) The HFW Facilitator will lead a discussion during provider meetings and CFTs to discuss client and/or family progress and assess for readiness to transition to a different level of care based on benchmarks and goals from the Plan of Care and completed plan of care action steps. See CFT Plan of Care, Page 1, Section Goal 1.
b) When a change in care is indicated, the HFW Facilitator facilitates discussion with the HFW team through a combination of individual calls to providers, collaboration during the provider meetings, and Child and Family Team meetings to create an individualized transition plan by identifying continued needs, access and level of appropriate services, and support. Wraparound Program Leadership monitors adherence to this process through case file reviews and supervision meetings, where documentation of transition discussions and Safety Plan development is tracked. See FSP Discharge Safety Plan.
c) HFW Facilitator and Clinician will complete the appropriate discharge paperwork in collaboration with the HFW team. The Clinician will consolidate the gathered information and include this in the youth’s discharge summary, which includes recommended referrals and services. See Discharge Summary Note, Bullet Point 15 Prognosis and recommendations/referrals made. The Edgewood HFW provider team receives annual training on the transition process and coaching and supervision is available as needed. See Edgewood Wraparound High Fidelity Training Plan, Pages 8, 9, and 10, Appendix A New Hire Onboarding Checklist.
d) The HFW Edgewood staff creates a discharge safety plan, which includes formal support and resources the youth and family can access past formal HFW, and provides this to the family upon discharge. See FSP Discharge Safety Plan, Page 3 People Who Can Help.
6.2 Develop a Post-Transition Safety Plan
a) Upon discharge, The HFW Facilitator or other HFW Edgewood staff will collaborate to reach an updated crisis and safety discharge plan and review the this with the youth and/or family and identify potential crisis situations that may occur after transition and include strategies that can be utilized past HFW services and emphasizing both formal and informal supports. See FSP Discharge Safety Plan, Pages 1 and 2 When I May Need Support, and Page 3, People Who Can Help Me.
b) When a change in care is indicated, the HFW Facilitator collaborates with the HFW team through a combination of individual calls to providers, provider meetings, and Child and Family Team meetings to create a crisis and safety transition plan. See FSP Discharge Safety Plan. The Edgewood HFW provider team receives annual training on the transition process and coaching and supervision is available as needed. See Edgewood Wraparound High Fidelity Training Plan, Pages 8, 9, and 10, Appendix A New Hire Onboarding Checklist.
c) Crisis and safety plans are reviewed by the Edgewood HFW team every 6 months and as needed when safety concerns arise during treatment in provider meetings, CFTs, and individual calls. See TPCY Safety Plan. See SM MH Risk Assessment.
6.3 Create a Commencement and Celebrate Success
a) If the youth and/or family have completed their goals and have agreed to transition out of HFW services, the HFW Facilitator coordinates with the HFW team, and youth and/or family to schedule a transition ceremony. Prior to the transition ceremony the HFW Facilitator gathers the youth and/or family’s preferences of ways to celebrate their progress, in conjunction with Edgewood’s core belief to serve in the context of their unique family system, culture, and community. See Program Statement SF Wraparound 04.2026, Page 6, Paragraph 2 Program Service Components. During the transition celebration, the youth and/or family are given a “Certificate of Completion”. See Client Graduation Certificate.
b) Wraparound Program Leadership encourages Wraparound Staff to attend celebratory events in support of client success. See Program Statement SF Wraparound, Page 6, Paragraph 1.
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
a) In conjunction with the Community Leadership Team, our High Fidelity Wraparound programs implement the following mechanisms for families to participate in decisions regarding local HFW implementation; Grievances, Consumer Perception Surveys, the WFI, and the sharing of our Strategic Plan which acts as master-CQI plan and is a public document accessible by all clients. See Edgewood QI Work Plan 2025-2026, Page 15, Grievances Paragraphs 4 and 5 and Page 16, Paragraphs 1-3 Paragraphs 1 and 2; Page 17, Consumer Satisfaction Paragraph 2 and Feedback Mechanisms Bullet Point 3; and Roles and Responsibilities Page 4, Paragraph 3.
b) Our Agency utilizes the mechanisms mentioned above (Grievances, Consumer Satisfaction Surveys, the WFI, and the sharing of our Strategic Plan) to implement family feedback in the decision making of service planning and implementation, policy and procedure development, workforce development and quality improvement and on a discussion related to family feedback are further discussed in Coaching and Supervision with each HFW provider to ensure service delivery is meeting the needs of the family. See Edgewood Wraparound High Fidelity Training Plan Page 5, Paragraph 2, Bullet Point 7.
7.2 Community Leadership Team
a) Wraparound Program Leadership actively participates on the Community Leadership team. See Program Statement TAY FSP 04.2026, Page 1, Paragraph 4.
7.3 Eligibility and Equal Access
a) Wrapround Youth meeting establish eligibility criteria, can receive Wraparound services and are not excluded based on severity or nature of needs. Wraparound Youth can qualify for Wraparound services based on various levels of severity or needs. See Program Statement SAYFE 04.2026, Page 2, Section 2 Screening and Admissions through Page 3, Paragraph 3, Bullet Point B, Sub-Bullet A.
b) Edgewood’s Wraparound Program recommended max caseload is identified as 8 cases per Wraparound Staff. See Program Statement TAY FSP 04.2026, Page 7, Paragraph 2 Evidence Based Practices.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
a) Edgewood’s Wraparound Programs provide high fidelity direct services and supports that are individualized to meet the immediate needs of each youth and family served. Rooted in the Full Service Partnership mission, all work is guided by the core belief that children, youth, and families are best served within the context of their unique family system, culture, and community. See Program Statement SAYFE 04.2026, Page 2, Paragraphs 1 Values through 3 Program Values.
b) Edgewood’s Wraparound Program staffing includes the required roles with varying titles and equivalent functions to the corresponding Staffing Wraparound required roles. See Edgewood Center HFW Staffing Crosswalk.
c) Edgewood’s San Francisco Wraparound Program Staff utilize the WFI through contract entity and Edgewood plans to utilize the DART that will be administered through UC Davis HFW credentialing. See Program Statement SF Wraparound 04.2026, Page 6, Paragraph 4 Data Management Systems.
8.2 Equitable Funding Across System Partners
8.3 Cost Savings are Reinvested
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
a) Flexible funds are available for our HFW Programs as a key component of our services include the availability of flexible funds which can be used to cover the cost of a range of expenses to support the treatment goals of the youth, emerging adult and/or their family. See Flex Funds Policy and Request Form, Page 1, Paragraph 2.
b) The Wraparound Flex Funds Policy details Flex Funds requests/appeals will be reviewed within 3-5 business and must meet the eligibility criteria defined in our Flex Funds Policy. See Flex Funds Policy and Request Form, Page 1, Policy Paragraphs 1 through 5 and Paragraph 7 Procedure, Bullet Point 3, Sub-Bullet A.
8.5 Collaborative Oversight of Flex Funds
a) Funders and Providers maintain access to view our Wraparound Flex Funds Policy and Request form for clear documentation of use and eligibility. All Flex Funds purchases are recorded, accompanied by a Flex Funds Request Form, and provided to our Agency Finance Department for reporting to County Providers and Funders on a monthly basis. The Flex Funds Request Form provides ability to clearly document the purpose of the request, eligibility for Flex Funds use, and total approved to be allocated by Flex Funds along with Family Contribution. See Flex Funds Policy and Request Form, Page 2.
b) Wraparound programs pool Flex Funds and contracts and budgets are created to meet the needs of all clients/families enrolled in Wrapround programs. See Flex Funds Policy and Request Form, Page 1, Paragraph 2 Policy.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
a) Flex Funds are funded through contracting entities. Availability of flexible funding is built into the contract. See FY 2025-2027 SMBHRS FSP Contract, Page26, Bullet Point IV, Paragraph 2, and Page 27, Bullet Point J, Sub-Bullet A, and Page 28, Bullet Point K, Sub-Bullet A.
b) If limitations in a single funding source arise, Edgewood’s Wraparound Programs would request the contracting entity to increase access to funding sources made available through the contracting entity, such as flex funds. FY 2025-2027 SMBHRS FSP Contract, Page 25, Bullet Point C, Third Level-Bullet i.
c) Edgewood’s HFW Programs’ contract entities describe qualifying flex funds expenses as expenses corresponding to the specific wellness and recovery goals of clients. The requirements pertaining to any funding force received by any youth/family do not prohibit the youth/family from accessing flex funds, should the need of the youth/family qualify for flex funds based off qualifying purchases, as described by the contracting entity. FY 2025-2027 SMBHRS FSP Contract, Page 25, Bullet Point 20 Flexible Funding, Sub-Bullet B, Third Level-Bullet i and ii.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
a) Edgewood monitors demographic composition of population served through demographic reporting captured at the point of enrollment. See Edgewood QI Work Plan 2025-2026, Page 13, Paragraph 4 Information Technology. See Client Demographic Form. Edgewood maintains a culturally responsive workforce and is dedicated to embedding trauma-informed principles throughout the organization, with an approach that honors the lived experiences of both our employees and those in our care through one of our key pillars Enhancing Client Centered Care. See Edgewood Handbook 2026 Final, Page 8, Paragraphs 1 through 4.
b) The Wraparound Programs ensure cultural representation through inclusion of other system identified natural supports and the child/youth and her/his family. See Program Statement Turning Point CY 04.2026, Page 3, Paragraph 5 Admissions Process, Bullet Point 4.
c) If a preferred qualified Wraparound staff and a natural support person who can communicate directly with clients and/or family members is not available; professional face-to-face interpretation services will be secured by contract from an external provider in a timely manner. See Program Statement Turning Point CY 04.2026, Page 6, Paragraph 4 Language and Communication Needs.
9.2 Tribally Responsive Workforce
a) HFW Staff are trained on Native American Youth Mental Health along with additional compliance trainings. See Edgewood Wraparound High Fidelity Training Plan, Page 2, Paragraph 2.
b) HFW Staff are trained on the service delivery when serving a Native American child including building relationship with tribal natural supports, tactics on mitigating generational trauma impact on Native youth using Western and Indigenous approaches, interpretation of Western clinical terminology in Indigenous culture, and practice of integrating Native culture into care. See Edgewood Wraparound High Fidelity Training Plan, Page 1, Paragraph 1.
9.3 Flexible and Creative Work Environment
a) HFW Leaders maintain and improve internal quality assurance and control processes in all Wraparound programs and services through Chart Review, Utilization Review, Compliance, and Internal Monitoring and Reviewing. See EDGE Manual – 2026_03, Pages 12 and 13.
b) Edgewood’s Workplace Conduct Policy includes maintaining a positive work environment and HFW Leadership promotes this positive work environment through team culture development opportunities. See Edgewood Handbook 2026 Final, Page 46, Paragraph 1. See How to Build a Healthy, Equitable, and Joyful Team Culture Survey FY25_26.
c) In order to ensure open lines of communication, HFW Leadership maintains an open-door policy and encourages staff to ask for clarification and remain curious about processes they may not understand. See EDGE Manual – 2026_03, Page 14, Paragraph 5.
d) HFW Leadership emphasizes the importance of the Wraparound Program Values through Compliance Trainings at the point of New Hire and Annually along with Program Statements detailing the 10 Principles of HFW. See Program Statement Turning Point CY 04.2026, Page 1, Paragraph 5-7 and Page 2, Paragraphs 1 through 3.
9.4 Hiring, Performance Evaluation, and Job Descriptions
a) The HFW Staffing is fulfilled within the Wraparound Programs through various roles and varying titles. See Edgewood Center HFW Staffing Crosswalk.
b) The Wraparound Program role descriptions include Edgewood’s agency description, program description, position description, core and essential functions, and applied knowledge, skills, and abilities. See TAY FSP Family Partner Employee Job Description.
c) All Wraparound job descriptions include Applied Skills, Knowledge, and Abilities in correspondence with HFW Staffing. See TAY FSP Family Partner Employee Job Description, Page 3, Paragraph 7 Applied Skills, Knowledge, and Abilities.
d) During the interview process, candidates for Wraparound positions are presented with several questions from role specific to scenarios regarding specific attitudes and skills essential to the position. See TAY FSP Case Manager Interview Questions, Pages 1 and 2, Paragraph 2 Position Related Questions and Paragraph 3 Scenario Prompts/Questions.
e) Edgewood HFW Leadership utilizes structured hiring practices, clearly defined job roles, and ongoing performance evaluation processes to ensure staff effectiveness and accountability. See Edgewood Handbook 2026 FINAL, Page 29, Paragraphs 1, 2, and 3.
9.5 Workforce Stability
a) Edgewood’s People and Culture Department has implemented opportunities Salary Advances to provide Staff with the opportunity to offset cost of living within San Mateo and San Francisco counties. See Edgewood Handbook 2026 FINAL, Page 28, Paragraph 5 Salary Advances.
b) Edgewood’s HFW recommended max caseload is identified as 8 cases per Wraparound Staff. See Program Statement Turning Point CY 04.2026, Page 7, Paragraph 1 Practices/Curriculum used in TPCY. To support management workloads, Edgewood’s People and Culture Department implements flexible or predictable working arrangements such as a modified schedule, job-sharing arrangements, and reductions or changes in work duties. See Edgewood Handbook 2026 FINAL, Page 28, Paragraph 1.
c) Edgewood identifies one of our key pillars as Advancing Retention & Leadership Opportunities, prioritizing retention strategies to strengthen a representative, forward-looking leadership pipeline along with opportunities for promotion and transfer opportunities. See Edgewood Handbook 2026 FINAL, Page 8, Paragraph 3 Key Pillars and Page 29, Paragraph 4 Job Postings.
d) Edgewood Wraparound Staff have the opportunity to receive Merit Based Increases based on performance accomplishments assessed during performance reviews 6-months after hire and annually thereafter. Annual performance reviews include the opportunities for professional development and leadership opportunities. See Edgewood Handbook 2026 FINAL, Page 29, Paragraphs 1, 2, and 3.
9.6 High Fidelity Training Plan
a) All Wraparound Staff will receive initial HFW training externally by attending the Statewide Standardized Foundational HFW Training through UC Davis RCFFP. See Edgewood Wraparound High Fidelity Training Plan, Page 2, Section 2 Initial Training and Orientation, Paragraph 3.
b) To move beyond one-time training events and establish a continuous learning approach that builds, reinforces, and advances staff skills over time, Wraparound Staff will receive ongoing trainings including role specific responsibilities. See Edgewood Wraparound High Fidelity Training Plan, Page 3, Paragraph 3 Ongoing Trainings and Page 4, Row 1 Wraparound Care Coordinators (HFW Facilitators).
c) To ensure ongoing staff competency and fidelity to High Fidelity Wraparound (HFW), all Wraparound Staff will receive Wraparound 101 delivered annually, along with a minimum requirement of quarterly booster trainings. See Edgewood Wraparound High Fidelity Training Plan, Page 2, Section 3 Ongoing Training (Annual, Booster and Role-Specific Trainings, Paragraph 1 Annual Training and Page 3 Paragraph 2 Booster Training.
d) Clinical and HFW Supervisors and Directors will attend general Wraparound training and receive initial, ongoing, and booster trainings related to leadership roles. See Edgewood Wraparound High Fidelity Training Plan, Page 4, Row 4 Fidelity Coach, Program Managers, and Directors.
e) All Wraparound Staff receive ICWA and Tribal Sovereignty training, Native American Youth Mental Health, when working with Native American children and families. See Edgewood Wraparound High Fidelity Training Plan, Page 2, Section 2 Initial Training and Orientation, Paragraph 1.
9.7 Community-based Training Program
a) Wraparound youth, families, and Peer Partners are incorporated into the delivery of required Wraparound trainings such as Boundaries for community-based programs, Building Natural Supports and Connections, and Advocacy. See Edgewood Wraparound High Fidelity Training Plan, Page 4, Row 2.
b) To strengthen alignment, collaboration, and effectiveness within the Wraparound programs, Community Partners will be engaged through intentional training opportunities. See Edgewood Wraparound High Fidelity Training Plan, Page 5, Section 5 Community Trainings.
9.8 Coaching and Supervision
a) Wraparound Staff receive initial training, coaching, and supervision covering values, skills, and knowledge related to HFW principles, phases and activities along with training on effective use of flex funds to support family needs. See Edgewood Wraparound High Fidelity Training Plan, Page 4, Row 3, Page 5, Section 4 Coaching and Supervision, Paragraph 2, and Appendix A, Pages 8, 9, and 10 San Mateo New Hire Orientation Checklist.
b) Wraparound Staff have access to coaching and supervision 24/7 or meet a minimum of weekly/biweekly, individually and/or as a group. See Edgewood Wraparound High Fidelity Training Plan, Page 5, Section 4 Coaching and Supervision, Paragraph 1.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
a) The Wraparound Fidelity Coach and HFW Program Leadership utilize Annual Consumer Perception Survey results and Wraparound Fidelity Index (WFI) survey results as primary data sources to drive practice improvement at the direct service level. Upon collection and analysis of survey results, HFW Program Leadership facilitates a structured debriefing meeting with program staff to review findings, discuss themes, and collaboratively generate ideas for improving service delivery and the quality of care provided to youth and families. Following the debriefing, discussions related to survey results and training needs are maintained topics for Coaching and Supervision. The Coaching/Supervision Form serves as an evaluation reviewed by the Training Department, Quality Management, Human Resources, and Agency Leadership to assess training needs. This process ensures that staff receive timely, relevant feedback and have access to training directly tied to their service provision. See Edgewood QI Work Plan 2025-2026, Page 9, Paragraph 8 and Page 17, Paragraph 2. See Edgewood Wraparound High Fidelity Training Plan, Page 5, Paragraph 2, Bullet Point 7 and Page 18 Coaching/Supervision Form.
b) Edgewood’s Quality Assurance and Improvement Department maintains and monitors internal quality assurance and control processes across all programs and services, as outlined in the EDGE manual. These processes are systematically analyzed to identify program needs and areas for improvement. See EDGE Manual – 2026_03, Page 12, Paragraph 1.
c) The Community Leadership Team reviews program-level concerns and system-wide issues affecting HFW implementation utilizing data that is gathered through Consumer Perception Surveys, WFI surveys, Grievances, and census reporting. These tools are used to identify system barriers that may be impeding effective Wraparound implementation, such as gaps in services, access issues, or structural challenges that fall outside the scope of individual staff practice. Findings relevant to system-level barriers are brought forward by Program Leadership to the Community Leadership Team through regularly scheduled meetings, where they are discussed, contextualized, and addressed at a leadership level. This process ensures that data does not solely inform frontline practice but also elevates systemic issues to the appropriate decision-making body, enabling the Community Leadership Team to respond with agency-wide or cross-program solutions that support and strengthen HFW implementation. See Program Statement Turning Point CY 04.2026, Page 4, Paragraph 3.
Fidelity Indicators
1.1 Timely Engagement and Planning
a) The intake process and initial engagement meeting are completed no later than 10 calendar days from referral, consistent with county and CA HFW timelines.
Upon receipt of a referral, the Supervisor assigns the case to a High Fidelity Wraparound Facilitator, Parent Partner, and Youth Partner on the same business day or as soon as operationally feasible. Assignment is documented in the Orange County Intervention Management System (OCIMS) and communicated to the assigned team members. The Parent Partner initiates first contact with the caregiver within 72 hours of referral receipt to begin engagement, explain the Wraparound process, and schedule the intake meeting. All outreach attempts, successful contacts, and barriers to engagement are documented in OCIMS case notes. The Facilitator contacts the referring party within 72 hours to gather collateral information, clarify presenting concerns, and identify immediate safety, placement, or service needs that may affect engagement and planning.
See Core Training Day 2 page 55
Core Training Day 2 page 139
New Care Coordinator Training, page 6
b) The Facilitator coordinates the initial Child and Family Team (CFT) meeting and completes the initial Plan of Care within 30 calendar days of enrollment, using information gathered from the youth, family, team members, and the IP-CANS.
See New Care Coordinator Training page 12
OCIMS Day 2 page 2
c) CFT meetings are held at minimum every 30–45 calendar days to review progress, revise strategies, and monitor action items. See
CORE Day 3, page 7.
Facilitation training page 17, 19
d) The Plan of Care is formally updated at least every 90 calendar days, or sooner based on family need, and redistributed to all team members. See
CORE Day 3, page 7.
New Care Coordinator Training, page 16
OCIMS Day 2 page 2
Wraparound Overview page 19
e) Supervisors monitor compliance with timelines through weekly supervision, chart audits, OCIMS reports, and county QA review.
See QA Site Review Tool and Site Review Tool
Core Training Day 3 page 65-66
Core Day 1 pages 57-58
f) All staff receive initial and ongoing training on engagement and planning expectations through county core training, OCIMS training, reflective supervision, field-based coaching, and agency Professional Growth meetings to ensure compliance with required timelines and fidelity standards.
See Mandatory-Training-for-Wraparound-Staff by Role pg. 1-9
Mandatory Staff Training and Development
Wraparound OC Staff Training Development
1.2 Led by Youth and Families
a.) During the engagement phase, the Facilitator, Parent Partner, and Youth Partner utilize structured discovery conversations to elicit the youth’s and family’s voice, preferences, priorities, and vision for success. This information is used to develop the Family Vision Statement and Team Mission Statement. In cases involving an Indian youth, efforts would be made to actively engage the Tribe as an equal partner, ensuring their voice is incorporated into the Vision and Mission in alignment with cultural values and practices.
See CORE Day 3 Training – Family Vision and Team Mission, page 10-14.
OCIMS Day 2 pages 4-8
b.) The youth and family actively guide all planning and decision-making during Child and Family Team meetings, including approval of goals, strategies, and action steps within the Plan of Care. Facilitators intentionally elicit and document family values, cultural identity, lived experience, strengths and natural supports throughout the engagement and planning phases. This includes identifying traditions, beliefs, language preferences and culturally relevant practices that inform service planning. This information is clearly documented in the youth’s case file, including the Strengths, Needs and the Wraparound Plan of Care.
See New Care Coordinator Training pg. 9-11
OCIM Day 3 +4 Meetings pg.
c.) Supervisors routinely review documentation, observe meetings, and utilize fidelity tools to ensure family voice and choice remain central throughout all phases of Wraparound.
See Team Observation Tool, page 1-2.
Core Day 1 page 57-58
d.) Family feedback is routinely gathered through the Wraparound Fidelity Index (WFI), satisfaction surveys, and quality assurance calls to support continuous quality improvement.
See Wraparound Fidelity Index (WFI), page 1-6
Core Day 2 pages 57-58
1.3 Strength-Based
a.) During engagement and ongoing service delivery, the Facilitator and Parent Partner identify and document strengths of the youth, family, team members, and natural supports using structured discovery conversations and IP-CANS assessment data. Strengths are reviewed regularly during CFT meetings, updated as new strengths emerge, and intentionally incorporated into team discussions, planning, and problem-solving. The CFT maintains a solution-focused, resilience-based approach, emphasizing progress, existing capabilities, and natural support rather than deficits or challenges. This practice promotes family engagement, empowerment, cultural responsiveness, and sustainable long-term success.Parent Partners play a critical role in this process by engaging caregivers in conversations that help identify family strengths, resilience factors, prior successes, and sources of hope. Parent Partners also utilize their lived experience in a strengths-based manner, sharing their story as clinically appropriate during the first Child and Family Team (CFT) meeting to support trust-building, engagement, and hope.
See CORE Day 2 Training – page 43.
CORE Day 2 pages 142-146
b.) A comprehensive strengths inventory is developed during the Engagement Phase and includes strengths of the youth, family, team members, natural supports, and relevant community resources. Facilitators utilize structured discovery tools, including the Integrated Practice – Child and Adolescent Needs and Strengths (IP-CANS), along with ongoing engagement and discovery conversations, to identify strengths that are meaningful, actionable, and relevant to the youth and family’s daily life. Identified strengths are incorporated into the Plan of Care and are directly linked to strategies, interventions, and action steps developed by the Child and Family Team.
See Core Day 2 page 64
OCIMS Day 2 Plan of Care page 11-12
c.) Staff receive ongoing training and reflective coaching in strengths-based practice through county core training, supervision, field-based coaching, Professional Growth meetings, and monthly Wrap Institute training. Supervisors reinforce the consistent use of strengths in engagement, facilitation, documentation, and quality assurance review.
See Mandatory Trainings of Wraparound Staff by Role page 1-2
Wraparound OC Staff Training Development
d.) Family feedback is routinely gathered through satisfaction surveys, Wraparound Fidelity Index (WFI), Team Observation Tool, and quality assurance follow-up calls, and findings are used to inform staff coaching, supervision, and continuous quality improvement efforts.
See Wrap Fidelity Index page 1-12
Core Day 2 pages 57-58
QA Site Review
Site Review Tool
1.4 Needs Driven
a.) During the Engagement and Planning Phases, Facilitators work collaboratively with the youth, family, and Child and Family Team (CFT) to develop clear functional needs statements that describe the underlying reasons why problematic situations or behaviors are occurring. These needs statements are written in behaviorally relevant and functional terms and are prioritized before goals, strategies, and action steps are established, ensuring that planning is purposeful and directly aligned with what is most important to the youth and family.
See Core Day 3 pages 15-34
New Care Coordinator Training page 17
b.) Facilitators, Youth Partners and Parent Partners receive ongoing training, reflective supervision, and county coaching to strengthen their ability to develop clear needs statements and maintain fidelity to needs driven planning practices. Needs are continuously reviewed during Child and Family Team meetings and updated as circumstances change or new information is identified. Progress toward meeting prioritized needs is monitored regularly, and the team collaboratively adapts strategies until the needs have been sufficiently addressed. The team intentionally utilizes needs focused planning rather than behavior focused or service driven planning, ensuring that interventions address the underlying causes of challenges across multiple life domains.
See Core Day 3 pages 15-34
Mandatory Staff Training by Role
Wrap OC Staff Training Development
c.) Facilitators utilize structured engagement, discovery conversations, and the Integrated Practice – Child and Adolescent Needs and Strengths (IP-CANS) assessment to identify needs that reflect the root causes and underlying reasons for behaviors, family stressors, and presenting challenges, rather than focusing solely on symptoms, deficits, or service gaps. Needs identified through the IP-CANS are incorporated into the individualized Wraparound Plan of Care and directly inform all strategies, supports, and interventions. The team intentionally utilizes needs focused planning rather than behavior focused or service driven planning, ensuring that interventions address the underlying causes of challenges across multiple life domains.
See New Care Coordinator Training page 20
OCIMS Day 2 pages 11-12
d.) Transition planning is guided by the determination, made collaboratively with the youth, family, and team, that prioritized needs have been sufficiently met and that sustainable supports are in place to maintain progress after formal Wraparound services conclude.
See New Care Coordinator Training pages 30-31
Wraparound Overview pages 16,20
Core Day 1 pages 33, 41-45
1.5 Individualized
a.) Documentation supports individualized planning; Forms and documentation, including the Wraparound Plan of Care, allow for flexibility in developing customized strategies, action steps, and supports that reflect each family’s unique situation. Facilitators utilize information gathered through engagement, discovery, and ongoing collaboration with the Child and Family Team (CFT) to design strategies that are meaningful, relevant, and sustainable for each family.
See OCIMS Day 3&4 page 8
Core Day 3 pages 6-8, 45, 64-68
New Care Coordinator Training pages 15-16
b.) Facilitators, Supervisors, Youth Partners and Parent Partners, participate in ongoing training and reflective coaching to strengthen their ability to develop flexible, creative, and individualized strategies that align with Wraparound principles. Facilitators promote creativity and flexibility in problem solving, ensuring that strategies are not limited to traditional services but instead reflect what will be most effective for the youth and family.
See Mandatory Training for Staff by role
Mandatory Staff Training and Development
Wraparound OC Staff Training Development
c.) Facilitators participate in Bi monthly Professional Growth and monthly Wrap Institute training where they receive ongoing training with topics that will further enhance their skill set to provide High Fidelity Wraparound services. Ongoing training assists in developing highly individualized and creative plans of care that are tailored to the unique needs, strengths, values, culture, and preferences of each youth and family. In cases involving an Indian youth, the Tribe would be engaged as an essential partner, and cultural values and practices are integrated into the individualized plan. Individualization is an ongoing process. Plans are regularly reviewed and updated during all CFT meetings to ensure they remain aligned with the family’s evolving needs and preferences.
See Mandatory Training for Wraparound Staff by role
Mandatory Staff Training and Development
Wraparound OC Staff Training Development
d.) Supervisors regularly review Plans of Care and case documentation to ensure strategies reflect individualized strengths, address prioritized needs, reduce risk over time.and outcomes, and that they incorporate natural supports and community based resources.
See Core Day 1 pages 57-58
Wraparound Contract: Service Component, section 5B page 27
e.) Wraparound gathers feedback from families through satisfaction surveys, fidelity tools such as the Wraparound Fidelity Index (WFI) through Family Support Network (FSN) and Team Observation Tool, and quality assurance follow-up calls. Feedback is used to inform continuous quality improvement, as well as staff training and coaching.
See Wraparound Fidelity Index pages 3-15
Mandatory Staff Training and Development
Team Observation Tool
QA Site Review Tool
Site Review Tool
1.6 Use of Natural and Community Based Supports
a.)Facilitators, Parent Partners, and Youth Partners work collaboratively with youth and families to identify individuals and resources within their existing networks—such as extended family members, friends, neighbors, mentors, faith-based connections, schools, and community organizations—that can provide meaningful, culturally relevant, and sustainable support. A natural and community support inventory is developed during the Engagement and Discovery Phases and is continuously updated throughout the Wraparound process to reflect evolving relationships, newly identified resources, and changing family needs. With family consent, these supporters are actively invited to participate in CFT meetings and are encouraged to take on meaningful roles in implementing strategies, action steps, and long-term support within the Wraparound Plan of Care.
See Natural Supports draft pages 3-31
Wraparound Overview page 23
Critical Thinking pages 7-9
Core Day 1 page 17
OCIMS Day 2 pages 29-33
b.) Staff receive ongoing training and reflective coaching on identifying, engaging, and sustaining natural supports, with specific emphasis on decreasing long-term reliance on formal services and promoting community-based stability. The program intentionally emphasizes the use of community-based settings, natural supports, and informal resources to ensure that supports remain accessible and sustainable beyond formal services. Strategies within the Plan of Care are designed to maximize the use of natural supports whenever appropriate, with the goal of reducing reliance on formal systems over time while strengthening the family’s long-term support network and community connection.
See Core Day 1 page 17
OCIMS day 2 pages 29-33
Natural Supports pages 3-31
c.) Facilitators and supervisors routinely review team composition, support inventories, and Plans of Care to ensure that natural and community supports are meaningfully integrated, assigned clear roles in action steps, and aligned with the family’s voice, preferences, and needs. This is also routinely reviewed during reflective supervision and case consultation.
See Core Day 1 49-50, 57-58
Wraparound Contract 5B pages 26-27
d.) Family feedback is routinely collected through satisfaction surveys, Wraparound Fidelity Index (WFI), Team Observation Tool, and quality assurance follow-up calls, and findings are used to inform continuous quality improvement, staff coaching, and training efforts.
See Wraparound Fidelity Index pages 3-15
OCIMS Day 3&4 pages 11-12
1.7 Culturally Respectful and Relevant
a.) During engagement and planning, facilitators gather Strengths, Needs, and Culture information with each family to identify cultural values, practices, traditions, and preferences. This information informs the development of the Wraparound Plan of Care, ensuring that strategies, supports, and team engagement are aligned with the family’s cultural context. Facilitators recognize that a family’s traditions, values, and heritage are critical sources of strength and resilience, and these are intentionally integrated into the Wraparound process.
See Critical Thinking pages 7-9
Core Day 1 page 17
OCIMS day 2 pages 11-12
b.) Staff receive ongoing coaching and training. Supervisors provide reflective coaching and training to staff on eliciting and integrating family culture into planning and service delivery. Staff are trained to provide culturally respectful and relevant strategies that honor the family’s traditions, values, and heritage.In cases involving an Indian child, the Tribe would be engaged as an equal partner in planning and decision making, and culturally relevant practices and perspectives are incorporated into the Plan of Care. Facilitators also connect families with community individuals and organizations that provide ongoing, culturally relevant support, promoting sustainability after the family transitions from formal HFW services.Family voice and culture are revisited throughout the process to ensure services remain aligned with their evolving needs, values, and cultural practices.
See Wraparound Contract 4F page 25
Critical Thinking pages 7-9
Core Day 1 page 17
c.) Family feedback is routinely elicited and used for quality improvement. Families are surveyed regarding their experience with culturally respectful and relevant services using satisfaction surveys, fidelity tools such as the Wraparound Fidelity Index (WFI) and Team Observation Tool and follow-up quality assurance phone calls. Feedback is used to inform continuous quality improvement and to provide targeted coaching and supervision to staff.
See Wraparound Fidelity Index pages 3-15
OCIMS Day 3&4 pages 11-12
Team Observation Tool
1.8 High-Quality Team Planning and Problem Solving
a.) Facilitators lead the team through structured Child and Family Team meetings, utilizing tools such as meeting agendas, action forms, poster boards, and written team agreements to establish clear roles, responsibilities, expectations, and decision making processes. Teams are intentionally structured to promote shared ownership, collaborative problem solving, accountability, team commitment, and optimism, with each team member taking responsibility for assigned tasks and action steps that support the youth and family’s identified needs and goals. Facilitator ensures that Child and Family Teams (CFTs) are composed of both formal and natural supports, including youth, caregivers, extended family, community supports, and representatives from relevant system partners such as Social Services, Probation, Behavioral Health / Health Care Agency, schools, and other agencies, who work collaboratively to develop, implement, and monitor the individualized Wraparound Plan of Care.Team agreements are developed with each CFT and documented in the youth’s case file to guide how the team will work together, communicate, and resolve challenges throughout the Wraparound process. The CFT actively engages in team based planning, brainstorming, and structured problem solving to address barriers, monitor strategy effectiveness, and adjust action steps as needed. This process intentionally emphasizes multiple perspectives, family voice and choice, shared accountability, and meaningful integration of natural and community support into decision-making.
See Core Day 1 pages 49-50
Core Day 2 page 70
Core Day 1 page 26
Core Day 2 pages 76-77
b.) Feedback from youth, families, and team members regarding collaboration, team engagement, and meeting effectiveness is routinely collected through meeting observations, satisfaction surveys, Wraparound Fidelity Index (WFI), Team Observation Tool, and quality assurance follow-up calls.
See Wraparound Fidelity Index pages 3-15
OCIMS Day 3&4 pages 11-12
Team Observation Tool
c.) Findings are reviewed regularly and used to inform continuous quality improvement, staff coaching, reflective supervision, and facilitator skill development.
See Wraparound Fidelity Index pages 3-15
OCIMS Day 3&4 pages 11-12
d.) Supervisors routinely review meeting agendas, action forms, team agreements, and Plans of Care to assess shared ownership, follow through on assigned tasks, and overall team functioning. This review process supports fidelity to the High Fidelity Wraparound model and strengthens the team’s ability to effectively solve problems and achieve meaningful outcomes for youth and families.
See Core Day 1 57-58
1.9 Outcomes Based Process
1.9 a.) Our High Fidelity Wraparound (HFW) program utilizes an outcomes-based and data-informed approach to monitor progress toward meeting the youth’s and family’s prioritized needs and achieving meaningful, measurable outcomes. The Child and Family Team (CFT) routinely tracks the implementation of strategies, completion of action items, and progress toward individualized goals outlined in the Wraparound Plan of Care.
OCIMS Day 2 pages 15-16
b.) The team utilizes structured tools including Action Forms, CFT Meeting Agendas, poster boards, and the Wraparound Plan of Care to track progress and make real-time adjustments to strategies and assignments. Families are actively engaged in reviewing outcomes, identifying successes and barriers, and providing ongoing feedback, ensuring that the planning process remains collaborative, strengths-based, and responsive to changing needs.
Core Day 2 page 70
c.) Each identified need within the Plan of Care is intentionally linked to specific, measurable outcomes, strategies, action steps, responsible team members, and clear time frames, ensuring that progress is objective, quantifiable, and meaningful to the youth and family. Progress is formally reviewed during monthly Child and Family Team meetings, or more frequently as clinically indicated, and is used to inform any needed adjustments to strategies, supports, or action items.
New Care Coordinator Training pages 3-36
OCIMS Day 2 pages 1-37
d.) The Integrated Practice – Child and Adolescent Needs and Strengths (IP-CANS) assessment is completed by trained Facilitators and/or clinical staff and is shared with the full CFT to support collaborative decision-making.
OCIMS Day 2 page 11-12
Core Day 2 page 48
e.) IP-CANS data is used to monitor changes in needs, strengths, and functioning across life domains and to support ongoing team-based problem-solving and transition readiness planning. However, IP-CANS data is not used in isolation; facilitators also monitor action item completion, goal attainment, family feedback, crisis reduction, and team progress toward the Family Vision and Team Mission.Progress data and outcome trends are also reviewed during supervision and quality assurance processes to support continuous quality improvement (CQI), staff coaching, and transition planning when identified needs have been sufficiently met.
OCIMS Day 2 page 11-12
Core Day 2 page 48
1.10 Persistence
1.10 a.) Our High Fidelity Wraparound (HFW) program views setbacks, crises, and challenges not as evidence of failure by the youth or family, but as critical information that indicates a need to revise, strengthen, and individualize the Plan of Care. The Child and Family Team (CFT) remains committed to the youth and family and continues working collaboratively until identified needs have been sufficiently addressed and the family, with preference given to family voice and choice, agrees that services are ready to transition.
See Wraparound Contract pages 11, 20, 23-24
b.) The program provides clear processes for teams to access additional support when challenges arise, including reflective supervision, county coaching, community resources, flex funds, safety planning support, and consultation with system partners. Facilitators and CFTs maintain engagement, demonstrate flexibility, and utilize creative, strengths-based problem-solving strategies when progress is slow, crises occur, or barriers arise. Plans of Care, crisis plans, and action steps are routinely revisited during monthly Child and Family Team meetings—or more frequently as needed—to ensure that strategies are adapted and remain aligned with the youth’s and family’s priorities, evolving needs, and cultural preferences.
See
Wraparound OC Staff Training Development
Mandatory Staff Training and Development (Parent Partner Professional Growth, Youth Partner Professional Growth, Care Coordinator Professional Growth, Supervisor Professional Growth, Wraparound Institute)
Core Day 4 pages 8-21
c.) Facilitators receive ongoing coaching and training in post-crisis safety planning, conflict resolution, de-escalation, structured brainstorming, and ongoing plan revision, consistent with High Fidelity Wraparound principles. In addition, assigned staff are provided agency issued phones and access to 24/7 supervisory support to ensure timely response to family crises and urgent needs, reflective of the flexible scheduling and crisis response needs of youth and families. This structure supports the program’s commitment to persistence, crisis stabilization, and family-centered continuity of care.
See Facilitation Training pages 1-28
1.11 Transitions as a part of the Fourth Phase of HFW
a.) Transition planning is introduced at the onset of services and reinforced throughout all phases of the High Fidelity Wraparound (HFW) process, so that youth and families understand that formal Wraparound services are designed to build long term stability and sustainable support rather than create dependency on the program. The Child and Family Team (CFT) maintains clear communication from the beginning that transition is a purposeful and strengths based part of the Fourth Phase of HFW.
Transitions are planned well in advance and occur only when the youth, family, and team collectively determine that prioritized needs have been sufficiently met, benchmarks have been achieved, and sustainable supports are in place. Transition does not occur due to unfavorable events, placement disruptions, or administrative requirements alone. Preference is always given to family voice and choice in determining readiness for transition. Transition planning includes identifying and strengthening natural supports, community-based resources, ongoing service connections, crisis supports, and sustainable informal networks that will remain in place after HFW concludes. The team also ensures that families know how to independently access services and supports in the future.
See New Care Coordinator Training pages 30-34
Core Day 1 pages 41-45
b.) Transitions are celebrated as a Commencement and recognition of family growth, resilience, and achievement, in a manner that reflects the family’s culture, values, traditions, and preferences. Families actively co-design the transition celebration and may invite natural supports, team members, and community partners to strengthen continuity of support beyond formal services.
Administrative structures support the transition and celebration process through: access to flexible funds, allocation of staff time for community resourcing and transition planning, development of community partnerships and natural supports and ensuring staff availability to attend celebrations and commencement activities.
This process ensures that transitions are meaningful, strengths-based, and reflective of the Fourth Phase of High Fidelity Wraparound.
See Core Day 1 pages 41-45
New Care Coordinator Training pages 30-34
Expected Outcomes
2.1 Youth and Family Satisfaction
The program has established policies and procedures to routinely collect, review, and respond to satisfaction data.
Youth and family satisfaction is gathered through multiple methods, including satisfaction surveys, quality assurance follow up calls, and fidelity tools such as the Wraparound Fidelity Index (WFI) Family Support Network staff contact each family at the close of services and conduct the WFI with each participant and family member. All team members are also interviewed and the data is compiled and shared with the program without identifying information. In cases involving an Indian child, efforts will be made to actively engage the Tribe and gather feedback regarding their experience in the Wraparound process. Supervisors and leadership review satisfaction data regularly to inform continuous quality improvement efforts, including staff training, coaching, and program enhancements. This ensures services remain responsive to the needs, preferences, and experiences of youth, families, and Tribes.
See Wraparound Fidelity Index pages 3-15
OCIMS Day 3&4 pages 11-12
2.2 Improved School Functioning
Policies and procedures are in place to record and evaluate school attendance and performance through OCIMS documentation, progress notes, Child and Family Team meeting minutes, school reports, parent and youth reports, and when applicable, IEP documentation and vocational progress updates. Data is reviewed through supervision and quality assurance processes to monitor attendance trends, academic improvement, and school-related goals within the Plan of Care.
Our HFW teams routinely collect information from the parent and youth regarding school attendance, academic performance, behavioral functioning, and school engagement. This information is reviewed during Child and Family Team meetings and incorporated into the individualized Plan of Care as measurable goals and action items. When appropriate, the HFW team participates in IEP meetings, school success meetings, SST meetings, and other educational planning forums to advocate for the youth’s needs and ensure alignment between the educational plan and the family vision. The team facilitates communication and meetings with school staff, caregivers, and community supports to identify strengths-based solutions and increase school stability and success.
See Core Day 4 pages 17-19, 22-28
Site Review Tool
QA Site Review Tool
Core Day 4 Pages 71-19, 22-28
2.3 Improved Functioning in the Community
Policies and procedures are in place to record, monitor, and evaluate youth engagement with community activities and overall community functioning. This includes documentation in OCIMS, progress notes, action forms, meeting minutes, IP-CANS outcome measures, and county reports that track community participation, justice involvement when applicable, school attendance, pro-social engagement, and access to natural/community supports. Data is reviewed through supervision, chart review, and quality assurance processes to evaluate progress and identify areas where additional support or intervention may be needed.
Outcome data is also used at the program level to evaluate effectiveness of HFW interventions in improving youth stability, reducing isolation, increasing community participation, and supporting successful functioning in the least restrictive environment.
The program intentionally promotes community integration and increased functioning through individualized strategies that may include connection to mentoring, school activities, recreational programs, cultural events, community classes, skill-building activities, and pro-social supports that align with the youth’s interests and strengths. Progress in community engagement is reviewed regularly during Child and Family Team meetings and is incorporated into measurable action items and outcome goals within the Plan of Care.
See Core Day 3 pages 15-34
OCIMS Day 2 page 11-12
New Care Coordinator Training pages 15-28
Site Review Tool
QA Site Review Tool
2.4 Improved Interpersonal Functioning
Policies and procedures are in place to record and evaluate interpersonal functioning outcomes through OCIMS documentation, IP-CANS assessments, Wraparound Fidelity Index (WFI) feedback, progress notes, CFT meeting reviews, and family satisfaction tools. Supervisors and leadership review this data to assess progress in family functioning, communication, conflict reduction, and peer relationship outcomes, and use findings to strengthen service planning and program quality improvement efforts.
The individualized Plan of Care includes strategies specifically designed to address family stress, conflict resolution, emotional regulation, relationship building, and pro-social peer engagement. Through these interventions, families often experience reduced stress and strain within the home environment and increased confidence in managing challenges together. Youth are also supported in developing and maintaining positive friendships, trusted adult relationships, and pro-social peer connections through school engagement, community activities, mentoring, and individualized natural support strategies. Family Support Network (FSN) resources, community activities, and family-centered supports may also be utilized to strengthen family connection and reduce isolation.
See OCIMS Day 2 page 11-12
New Care Coordinator Training pages 15-28
Site Review Tool
QA Site Review Tool
OCIMS Day 3 page 3
Core Day 1 pages 93-96
2.5 Increased Caregiver Confidence
Policies and procedures are in place to record and evaluate caregiver confidence and connectedness to community resources through OCIMS documentation, progress notes, Child and Family Team meeting reviews, IP-CANS indicators, WFI feedback, crisis call tracking, and family satisfaction tools. These measures are routinely reviewed through supervision and quality assurance processes to evaluate growth in caregiver confidence, stability, and successful use of supports over time.
Caregivers receive ongoing support through the Wraparound team, including the Facilitator, Parent Partner, Youth Partner, and natural supports, with intentional coaching around problem-solving, communication, de-escalation, safety planning, and use of community resources. Parent Partners and support resources further strengthen caregiver confidence by providing peer support, advocacy, and direct linkage to community-based services and supports.
As families progress through the HFW process, increased caregiver confidence is reflected through reduced crisis calls, increased positive statements by the caregiver regarding their ability to manage situations, improved use of natural and community supports, and a reduction in family conflict.
See Site Review Tool
QA Site Review Tool
Core Training Day 1 pages 49-59
2.6 Stable and Least Restrictive Living Environment
2.6 Policies and procedures are in place to record, monitor, and evaluate placement stability, frequency of placement changes, and type of placement changes through OCIMS documentation, county reports, case reviews, Child and Family Team meeting minutes, and quality assurance processes. Leadership and supervisors review placement trends and outcome data to strengthen permanency planning, reduce disruptions, and improve program effectiveness in maintaining youth in the least restrictive environment.
Through the Child and Family Team (CFT) process, the team proactively addresses the needs that contribute to placement instability, including behavioral health concerns, family conflict, safety needs, caregiver stress, school related challenges, and lack of natural supports. Individualized Plans of Care, crisis and safety plans, flex fund resources, natural supports, and community based services are used to stabilize the youth in their current placement and strengthen permanency outcomes.
The HFW team works collaboratively with caregivers, social workers, probation officers, behavioral health providers, schools, and community supports to reduce risk factors that may lead to higher levels of care such as detention, psychiatric hospitalization, treatment centers, STRTP placement, or residential disruption. When placement changes do occur, the team responds quickly to identify causes, support stabilization, and reduce further movement.
OCIMS Day 2 pages 2-37
Natural Supports 2026 pages 2-33
Core Day 3 pages 81-87
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Policies and procedures are in place to record, monitor, and evaluate the frequency of hospital visits, including emergency department visits, psychiatric hospitalization, and other crisis-related medical or behavioral health admissions. These events are monitored through Special Incident Reports (SIRs), staff supervision, and direct family reports, as well as documentation in OCIMS and county reporting systems. The Special Incident Report (SIR) process specifically requires documentation of medical and psychiatric hospitalization events, which supports ongoing tracking and quality assurance review.
Supervisors and leadership review hospitalization trends through chart review, case consultation, and quality assurance processes to identify service gaps, strengthen crisis prevention strategies, and improve team response to behavioral health needs. This data is also used to inform staff training and program improvement efforts related to crisis stabilization and least restrictive care.
The individualized Plan of Care and Crisis and Safety Plan include proactive strategies such as de-escalation techniques, caregiver coaching, community behavioral health linkages, natural supports, crisis response planning, and timely team intervention, all of which are designed to stabilize youth in the home and community setting. The team also responds quickly to early warning signs and high-risk situations to reduce the likelihood of emergency department or inpatient admissions.
See Core Day 3 pages 58-68
Wraparound OC SIR Training pages 2-17
2.8 Reduction in Crisis Visits
Policies and procedures are in place to record and evaluate the frequency of crisis incidents and the level of professional support involved when crises occur. Crisis events are monitored through Special Incident Reports (SIRs), progress documentation, family reports of incidents, Child and Family Team meeting reviews, and supervisor case consultation. For probation-involved youth, additional crisis-related information is also gathered through reports from the assigned Probation Officer, which supports coordination across systems and strengthens the accuracy of crisis tracking. This data is reviewed through supervision and quality assurance processes to evaluate progress in crisis reduction, strengthen prevention strategies, and ensure that families are increasingly able to manage challenging situations with reduced need for professional intervention.
See Wraparound OC SIR Training
Through the Child and Family Team (CFT) process, the team works collaboratively with the youth, family, and natural supports to develop individualized Crisis and Safety Plans that include proactive strategies, early warning signs, de-escalation techniques, and clearly identified supports that can be accessed before a situation escalates. Parent Partners, Youth Partners, caregivers, family members, schools, mentors, and other natural supports are actively included in crisis planning so that support systems remain sustainable beyond formal services.
See Core Day 3 pages 58-61
Core Day 2 pages 16-23
Core Day 1 pages 88-90
Wraparound OC SIR Training pages 2-17
2.9 Positive Exit from HFW
Policies and procedures are in place to record, monitor, and evaluate when and why families exit HFW services. Exit reasons, transition benchmarks, commencement documentation, and post-transition support are documented in OCIMS and reviewed through supervision and quality assurance processes. Additional outcome measures include the Wraparound Fidelity Index (WFI), family report of experience, satisfaction surveys, and confirmation that the youth remains in a home-like setting upon commencement of services. This data is reviewed to ensure that families are exiting based on positive progress and stabilization, and to confirm that discharges are not occurring as a result of adverse events, crisis escalation, or preventable placement disruption. Findings are also used to strengthen transition planning and program quality improvement efforts.
Transition and commencement occur only when the Child and Family Team (CFT), youth, and caregivers collaboratively determine that the family has developed the stability, supports, and confidence necessary to sustain progress after formal HFW services conclude. A positive exit from HFW is demonstrated through successful completion of the Transition Plan and Commencement process, sustained use of natural and community supports, reduction in crisis incidents, improved caregiver confidence, and the youth’s ability to remain in a safe, stable, home-like setting.
See OCIMS Training
New Care Coordinator Training pages 30-34
Core Day 1 pages 41-45
Engagement
3.1 Orientation
a.) Our High Fidelity Wraparound (HFW) program ensures that all youth and families receive a comprehensive orientation to the Wraparound process at the onset of services. Orientation begins with the Parent Partner, who initiates engagement by contacting the caregiver to schedule the intake appointment and provide an initial overview of Wraparound services in a family-friendly and supportive manner. During the intake meeting, the Facilitator provides a more detailed explanation of the HFW process to the youth and family. This includes an overview of the Wraparound principles and phases, legal and ethical considerations (including confidentiality and consent), Child and Family Team Meetings and a clear description of the roles and responsibilities of all team members.
See Core Day 2 pages 55-56, 61
b.) Facilitators check for understanding, answer questions, and revisit orientation information as needed throughout the engagement phase to ensure families feel informed, comfortable, and empowered to participate in the Wraparound process. All intake documents are presented to the family for signatures. Each document is explained to the family and all ethical and legal considerations are discussed.
See Core Day 2 pages 55-56, 61
c.) Each team member is made aware of their role and responsibility in the wraparound process. Special emphasis is placed on the role of the youth and family as central decision-makers, as well as the importance of natural supports. In cases involving an Indian child, the role of the Tribe would be explained as an equal partner in the process, and efforts are made to ensure culturally respectful engagement. The time commitment, importance of consistency, confidentiality of the meeting content, strengths based nature of the process and the process for deciding on action steps.
See Core Day 1 page 12
3.2 Safety and Crisis stabilization
a.) During the engagement phase, the HFW team addresses immediate safety and crisis concerns so families can fully participate in the Wraparound process. Initial safety discussions occur with the family at intake and during early team meetings. When an immediate crisis response plan is needed, the team will complete that plan with the family and ensure the family has immediate support and access to 24/7 crisis response when needed. This is documented in the youth’s file.
See Core Day 3 pages 58-68
New Care Coordinator Training pages 3-5
Wraparound Contract page 20
b.) An immediate crisis plan does not replace the HFW Safety Plan which is developed during the plan development phase. All concerns from the immediate crisis plan will be utilized to inform the Safety Plan and transferred to the Safety Plan as appropriate. At the initial intake meeting families are provided with a list of our staff which will be working with the family. This list includes contact information and how to access staff in a crisis. Our teams are responsive to family crisis 24/7 throughout Wraparound services.
See Core Day 3 pages 58-68
New Care Coordinator Training pages 3-5
Wraparound Contract page 20
Core Day 1 page 59
c.) Families are provided with clear guidance on accessing 24/7 crisis response services, including the HFW team which is provided an agency phone to be available 24/7 to youth and families should a crisis arise, county hotlines, mobile crisis teams, and emergency contacts. Facilitators review this information with families to ensure they understand how to access support quickly if needed.
See Wraparound Contract page 20
Core Day 1 page 59
3.3 Strengths, Needs, Culture and Vision Discovery
a.) The Family Vision is brainstormed with the family team during the initial meeting and upon being finalized it is prominently included on the Plan of Care and documented in the chart. The vision is revisited if the goals of the family change.
See Core Day 3 pages 9-13
b.) Our teams initiate conversations to facilitate strengths, needs, and cultural discovery and document that throughout the life of the services. This is to reflect the evolving needs and growth of the youth and family. The process emphasizes family voice and choice, recognizes natural supports, and incorporates tribal perspectives when applicable. This document is shared with new members to assist them in seeing the family from a strengths perspective and setting the expectations from initial participation. Any new information shared by the family that they would like for the team to prioritize is included in the Plan of Care updates which occur every 90 days.
New Parent Partner Training pages 27-34
Core Day 2 pages 142-146
3.4 Engage All Team Members
a.) Our wrap teams are invested in learning about the family and complete an inventory that highlights a family’s strengths, natural supports, and resources. This document is updated regularly and shared with new team members. The document is kept in the youths file.
See Core Day 2 142-146
b.) At the time of intake and Plan of Care review the team will work to identify if the right people are at the table and ensure that Children’s System of Care partners are identified and engaged to join the Child and Family team with the permission of the family.
See Natural Supports 2026, pages 2-34
c.) Every opportunity is taken to engage the family’s natural support. Through identifying regular contacts, people the family spends time with, and who they reach out to on holidays, our care coordinators are able to help the family identify their natural supports and engage them in a discussion on what role they could play in the family team. In the case of Indian children the facilitator would reach out to the identified representative of the tribe and engages them in participating in the Child and Family team and discusses their potential role with the family.
See Natural Supports 2026, pages 2-34
d.) All staff document their interaction with a family through case notes, meeting agendas, Plan of Care updates. Supervisors work closely with staff to ensure that documentation represents the team’s work with a family and includes team building and engagement activities.
See Core Day 1 pages 57-58
3.5 Arrange Meeting Logistics
a.) The High Fidelity Wraparound (HFW) team ensures that Child and Family Team (CFT) meetings are scheduled at times and in locations that are convenient, accessible, and responsive to the unique needs of the youth and family. Priority is always given to family voice and choice, with consideration for caregiver work schedules, school commitments, transportation barriers, cultural preferences, trauma history, and any accessibility needs to ensure equitable participation for all youth and families. Staff work collaboratively with families and team members to identify meeting times that maximize participation from both formal and natural supports while remaining aligned with family preferences. Our teams maintain flexibility in work hours and scheduling practices, including evenings, weekends or alternative locations when needed, to reduce barriers to engagement. The HFW team also proactively arranges meeting logistics such as transportation support, interpretation or translation services, telehealth capability, childcare coordination when available, and technology support to ensure all team members can participate fully.
See Wraparound Contract page 23
Wraparound Overview page 17
Wraparound Contract page 20
b.) Staff receive ongoing coaching and training on collaborative scheduling practices, accessibility planning, and family-centered engagement strategies to reinforce this expectation across all HFW phases.
See Mandatory Staff Training and Development
Wrap OC Staff Training Development
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
a.) During the initial team meeting, the Facilitator guides team members in developing formal team agreements that outline how the team will communicate, participate in meetings, resolve conflict, and make shared decisions. These agreements reinforce psychological safety, family voice and choice, and clear expectations for all formal and natural supports. The Facilitator supports the team in developing a Team Mission Statement that clearly defines the overall purpose of the HFW team and aligns directly with the Family Vision established during engagement. This mission statement serves as the team’s guiding framework for decision-making, problem-solving, and development of the Wraparound Plan of Care. Team agreements, the strengths inventory, and the mission statement are completed and documented in the youth’s chart prior to development of the formal plan of care, ensuring the planning process remains family-driven, strengths-based, and aligned with shared team goals.
See Core Day 3 pages 9-14
Core Day 2 pages 142-146
Core Day 1 pages 49-50
b.) At this same stage, the team also expands upon the strengths identified during engagement by discussing and documenting additional strengths of the youth, family, team members, natural supports, and community resources. These strengths are incorporated into the youth’s file and are continuously updated as new strengths emerge throughout the process. The use of poster boards, visual mapping, and structured discussion activities may be used to make strengths visible and interactive during meetings.
See Core Day 2 pages 142-146
New Care Coordinator Training page 21
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
a.) Our teams utilize tools such as the IP CANS to identify underlying needs for the youth, focused discussions with family members identifying their worries and concerns for the youth and family and the brainstorming process to capture and prioritize the needs of the family. The brainstorming process also facilitates the development of interventions and resources to support the youth and family in achieving their goals. The documentation standards are designed to ensure that all interactions with a family are captured to reflect the work that is being done.
See OCIMS Day 2 page 11-12
New Care Coordinator Training page 20
b.) Our teams are intentionally solution focused and develop specific, measurable, achievable, realistic time limited goals that are crafted for the Plan of Care to ensure that everyone is working toward the same goal with the family. Strength based intervention strategies are utilized to begin addressing the underlying needs.
See OCIMS Day 2 pages 2-24
Core Day 3 pages 8-55
c.) The goals and outcomes are developed collaboratively through the Child and Family team process to ensure all team members have the opportunity to provide input. The final goals that appear on the POC are ones that consensus was reached and the entire team agrees to support the plan.
See Core Day 3 pages 8-55
OCIMS Day 2 pages 5-55
d.) The brainstorming process is documented on agendas, documentation notes and informal notes.
See Core Day 1 pages 93-96
e.) Facilitators attend multiple training sessions to ensure they are able to guide the Child and Family team in the brainstorming process to identify, prioritize and select strategies to meet the identified needs. The facilitators then craft action items to assist family teams in meeting their identified needs. Facilitators ensure that the action items are manageable, assigned to a team member and given a time frame to be completed.
See Mandatory Staff Training by Role
New Care Coordinator Training pages 3-36
f.) The facilitator collects all the information from the CFT and translates the brainstorming and agreements of the family team into the Plan of Care. This plan is shared with the team and reviewed every 30-45 days to ensure action items are being completed. This is documented through case notes and updates to the plan of care.
See Core Day 1 pages 93-96
Core Day 3 page 8
4.3 Develop an Individualized Child or Youth and Family Plan
a.) Facilitators receive ongoing coaching and training in collaborative planning, trust-building, and fidelity to HFW principles.
See Facilitation Training pages 4-28
Mandatory Staff Training and Development
b.) Services are coordinated across Children’s System of Care partners and are delivered in the youth’s home and community whenever possible, with priority given to family voice and choice, accessibility, and convenience.
See Wraparound Overview page 10, 17
Core Day 1 page 15
New Care Coordinator Training page 27
c.) The Facilitator leads a high quality team process that intentionally elicits multiple perspectives from formal providers, natural supports, family members, community partners, and when applicable, the Tribe, in order to build trust, shared ownership, and a unified vision for success. The resulting Plan of Care is directly aligned with the Family Vision and Team Mission Statement and addresses the youth’s and family’s prioritized needs across multiple life domains, including home, school, behavioral health, safety, social connections, and community functioning. Goals, strategies, and action items are clearly documented, culturally relevant, and individualized to the youth and family’s strengths, values, trauma history, and daily routines. Each action step identifies the responsible team member, target completion date, and expected outcome so that all participants understand their role and accountability. The HFW team ensures the plan reflects a balanced mix of formal services, natural supports, family resources, and sustainable community based supports, with intentional planning to increase reliance on natural and informal supports over time. The Plan of Care also includes benchmarks for graduated transition to less restrictive, less intrusive, and less formal supports throughout the HFW process, allowing the family to move at a pace that feels safe, realistic, and sustainable.
See Core Day 1 pages 57-58
Wraparound Contract page 22
New Care Coordinator Training pages 15-25
Core Day 3 pages 8-70
OCIMS Day 2 pages 1-37
d.) Completed Plans of Care are documented in the youth’s chart, distributed to all team members, and routinely reviewed by supervisors and coaches as part of continuous quality improvement to ensure fidelity, quality, and meaningful outcomes.
See Core Day 1 pages 57-58
Wraparound Contract page 22
OCIMS Day 2 pages 1-37
4.4 Develop a Crisis and Safety Plan
a.) Building on the crisis response discussions initiated during engagement, the Facilitator guides the team in creating highly individualized Crisis and Safety Plan that clearly identifies warning signs, triggers, early intervention strategies, de-escalation approaches, proactive and reactive crisis response steps, and who should be contacted for support 24/7, including natural supports, formal providers, crisis response resources, and emergency contacts. Development of the Crisis and Safety Plan occurs through a team based, strengths oriented, culturally relevant and family driven process, ensuring shared ownership and clear understanding of each team member’s role during times of crisis. The plan is documented in the youth’s chart and is currently embedded within the Wraparound Plan of Care, ensuring accessibility and integration with the broader service strategy. As the program continues to strengthen fidelity practices, this plan is scheduled to transition into a standalone safety planning document in the upcoming year.
See OCIMS Day 2 pages 1-37
CORE Day 3 pages 7-54, 58-70
b.) Facilitators receive ongoing training and reflective coaching in collaborative safety planning, post-crisis debriefing, cultural responsiveness, and effective use of natural supports.
See Mandatory Training for Staff by Role
Mandatory Staff Training and Development
Wrap OC Staff Training Development
c.) Crisis and Safety Plans are routinely reviewed by supervisors to ensure strategies are individualized, culturally relevant, demonstrate a clear proactive-to-reactive progression, and support continuous quality improvement.
See CORE Day 1 pages 57-58
Implementation
5.1 Implement The Plan of Care
a.) During each HFW team meeting, the Facilitator uses meeting agendas, action forms, and meeting minutes to guide the review of assigned strategies and action items, monitor completion of individual responsibilities, and evaluate whether interventions are effectively meeting prioritized needs and desired outcomes. The team discusses barriers, identifies supports needed to maintain momentum, and collaboratively revises strategies when progress is limited or new needs arise. This ongoing monitoring process ensures the Plan of Care remains responsive, family driven, and aligned with the youth’s evolving needs across life domains. In addition to tracking implementation, the HFW team intentionally celebrates successes and progress as they occur, reinforcing team motivation, youth and family engagement, and recognition of strengths. Celebrations may include verbal acknowledgment during meetings, updates on poster boards, recognition of completed milestones, or culturally meaningful ways identified by the family.
See New Care Coordinator Training pages 15-34
OCIMS Day 2 pages 15-34
b.) Facilitators and staff receive ongoing training and reflective coaching on implementing Plans of Care with fidelity, maintaining shared accountability, and integrating celebration of progress into the team process as a core practice expectation.
See OCIMS Day 2 pages 15-34
Mandatory Training for Staff by Role
5.2 Review and Update The Plan of Care
a.) The High Fidelity Wraparound (HFW) Facilitator leads the Child and Family Team (CFT) in an ongoing process of reviewing, evaluating, and updating the Plan of Care to ensure it remains responsive to the evolving needs of the youth and family. During each HFW team meeting, the team reviews the Plan of Care, including its current strategies, action items, progress toward outcomes, and the overall effectiveness of interventions in meeting prioritized needs. This team based review process allows the family, youth, natural supports, and formal providers to assess what is working well, identify barriers, celebrate progress, and collaboratively determine when goals, strategies, or action steps should be revised.
See New Care Coordinator Training pages 15-34
OCIMS Day 2 page 2
b.) As new needs emerge, successes are achieved, or additional strengths and supports are identified, the Facilitator guides the team in adjusting the Plan of Care to reflect these changes. Updates may include modifying goals, reassigning responsibilities, identifying new natural or community supports, incorporating flex fund resources, or revising timelines and deliverables. All changes are documented in the youth’s file and entered into OCIMS to ensure clear record keeping and continuity across Children’s System of Care partners.
See Natural Supports 2026 pages 12-13
OCIMS Day 2 page 2
Core Day 1 pages 93-96
c.) The Facilitator communicates all updates to team members through meeting minutes, updated action forms, attendance tracking, and direct follow up communication as needed. Documentation includes task completion, new assignments, team attendance, use of formal and natural supports, use of flex funds and receipts, and any revisions made to the Plan of Care. At minimum, the Plan of Care is formally updated during an HFW team meeting and redistributed to all team members every 90 days, and more frequently whenever the youth’s and family’s needs require plan modification.
See Core Day 1 pages 93-96
OCIMS Day 2 page 2
New Care Coordinator Training
d.) Forms and documentation processes are designed to remain flexible and individualized so the Wraparound process continues to align with family voice, changing priorities, and team capacity.
See OCIMS Day 2 page 2
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
a.) The High Fidelity Wraparound (HFW) Facilitator continually monitors and strengthens team cohesion, trust, and commitment to ensure the Child and Family Team (CFT) remains effective, collaborative, and aligned with the family’s vision and goals. Team agreements established during the planning phase are actively utilized during HFW team meetings to reinforce expectations for communication, shared decision-making, respect, accountability, and conflict resolution. These agreements are reviewed regularly and remain visible during meetings to support psychological safety, strengthen relationships, and maintain a clear structure for collaboration.
See Core Day 2 page 70
New Care Coordinator Training pages 24-29
b.) Facilitators receive ongoing training and coaching in team development, engagement strategies, conflict navigation, and sustaining effective collaboration throughout the HFW process.
See Facilitation Training pages 4-28
Wrap OC Training Development
c.) As the needs of the youth and family evolve, the Facilitator works with the team to identify and develop additional natural supports, community connections, and sustainable resources, intentionally expanding the support network while preserving team cohesiveness. The use and effectiveness of natural supports are monitored over time through team discussion, action item follow through, and supervisory chart review, with facilitators receiving feedback through coaching and reflective supervision to strengthen this practice.
See Natural Supports pages 12-13
d.) When new team members—whether formal providers, natural supports, school partners, or community resources—are added, the Facilitator follows a structured orientation process to ensure seamless integration into the team. This includes explaining the HFW process and principles, reviewing the current Plan of Care, clarifying strategies and team roles, and engaging in team-building activities that support trust, connection, and shared ownership.
See Wraparound Onboarding Process pages 1-16
Transition
6.1 Develop a Transition Plan
a.) When the youth and family have made sufficient progress toward the team mission, identified goals, and prioritized needs, the High Fidelity Wraparound (HFW) Facilitator leads the Child and Family Team (CFT) in determining readiness for transition from formal Wraparound services. This determination is made collaboratively with the youth, family and team and is based on ongoing progress monitoring, successful completion of action items, increased stability across life domains, and the family’s expressed confidence and readiness to transition. Family voice and choice remain central to this decision making process.
See New Care Coordinator Training pages 30-34
Wraparound Overview page 20
Core Day 1 pages 41-45
b.) Once the youth, family, and team agree that transition is appropriate, the Facilitator guides the team in developing an individualized Transition Plan. This plan outlines the youth’s and family’s ongoing needs, identifies services and supports that will continue beyond formal HFW, and clearly documents how any remaining supports currently provided by HFW staff will be gradually transitioned to natural supports, community resources, and ongoing formal service providers as appropriate. The Transition Plan includes clearly defined roles, timelines, responsible parties, and contact information to ensure continuity of care and reduce risk of service disruption. The finalized Transition Plan is documented in the youth’s file, distributed to all team members, and reviewed to verify that identified supports will remain accessible and sustainable after formal HFW services conclude.
See Core Day 1 pages 41-45
New Care Coordinator Training pages 30-34
c.) The transition planning process occurs within a team based, collaborative environment and includes formal providers, natural supports, community partners, and Facilitators receive ongoing training and coaching in transition readiness assessment, sustainability planning, and family-centered discharge practices to support fidelity to the fourth phase of HFW.
See Core Day 1 pages 41-45
New Care Coordinator Training pages 30-34
d.) Facilitators provide education to families regarding available post transition supports and resources and ensure families understand how to access these resources after discharge including post adoption service resources for families utilizing Adoption Assistance Program (AAP) funding when applicable.
See Core Day 1 pages 41-45
6.2 Develop a Post-Transition Safety Plan
a.) As part of the fourth phase of High Fidelity Wraparound (HFW), the Facilitator leads the Child and Family Team (CFT) in reviewing and updating the existing Crisis and Safety Plan to reflect the youth’s and family’s needs after transition from formal Wraparound services. If needed, a new post-transition crisis and safety plan is developed in collaboration with the youth, family, natural supports, community partners, and formal providers who will remain involved after HFW concludes. This planning process is family driven and ensures that the youth and family play a central role in identifying potential crisis situations that may arise following discharge, as well as the strategies they believe will be most effective and culturally relevant. The updated post transition safety plan identifies anticipated triggers, high-risk situations, warning signs, and both proactive and reactive response strategies that can be implemented by the family and ongoing support after formal services end. The plan prioritizes the use of natural supports and sustainable community resources, including relatives, trusted family friends, school contacts, mentors, parent support resources, community based organizations, and services such as resource supports, parent mentoring, and other resiliency services available to families in Orange County. The plan clearly identifies who the family can contact 24/7, what steps should be taken in escalating situations, and what community support remains available after discharge. Completed plans are documented in the youth’s file and entered into OCIMS as part of the formal transition documentation.
See OCIMS Day 2 pages 25-28
b.) This updated safety planning process occurs within a team based and collaborative environment, with Facilitators receiving ongoing training and reflective coaching in crisis prevention, post-transition stabilization planning, culturally responsive safety planning, and use of natural supports.
See Core Day 1 pages 41-45
c.) Supervisors routinely review post-transition safety plans to ensure individualized strategies, appropriate proactive-to-reactive progression, cultural relevance, and sustainable use of community and natural supports for continuous quality improvement and fidelity monitoring.
See Core Day 1 pages 41-45
6.3 Create a Commencement and Celebrate Success
a.) As part of the final phase of High Fidelity Wraparound (HFW), the Child and Family Team (CFT) intentionally creates a meaningful commencement and celebration process that honors the youth’s and family’s accomplishments, resilience, and progress throughout services. The Facilitator leads the team in planning a celebration that reflects a positive and empowering transition from formal Wraparound services and is aligned with the family’s culture, values, traditions, and preferences. Family voice and choice remain central in determining how this milestone is recognized, whether through a final team meeting celebration, certificate presentation, shared meal, culturally meaningful acknowledgment, family gathering, or participation in a community activity that is important to the youth and family.
The team uses the commencement process to highlight successes achieved in relation to the Family Vision, Team Mission, and identified goals, while reinforcing the strengths and supports that will remain in place after discharge. Celebrations are designed to reinforce the youth’s and family’s growth, recognize the contributions of natural supports and team members, and encourage confidence in the family’s ability to sustain progress beyond formal HFW.
See Core Day 1 pages 41-45
Wraparound Overview page 20
New Care Coordinator Training pages 30-34
b.) Administrative structures within the program support this process by allowing the use of flex funds, community partnerships, staff time, and available family support resources to ensure celebrations are meaningful and accessible. Family support resources, including special occasion supports and community resource connections, may be utilized to assist with family centered celebrations and successful commencement activities. Staff are encouraged and supported to attend commencement celebrations whenever possible to reinforce continuity, relationship closure, and positive transition. The completion of commencement activities and final transition progress are documented in the youth’s file and entered into OCIMS as part of the discharge and closure documentation process.
See Core Day 1 pages 41-45
Wraparound Overview page 20
New Care Coordinator Training pages 30-34
Wraparound Contract page 23
Core Day 3 pages 81-83
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
a.) The High Fidelity Wraparound (HFW) program actively integrates youth and family voice at all levels of program development, implementation, and continuous quality improvement. The program recognizes youth and families as essential partners whose lived experiences directly inform how services are delivered and improved. Multiple mechanisms are in place to ensure families have meaningful opportunities to participate in decisions regarding local HFW implementation. These include family satisfaction surveys, quality assurance follow-up calls, the Wraparound Fidelity Index (WFI), case reviews, and feedback gathered through Parent Partners, Youth Partners, and Family Support Network (FSN) resources. The WFI is administered approximately four months into services and collects feedback from caregivers, youth, the Parent Partner, Youth Partner, and Care Coordinator, and when applicable, the Tribal Representative. This data is tracked and followed by FSN and program leadership as part of fidelity and quality improvement efforts.
See OCIMS Day 3-4 pages 11-12
Wraparound Fidelity Index Supervisor Professional Growth: pages 1-18
Core Day 2 pages 57-58
Wraparound Overview page 11
b.) Family and youth feedback is reviewed by supervisors, leadership, and quality assurance staff to identify trends, service gaps, training needs, and opportunities to strengthen policies and procedures. This feedback is used to inform service planning practices, staff coaching priorities, workforce development initiatives, fidelity improvement strategies, and program level decision making. The program’s commitment to family voice and choice extends beyond the direct service level and is embedded in the agency’s leadership and community partnership framework to ensure the Wraparound model remains responsive, culturally relevant, and family centered.
See Wraparound Fidelity Index Supervisor Professional Growth: pages 1-18
Team Observation Tool
Wraparound Overview page 11
7.2 Community Leadership Team
a.) Our agency maintains an identified program representative, typically at the director, supervisor, or administrative leadership level, who actively participates in county leadership meetings, WRIT trainings, quality assurance reviews, and systems collaboration efforts. This representative serves as the formal liaison between our agency and the county’s Community Leadership Team structure and is responsible for communicating county updates, policy changes, fidelity expectations, training requirements, and system level improvement initiatives back to agency leadership and front line staff. Our High Fidelity Wraparound (HFW) program actively participates in Orange County’s established community and systems-level leadership structure to ensure fidelity to the California Wraparound Standards and support collaborative decision-making across child-serving systems. At the county level, Orange County maintains formal inter-agency leadership and oversight structures, including the Wraparound Review and Intake Team (WRIT) and the Wraparound Oversight Group (WOG), which bring together representatives from the Social Services Agency (SSA), Children and Youth Behavioral Health (CYBH), Probation, the Department of Education, Family Support Network (FSN), contracted Wraparound providers, and other community partners.
See Wraparound Overview pages 9-12
Wrap OC Staff Meetings
Wrap OC Training Development
Core Day 2 pages 121-123
Core Day 4 pages 17-19
7.3 Eligibility and Equal Access
a.) Our High Fidelity Wraparound (HFW) program ensures that eligibility, referral, and access processes are structured to provide equitable, timely, and appropriate services to all youth and families who meet county established criteria, regardless of the severity or complexity of their needs. Youth are eligible for services when they meet Orange County Wraparound criteria, including youth living in a home-like setting who are involved with or referred through the Social Services Agency (SSA), Probation, or Children and Youth Behavioral Health (CYBH). The program does not exclude youth or families based on the intensity of need, crisis history, behavioral health complexity, placement risk, or family system challenges.
See Wraparound Overview page 7
b.) To ensure equitable access and adequate service intensity, staffing structures are intentionally designed to support the frequency and responsiveness required by High Fidelity Wraparound. Each assigned team includes a Supervisor, Facilitator, Parent Partner, and Youth Partner, with staffing and caseload distribution monitored by leadership to ensure staff can meet the individualized needs of families, including crisis response and increased contact frequency during periods of instability. The program also ensures families have access to an adequate array of services and 24/7 crisis support, including immediate linkage to crisis resources, emergency Child and Family Team meetings, natural supports, formal providers, and after-hours support pathways when needed. Initial crisis needs are assessed beginning at referral and during first family contact to ensure immediate response for families experiencing urgent concerns.
See Wraparound Contract page 20
Wraparound Overview page 13
Core Day 4 pages 8-28
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
a.) The program allocates funding for immediate individualized needs through flex funds, which are used strategically to support safety, crisis stabilization, engagement, pro-social activities, transition celebrations, culturally relevant interventions, and other family driven needs that support the Plan of Care. These expenditures are closely tied to identified needs within the Plan of Care and reviewed through established fiscal and quality assurance procedures.
See Wraparound Contract pages 28-29
Money Matters pages 3-27
Core Day 3 pages 81-83
b.) Program contracts and fiscal structures support the required HFW staffing model, including Supervisors, Facilitators, Parent Partners, and Youth Partners, ensuring adequate personnel capacity to provide high intensity, family centered, community based services. Funding also supports ongoing workforce development through required county and agency trainings, reflective supervision, fidelity coaching, and professional growth opportunities to maintain high quality service delivery and adherence to CA Wraparound Standards.
See Wraparound Contract page 33
Mandatory Training for Wraparound Staff by Role
Wrap OC Staff Meetings
Wrap OC Staff Training and Development
c.) Fiscal practices include dedicated support for required data collection and management systems, including OCIMS, which serves as the county’s official communication hub, documentation platform, reporting system, and compliance monitoring tool. Funding supports system access, data entry requirements, reporting workflows, outcome tracking, and fidelity monitoring necessary for continuous quality improvement and contract compliance.
See Money Matters pages 3-27
OCIMS Day 1 pages 3-23
OCIMS Day 2 pages 2-36
OCIMS Day 3 pages 2-13
8.2 Equitable Funding Across System Partners
N/A – County Procedures Only
This section pertains to county-level fiscal oversight, cross-system cost sharing agreements, and systems-of-care funding allocation. As a contracted High Fidelity Wraparound provider, this section is completed by the county and is not applicable to provider response requirements.
8.3 Cost Savings are Reinvested
N/A – County Procedures Only
This section pertains to county-level fiscal oversight, cross-system cost sharing agreements, and systems-of-care funding allocation. As a contracted High Fidelity Wraparound provider, this section is completed by the county and is not applicable to provider response requirements.
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
a.) Our High Fidelity Wraparound (HFW) program maintains a clearly defined and timely process to ensure youth and families have access to flexible funds (flex funds) when urgent and individualized needs cannot be met through existing formal, natural, or community based resources. Flex funds are an integral component of the HFW funding plan and are used strategically to support immediate family stabilization, crisis response, engagement, safety, pro-social activities, culturally relevant needs, and successful implementation of the individualized Plan of Care. Requests for flex funds are first discussed and recommended within the Child and Family Team (CFT) process, ensuring that the youth, family, natural supports, and team members collaboratively identify the need and confirm that the request aligns with the team mission, Plan of Care, and family vision. The team evaluates whether the requested use of funds supports identified needs, builds on family strengths, is culturally relevant, strengthens natural supports and community capacity, represents a responsible investment, and includes a plan for sustainability or step down over time.
See Money Matters pages 3-27
Core Day 3 pages 81-83
b.) The program prioritizes timely access, especially in urgent or crisis situations involving transportation, food, shelter, childcare, culturally specific supports, or transition needs. The approval process is clearly defined and follows county and provider procedures. Requests under established thresholds are reviewed and approved internally by supervisors and agency leadership. Requests at higher thresholds, including those requiring county level approval, are submitted through the WRIT liaison review process and documented within OCIMS. Each request must be tied directly to the Plan of Care and documented in meeting notes and the Individual Service Report/flex fund expenditure forms, including receipts, justification, identified need, and sustainability planning. When requests are denied, the denial reason is clearly communicated to the team and family, including the rationale for the decision and discussion of alternative resources, community support, or revised planning options. Supervisors and administrative staff provide oversight to ensure accountability, timely review, and transparent communication throughout the approval and appeal process.
See Money Matters pages 3-27
Core Day 3 pages 81-83
8.5 Collaborative Oversight of Flex Funds
a.) Flex fund usage, availability, approvals, denials, and expenditure balances are tracked through established OCIMS flex fund tracking tools, allowing transparent communication to funders, WRIT, provider leadership, and administrative teams. Reporting includes the amount, purpose, HFW team recommendation, approval status, and receipts to support fiscal accountability and equitable resource management across the program. Oversight occurs at multiple levels. Supervisors and agency leadership review requests for appropriateness, contract compliance, and alignment with the family’s Plan of Care. Requests that require county level approval are further reviewed through the WRIT liaison process, which includes verification of justification, team recommendation, meeting note documentation, and alignment with identified needs and system requirements. This collaborative review structure ensures shared oversight between providers and county funders and promotes responsible stewardship of public funds.
See Money Matters pages 3-27
Core Day 3 pages 81-83
Wraparound Contract pages 28-29
b.) Flexible funds are managed through a pooled funding structure that allows resources to be available based on individualized need rather than by case specific allocation, ensuring that all enrolled youth and families have access to timely support when urgent needs arise. Requests for flex funds originate through the Child and Family Team (CFT) process, where the team collaboratively identifies the need, discusses alternatives, and makes a formal recommendation regarding the purpose, amount, and alignment with the Plan of Care. This recommendation is documented in meeting notes and action forms and entered into OCIMS.
See Money Matters pages 3-27
Core Day 3 pages 81-83
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
a.) Our High Fidelity Wraparound (HFW) program utilizes a braided funding approach across the Children’s System of Care to ensure that the needs of youth, families, Tribes, and communities are met without limitation by any single funding source. Program resources and flex funds are supported through collaborative county and provider partnerships that include Social Services Agency (SSA), Children and Youth Behavioral Health / Health Care Agency (CYBH/HCA), Probation, Family Support Network (FSN), and contracted Wraparound provider resources.
See Money Matters pages 3-27
Core Day 3 pages 81-83
Core Day 4 pages 8-14
b.) When limitations exist within one funding source, the HFW team and program leadership actively explore alternative resources, community-based supports, county-funded options, Family Support Network resources (FSN), and other available systems-of-care funding streams to ensure families continue to receive timely support. This may include increased reliance on flex funds, FSN resources, community resource centers, natural supports, CalWORKs-linked resources, Medi-Cal specialty mental health services, county support programs, or other partner agency resources depending on the family’s needs and eligibility.
See Core Day 4 pages 8-14
Wraparound Contract pages 14-15
Wraparound Overview page 11
c.) The program’s fiscal and case coordination processes are intentionally structured so that requirements of any single funding source do not prevent families from accessing flexible funds or critical supports.
See Core Day 4 pages 8-14
Money Matters pages 3-27
Core Day 3 pages 81-83
Wraparound Contract pages 14-15
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
a.) Program leadership monitors the demographic composition of the population served and utilizes this information to guide recruitment, outreach, and hiring processes in an effort to align staffing with community needs.
See Wraparound Contract page 12, 19
b.) The HFW staffing model includes roles that are especially important in culturally responsive practice, including Care Coordinators, Parent Partners, Youth Partners, and Supervisors, with intentional emphasis on hiring staff whose lived experience, community knowledge, and linguistic abilities strengthen engagement with families. When the program is unable to immediately hire staff who fully match the family’s cultural, racial, or linguistic needs, the team actively works to meet those needs through alternative supports, including engagement of natural supports, culturally aligned community partners, faith-based resources, Family Support Network (FSN) resources, school-based supports, and when applicable, Tribal representatives and culturally specific service providers.
See Wraparound Contract page 19
Core Day 4 pages 8-14
Wraparound Contract pages 14-15
c.) For families requiring services in a language not spoken by assigned staff, the program ensures access to translation and interpretation services, including Language Line, American Sign Language (ASL) supports, or trusted natural supports identified by the family when appropriate.
See Money Matters page 13
Core Day 4 page 9
9.2 Tribally Responsive Workforce
a.) Staff are trained on the importance of tribal sovereignty, culturally respectful communication, historical context, and collaborative advocacy practices to ensure services are delivered in a manner that honors the child’s and family’s tribal identity and rights. Facilitators, Supervisors, Care Coordinators, Parent Partners, and Youth Partners receive ongoing training and coaching related to cultural humility, tribal engagement, collaboration with Tribal representatives, and respectful communication practices. This tribal responsive practice is grounded in respect, collaboration, and advocacy, with the goal of promoting positive youth and family outcomes through culturally rooted systems of care and sustainable tribal partnerships.
See Critical Thinking pages 7-9
Wraparound OC Staff Training Development
b.) When serving an Indian child, the Child and Family Team (CFT) would actively build partnerships with Tribal representatives, tribal social services, and culturally specific tribal resources. The HFW team would work collaboratively with the family and Tribe to encourage participation in tribal traditions, ceremonies, cultural events, and other community-based supports that strengthen identity, belonging, and healing. The team also seeks to understand and incorporate the value of services, resources, and support offered by the Tribe, ensuring these are reflected in the Plan of Care, Crisis and Safety Plan, and Transition Plan as appropriate.
See Core Day 3 page 38
Core Day 1 page 12-17
Critical Thinking pages 7-9
Core Day 2 page 51
9.3 Flexible and Creative Work Environment
a.) Program quality and improvement are supported through structured leadership processes including reflective supervision, chart review, fidelity monitoring, coaching feedback, county training, and regular professional development forums. Staff participate in bi-monthly Professional Growth meetings and monthly Wrap Institute sessions, which provide opportunities to review practice standards, strengthen skills, share case-based problem solving strategies, and reinforce compliance with High Fidelity Wraparound expectations.
See Mandatory Training for Wraparound Staff by Role
Site Review Tool
QA Site Review Tool
Team Observation Tool
Core Day 1 page 58
b.) Leadership intentionally promotes staff cohesion and a positive team environment through open communication, cross-role collaboration, and recognition practices that reinforce Wraparound values. Examples include team meetings, supervisor check-ins, case consultation, and staff recognition initiatives which celebrate staff performance aligned with the ten principles of Wraparound and encourage strengths based, principle driven practice. This creates a culture of engagement, appreciation, and shared mission.
See Core Day 1 page 57-58
Core Day 2 page 65-67
c.) Open communication is further supported through accessible leadership, routine supervisory support, collaborative problem solving meetings, and county/provider communication structures that ensure staff have clear channels for feedback, coaching, and escalation of concerns.
See Wrap OC Staff Meetings – TA
Core Day 1 page 57-58
d.) Staff are encouraged to bring forward ideas, identify barriers, and collaborate on creative strategies that strengthen service delivery while remaining aligned with HFW principles, values, phases, and activities. Through these processes, leadership maintains a clear and consistent emphasis on the HFW mission, fidelity standards, and a creative work environment that empowers staff to respond flexibly to family needs while maintaining compliance with the CA HFW model.
See Core Day 1 pages 10-22
9.4 Hiring, Performance Evaluation, and Job Descriptions
a.) Within our staffing model, core roles include the Care Coordinator / HFW Facilitator, Parent Partner, Youth Partner, Supervisor / Manager, and licensed clinical consultation or supervisory support as needed. Additional functions such as fidelity coaching, family support, and quality assurance may be embedded within supervisory and leadership roles while maintaining clearly defined expectations and responsibilities.
see Core Day 1 pages 48-58
New Parent Partner Training pages 7-11
New Youth Partner Training pages 7-11
New Care Coordinator Training pages 3-34
b.) All role descriptions include the purpose of the position, required functions, Wraparound specific competencies, and expectations related to family voice and choice, strengths-based planning, cultural responsiveness, crisis support, documentation, and fidelity to the HFW phases and principles.
See Core Day 1 pages 48-59
New Parent Partner Training pages 7-11
New Youth Partner Training pages 7-11
New Care Coordinator Training pages 3-34
c.) Job descriptions are specifically developed to reflect Wraparound best practices, including the attitudes, skills, knowledge, lived experience, and competencies most likely to support successful service delivery. Particular emphasis is placed on family engagement skills, flexibility, collaborative team facilitation, cultural humility, crisis response, documentation accuracy, creativity in service planning, and strengths based practice.
See Core Day 1 pages 48-59
New Parent Partner Training pages 7-11
New Youth Partner Training pages 7-11
New Care Coordinator Training pages 3-34
d.) The hiring process includes multiple opportunities for candidates to demonstrate the attitudes and skills essential to the position. This includes structured interview questions, scenario based problem solving exercises, role play related to Child and Family Team facilitation, crisis response discussion, and assessment of strengths based and family centered practice approaches.
See Wraparound Interview Questions pages 1-3
Wraparound Onboarding Process pages 1-16
e.) Once hired, employees are provided with clear performance expectations, role-specific job descriptions, regular supervision, reflective coaching, fidelity review, and ongoing performance feedback. Staff receive frequent coaching through supervision, chart review, Professional Growth meetings, monthly Wrap Institute, and county required training to support their continued success and compliance with HFW standards. Performance evaluations incorporate role expectations, fidelity indicators, documentation quality, engagement practices, and collaboration with youth, families, and team members.
See Mandatory Training for Wraparound Staff by Role
Wrap OC Staff Meetings
Team Observation Tool
Wraparound Onboarding Process pages 1-16
Wrap Day 1 pages 57-58
9.5 Workforce Stability
a.) Compensation and benefit structures are reviewed in alignment with county contract expectations, labor market conditions, and organizational sustainability to promote workforce retention. Our agency implements compensation practices that are regularly reviewed to ensure wages remain competitive and responsive to the cost of living within the local service area, supporting recruitment and retention of qualified staff across all Wraparound roles, including Care Coordinators, Parent Partners, Youth Partners, and supervisory staff.
See Wraparound Contract Question 8: page 13
b.) Our program also prioritizes manageable workloads and caseload assignments to ensure staff are able to provide the intensity and responsiveness required by High Fidelity Wraparound without compromising quality of care or staff well being. Caseloads are monitored by supervisors and leadership to maintain appropriate staff-to-family ratios, support timely response to crises, and ensure adequate time for documentation, Child and Family Team meetings, coaching, and community based service delivery.
See Wraparound Contract page 27
c.) Career growth and advancement opportunities are clearly communicated and accessible to all staff, including positions rooted in lived experience, such as Parent Partner and Youth Partner roles. Promotion pathways into lead, supervisory, training, coaching, and quality assurance functions are intentionally structured to support professional development and leadership growth without creating barriers for staff with lived experience.
See Wraparound Contract Question 8: page 13
d.) The organization provides opportunities for wage increases, expanded leadership responsibilities, mentoring roles, training facilitation, and project leadership opportunities that do not require a formal position change in order for staff to grow professionally and financially.
See Wraparound Contract Question 8: page 13
9.6 High Fidelity Training Plan
a.) All new staff receive initial HFW training as part of onboarding, which includes foundational instruction in the California High Fidelity Wraparound model, family voice and choice, strengths-based and needs driven planning, cultural responsiveness, crisis and safety planning, documentation expectations, Child and Family Team facilitation, and county required workflows such as OCIMS. This initial training is supported through county core trainings, agency orientation, role shadowing, and supervised field-based coaching.
See Core Day 1
Core Day 2
Core Day 3
Core Day 4
OCIMS Day 3
Facilitation Training pages 7-28
New Parent Partner Training pages 3-38
New Care Coordinator Training pages 3-34
Critical Thinking pages 2-18
Natural Support Training pages 2-33
Mandatory Training for Staff by Role
Wraparound Overview pages 2-27
Wraparound Onboarding Process
b.) Ongoing training occurs through multiple formal and informal structures, including bi-monthly Professional Growth meetings, monthly Wrap Institute sessions, reflective supervision, coaching, chart review feedback, peer shadowing, case consultation, and county-sponsored trainings. These activities support both general Wraparound practice and role specific skill development for Facilitators, Parent Partners, Youth Partners, Supervisors, and other program staff.
See Mandatory Staff Training by Role
Core Day 1 pages 57-58
Wrap OC Staff Training Development
c.) All staff receive annual booster trainings to reinforce fidelity to HFW principles and strengthen skills related to planning, implementation, documentation, crisis response, engagement, cultural humility, and transition practices.
See Wraparound Staff Training by Role
Wrap OC Staff Training Development
d.) Supervisors and managers receive additional leadership and fidelity focused training, including coaching strategies, staff development, chart review, performance feedback, quality assurance, and compliance with HFW standards.
See Wraparound OC Staff Development
QA Site Review Tool
Site Review Tool
Wrap OC Staff Training Development
e.) The County of Orange is currently working on developing a training that will specifically coach our staff members on ICWA and Tribal sovereignty, including instruction on respectful collaboration with Tribes, culturally rooted supports, and the role of Tribal representatives as equal partners when serving Indian children and families. In addition, leadership identifies emerging community needs and provides additional trainings to support populations with unique and specialized needs, including trauma-informed practice, language access, developmental disabilities, and other specialized populations as needed.
This multi-layered training structure ensures staff competency, leadership development, fidelity compliance, and sustained high quality service delivery across all levels of the program.
See Core Day 1 page 12
Core Day 2 page 51
9.7 Community-based Training Program
a.) Youth, caregivers, Parent Partners, Youth Partners, and individuals with current or prior Wraparound experience are meaningfully incorporated into the delivery of training, particularly those focused on family voice and choice, engagement, cultural humility, crisis response, transition, and team collaboration. Staff with lived experience, including Parent Partner trainers and family support leaders, help facilitate training, share real-world perspectives, and strengthen staff understanding of the family experience within Wraparound. This practice is reflected in agency and county trainings, including Family Support Network (FSN) based training facilitated by Parent Partner leadership and community support staff.
See Core Day 4 page 36
New Parent Partner Training page 8-10
b.) The program also actively promotes training opportunities to system and community partners, including Social Services Agency (SSA), Children and Youth Behavioral Health (CYBH), Probation, school personnel, community providers, and Family Support Network partners, to strengthen their understanding of the HFW model and improve their participation on Child and Family Teams (CFTs). These trainings help ensure that team members from other systems have clear context regarding HFW principles, phases, roles, and expectations, which strengthens cross-system collaboration and continuity of care.
See Mandatory Training for Wraparound Staff by Role
Wrap OC Staff Meetings
Wrap OC Training and Development
9.8 Coaching and Supervision
a.) New staff participate in an initial apprenticeship process that includes formal onboarding, role specific training, peer shadowing, supervised field experience, chart review guidance, and reflective coaching. This apprenticeship emphasizes family voice and choice, strengths based and needs driven planning, Child and Family Team facilitation, crisis and safety planning, cultural responsiveness, documentation standards, and the effective and appropriate use of flex funds to support individualized family needs.
During this initial learning period, staff are supported through side-by-side coaching with supervisors, experienced team members, and role-specific peers such as Parent Partners, Youth Partners, and Facilitators.
See Wraparound Onboarding Process Pages 1-16
New Youth Partner Training pages 2-29
New Parent Partner training pages 3-39
New Care Coordinator training pages 3-36
b.) Ongoing coaching and supervision continue throughout employment through regular reflective supervision, case consultation, Professional Growth meetings, monthly Wrap Institute, fidelity review, chart audits, and real-time support from supervisors and leadership. Leadership ensures that staff have access to supervision and coaching 24/7 as needed, particularly in response to crisis situations, safety concerns, after-hours team support needs, and urgent family situations that require immediate consultation. This flexible supervision structure reflects the program’s commitment to responsive service delivery and the reality of community based Wraparound work.
See Mandatory Training for Wraparound Staff by Role
Wrap OC Staff Meetings
Wrap OC Training and Development
Wraparound Contract page 20
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
N/A only for county.
10.2 Evaluation Metrics & Outcomes
a.) Data collected through OCIMS, county outcome reports, Wraparound Fidelity Index (WFI) results, IP-CANS assessments, chart reviews, and family feedback, is used to improve service provision with youth and families by providing timely feedback to staff and supervisors regarding documentation quality, progress toward goals, timeliness of Child and Family Team meetings, action item completion, family satisfaction, fidelity indicators, and outcomes. Supervisors review data during reflective supervision, Professional Growth meetings, and chart audits to identify staff strengths, areas for improvement, and training needs. This data is also used to guide individualized coaching, booster trainings, and workforce development initiatives.
See OCIMS Day 2 page 11-12
b.) At the program level, leadership utilizes data trends to identify service gaps, workflow barriers, staffing needs, documentation compliance issues, access concerns, and outcome disparities in order to improve overall program effectiveness. Data is reviewed through quality assurance meetings, county reports, fidelity monitoring, and leadership review processes to strengthen family engagement, crisis response, transition planning, and service coordination practices.
See Wraparound Fidelity Index pages 1-18
Site Review Tool
QA Site Review Tool
Team Observation Tool
c.) At the systems level, program leadership uses data and trend analysis to identify system barriers that affect High Fidelity Wraparound implementation, such as delays in referrals, cross-agency communication challenges, access limitations, or resource gaps. These findings are communicated to county partners, WRIT, and the Community Leadership Team to support collaborative problem-solving and system-level improvement efforts that strengthen the overall Children’s System of Care.
See Wraparound Fidelity Index
Site Review Tool
QA Site review Tool
Team Observation Tool
Fidelity Indicators
1.1 Timely Engagement and Planning
Fred Finch Wraparound demonstrates fidelity to Timely Engagement and Planning through structured intake, defined service timelines, ongoing monitoring, and supervisory oversight:
(a) First contact with families is made within 3 business days and no later than 10 calendar days after referral received. Upon referral, Wrap Connections staff initiate outreach immediately and schedule intake within required timelines, prioritizing engagement, safety, and orientation to the Wraparound process.
Evidence: Wrap Connections Process Checklist, p.34; Documentation Certification Policy & Procedure, p.80.
(b) The initial Wraparound Plan of Care is completed within 30 calendar days of service start. Facilitators use standardized documentation tools and supervision oversight to ensure timely development of the plan aligned with identified needs and strengths.
Evidence: Wrap Connections Process Checklist, p.34; Documentation Certification Policy & Procedure, p.80.
(c) Plans of Care are reviewed within the context of a Child and Family Team (CFT) meeting at least every 30–45 days. Meetings include structured agendas and documentation of progress, needs, and strategy effectiveness.
Evidence: Wrap Connections Process Checklist, p.34; Internal Quality Records Review Policy, p.94.
(d) Plans of Care are updated, documented in the youth’s record, and distributed to all team members at least every 90 days, or more frequently as needed. Updates reflect changes in needs, progress, and team input on Wraparound Plan of Care.
Evidence: Documentation Certification Policy & Procedure, p.80; Internal Quality Records Review Policy, p.94.
(e) Staff and supervisors receive ongoing feedback regarding timeliness through supervisory chart reviews, internal quality record reviews, and CQI monitoring. Performance expectations are reinforced through coaching and evaluation processes.
Evidence: Internal Quality Records Review Policy, p.94; Continuous Quality Improvement (CQI) Plan, p.67.
(f) Staff are trained in timely engagement strategies, including alternative approaches when contact is difficult (e.g., flexible scheduling, community-based outreach, and use of natural supports). Training is provided during onboarding and reinforced through ongoing supervision and consultation groups.
Evidence: New Hire Orientation Checklist, p.189; Continuous Quality Improvement (CQI) Plan, p.67.
1.2 Led by Youth and Families
Fred Finch Wraparound ensures services are led by youth and families by prioritizing family voice, shared decision-making, and ongoing feedback:
(a) Youth and family perspectives drive all planning through the development and ongoing use of the Family Vision and Team Mission statements. Facilitators elicit and document these during engagement and ensure they guide decision-making throughout all phases of Wraparound. In cases involving Indian children, Tribal representatives are engaged as equal team members, and their perspectives are incorporated into planning in alignment with ICWA principles.
Evidence: Care Plan Template, p.37; Wrap Plan Template, p.39; Training Policy & Procedure, p.153.
(b) Family values, culture, expertise, capabilities, interests, and strengths are actively elicited, documented, and integrated into the youth’s case file and Plan of Care. These elements are continuously referenced and updated to ensure services remain aligned with family preferences.
Evidence: Care Plan Template, p.37; Wrap Plan Template, p.39.; Wrap Activities p.13
(c) Supervisors and coaches routinely review Plans of Care, meeting documentation, and case records to ensure that youth and family voice is reflected in all aspects of planning and service delivery. Supervisory feedback and coaching are used to reinforce fidelity to family-driven practice and build staff competency.
Evidence: Performance Evaluation – Direct Care Staff, p.203; Continuous Quality Improvement (CQI) Plan, p.67.
(d) Family feedback is routinely collected through Parent Advisor Group (PAG), satisfaction surveys, quality assurance outreach, WFI, and fidelity-informed review processes. Feedback is analyzed and incorporated into Continuous Quality Improvement (CQI) activities to strengthen practice and ensure services remain youth- and family-driven.
Evidence: WFI, p.27; Continuous Quality Improvement (CQI) Plan, p.67.
1.3 Strength-Based
Fred Finch Wraparound implements a strength-based approach by identifying, documenting, and utilizing functional strengths to guide planning and service delivery:
(a) A strengths inventory is developed collaboratively with the youth, family, team members, and community supports during engagement and is continuously updated throughout the Wraparound process. Strengths are documented in the Plan of Care and referenced during Child and Family Team (CFT) meetings to guide planning and strategy development.
Evidence: Care Plan Template, p.37; Wrap Plan Template, p.39.
(b) Individualized strengths are identified using multiple sources, including but not limited to the IP-CANS assessment. IP-CANS is a required tool used to identify functional strengths and integrate them into planning and service delivery.
Evidence: IP-CANS, p.96; Care Plan Template, p.37.
(c) Staff receive ongoing training and coaching in strengths-based and solution-focused practices, emphasizing the use of strengths to drive decision-making rather than focusing on deficits. These practices are reinforced through supervision and fidelity-informed coaching.
Evidence: Training Policy & Procedure, p.153.
(d) Feedback from families regarding their experience of strengths-based services is routinely collected through satisfaction surveys, quality assurance processes, and CQI activities. This feedback is reviewed and used to inform staff training, supervision, and continuous quality improvement efforts.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67.
1.4 Needs Driven
Fred Finch Wraparound ensures services are needs-driven by identifying and prioritizing underlying needs to guide goal development, strategies, and transition planning:
(a) Underlying needs are identified and prioritized prior to the development of goals and strategies. Facilitators work collaboratively with youth, families, and team members to develop needs statements that reflect the root causes of behaviors, and these prioritized needs directly guide planning.
Evidence: Care Plan Template, p.37; Documentation Certification Policy & Procedure, p.80.
(b) Staff receive ongoing training and coaching in identifying underlying needs and developing needs statements that reflect the reasons behind behaviors rather than focusing on deficits. Training emphasizes needs-driven planning and is reinforced through supervision and coaching.
Evidence: Training Policy & Procedure, p.153.
(c) Identification of individualized needs includes, but is not limited to, those identified through the IP-CANS assessment. IP-CANS is a required tool used to support needs identification, prioritization, and integration into planning.
Evidence: IP-CANS, p.96.
(d) Transition from Wraparound services occurs based on team and family agreement that identified needs have been sufficiently met. Transition decisions are made collaboratively and reflect progress toward resolving underlying needs.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67; Documentation Certification Policy & Procedure, p.80.
1.5 Individualized
Fred Finch Wraparound delivers individualized services by tailoring Plans of Care to each youth and family’s strengths, needs, culture, and preferences:
(a) Documentation tools, including the Care Plan and Wrap Plan templates, are designed to support flexibility and customization, allowing facilitators to develop individualized plans based on each youth and family’s strengths, needs, culture, values, and preferences.
Evidence: Care Plan Template, p.37; Wrap Plan Template, p.39.
(b) Staff receive ongoing training and coaching in developing flexible, creative, and individualized strategies that move beyond standardized or formulaic approaches and reflect each family’s unique circumstances. Training is provided during onboarding and reinforced through ongoing supervision and consultation groups.
Evidence: Training Policy & Procedure, p.153.
(c) Facilitators receive ongoing coaching and supervision to lead the HFW team in customizing the Wraparound process and Plan of Care based on the youth and family’s strengths, needs, culture, and preferences, including incorporation of community and natural supports.
Evidence: Training Policy & Procedure, p.153; Documentation Certification Policy & Procedure, p.80.
(d) Plans of Care are routinely reviewed through supervision, documentation review, and CQI processes to ensure that strategies, goals, and outcomes are individualized and reflect family-identified priorities, community assets, and informal supports.
Evidence: Documentation Certification Policy & Procedure, p.80; Continuous Quality Improvement (CQI) Plan, p.67.
(e) Family feedback regarding the extent to which services are individualized and responsive to their needs is routinely collected through satisfaction surveys, quality assurance processes, WFI, and CQI activities. This feedback is used to inform staff coaching, supervision, and program improvement.
Evidence: WFI, p27; Continuous Quality Improvement (CQI) Plan, p.67.
1.6 Use of Natural and Community Based Supports
Fred Finch Wraparound integrates natural and community-based supports by identifying, engaging, and prioritizing these resources within service planning and delivery:
(a) A natural and community supports inventory is developed collaboratively with each family during engagement and is updated throughout the Wraparound process. Natural supports are identified as key members of the Child and Family Team and are documented in the Plan of Care.
Evidence: Wrap Connections Process Checklist, p.34; Care Plan Template, p.37.
(b) Staff receive ongoing training and coaching in identifying, engaging, and integrating natural supports into the Wraparound process, with an emphasis on reducing reliance on formal services and strengthening sustainable community-based supports.
Evidence: Training Policy & Procedure, p.153.
(c) Plans of Care are routinely reviewed through supervision, documentation review, and CQI processes to ensure that strategies and action items incorporate natural supports and community-based resources, and reflect a shift toward sustainability over time.
Evidence: Wrap Plan Template, p.39; Documentation Certification Policy & Procedure, p.80; Continuous Quality Improvement (CQI) Plan, p.67.
(d) Family feedback regarding their experience with natural supports and community-based strategies is routinely collected through satisfaction surveys, quality assurance processes, and CQI activities. This feedback is used to inform staff coaching, supervision, and program improvement.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67.
1.7 Culturally Respectful and Relevant
Fred Finch Wraparound ensures culturally respectful and relevant services by incorporating family culture, values, and traditions into all aspects of planning and delivery:
(a) A strengths, needs, and cultural discovery process is completed with each family prior to development of the Plan of Care. Cultural values, traditions, identity, and preferences are documented and integrated into planning to ensure services are culturally responsive. In cases involving Indian children, Tribal perspectives are incorporated and respected throughout the process.
Evidence: Care Plan Template, p.37; Wrap Plan Template, p.39.
(b) Staff receive ongoing training and coaching in culturally responsive practices, including eliciting and integrating family culture into planning and service delivery. Training includes ICWA and Tribal sovereignty when applicable, and is reinforced through supervision and coaching.
Evidence: Training Policy & Procedure, p.153.
(c) Family feedback regarding the cultural relevance and respectfulness of services is routinely collected through satisfaction surveys, quality assurance processes, and CQI activities. This feedback is used to inform staff training, supervision, and continuous quality improvement efforts.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67.
1.8 High-Quality Team Planning and Problem Solving
Fred Finch Wraparound promotes high-quality team planning and problem solving through collaborative team processes, shared ownership, and continuous feedback:
(a) Team agreements are developed collaboratively with the youth, family, and team members during the Wraparound process and are documented in the youth’s file. These agreements guide team participation, communication, and decision-making throughout all phases of service.
Evidence: Wrap Connections Process Checklist, p.34; Care Plan Template, p.37.
(b) Feedback from families and HFW team members regarding team engagement, collaboration, and effectiveness is routinely elicited through observations, satisfaction surveys, quality assurance outreach, and supervision processes.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67.
(c) Feedback collected from families and team members is reviewed and utilized as part of Continuous Quality Improvement (CQI) processes to inform staff coaching, supervision, and program improvement, ensuring high-quality team functioning and collaboration.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67; Performance Evaluation – Direct Care Staff, p.203.
(d) Plans of Care and meeting minutes are routinely reviewed through supervision, documentation review, and CQI monitoring to assess shared ownership, accountability, and follow-through on strategies and action items across all team members.
Evidence: Wrap Plan Template, p.39; Documentation Certification Policy & Procedure, p.80; Continuous Quality Improvement (CQI) Plan, p.67.
1.9 Outcomes Based Process
Fred Finch Wraparound utilizes an outcomes-based process by tracking measurable goals, monitoring progress, and using data to inform ongoing planning and decision-making:
(a) The Wraparound Plan of Care includes specific, measurable goals, strategies, and action items with clearly defined timeframes. These are developed collaboratively with the youth, family, and team and are directly linked to identified needs.
Evidence: Care Plan Template, p.37; Wrap Plan Template, p.39.
(b) Facilitators track completion of action items and monitor progress toward outcomes during Child and Family Team (CFT) meetings and through ongoing documentation. Progress is reviewed regularly and used to assess effectiveness of strategies.
Evidence: Wrap Plan Template, p.39; Documentation Certification Policy & Procedure, p.80.
(c) Plans and documentation processes allow for strategies and action items to be adjusted as needed based on progress and emerging needs. Changes are documented and communicated to all team members to ensure coordinated implementation.
Evidence: Documentation Certification Policy & Procedure, p.80; Continuous Quality Improvement (CQI) Plan, p.67.
(d) The IP-CANS assessment is completed by trained clinical staff (e.g., licensed or designated qualified staff) at required intervals and is shared with the Child and Family Team to inform planning. The process for completion and integration of IP-CANS data is guided by program policy and supervision.
Evidence: IP-CANS, p.96; Documentation Certification Policy & Procedure, p.80.
(e) Data from the IP-CANS is used to support tracking of needs, strengths, and progress and to inform team decision-making; however, it does not replace team-based monitoring of needs, goal completion, and action item completion when determining progress and transition readiness.
Evidence: IP-CANS, p.96; Continuous Quality Improvement (CQI) Plan, p.67.
1.10 Persistence
Fred Finch Wraparound demonstrates persistence by supporting teams to adapt plans, overcome barriers, and continue services until needs are met:
(a) Teams are supported to continue working with youth and families despite setbacks or limited progress. Challenges are viewed as indicators that strategies or plans need to be revised rather than as failure, and services continue until the team—guided by family voice and choice—agrees that needs have been sufficiently met.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67; Documentation Certification Policy & Procedure, p.80.
(b) Clear processes are in place for teams to access additional support when facing challenges, including requesting coaching and supervision, accessing flexible funds, and utilizing additional system or community resources to address barriers.
Evidence: Flex Funds Policy & Procedure, p.84; Continuous Quality Improvement (CQI) Plan, p.67.
(c) Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and leading teams in effective brainstorming and plan revision to ensure persistence in meeting family needs.
Evidence: Training Policy & Procedure, p.153.
1.11 Transitions as a part of the Fourth Phase of HFW
Fred Finch Wraparound ensures transitions are planned, needs-driven, and meaningful by preparing families for sustainability and celebrating successful completion of services:
(a) Transitions are planned in advance through a structured, team-based process and occur only when the youth and family’s identified needs have been sufficiently met. Families do not experience abrupt or unplanned discharge due to administrative requirements or adverse events. Transition planning includes preparation of natural supports, linkage to community resources, and development of post-Wraparound safety planning.
Evidence: Wrap Connections Process Checklist, p.34; Care Plan Template, p.37; Documentation Certification Policy & Procedure, p.80.
(b) Transitions out of Wraparound are celebrated in a manner that reflects the youth and family’s culture, values, and preferences. Administrative structures support participation in celebrations, including the use of flexible funds when appropriate, staff availability, and connection to community resources to support sustainability.
Evidence: Flex Funds Policy & Procedure, p.84; Continuous Quality Improvement (CQI) Plan, p.67.
Expected Outcomes
2.1 Youth and Family Satisfaction
Fred Finch Wraparound measures and utilizes youth and family satisfaction data to evaluate service quality and inform continuous improvement. Actively monitors youth, family, and (when applicable) Tribal satisfaction with the High-Fidelity Wraparound (HFW) process and perceived progress toward goals. Satisfaction data is collected at multiple points during service delivery and at transition, ensuring feedback reflects the family’s experience across all phases of Wraparound. Feedback mechanisms include structured satisfaction surveys, quality assurance follow-up, and team-based discussions. In cases involving Indian children, Tribal partners are engaged as appropriate to assess satisfaction with collaboration, communication, and cultural responsiveness.
Collected satisfaction data is reviewed through Continuous Quality Improvement (CQI) processes and shared with supervisors and leadership to inform practice improvements, staff coaching, and training priorities.
Evidence: Continuous Quality Improvement (CQI) Plan (Pg 67); Internal Quality Records Review Policy (Pg 94); Documentation Certification Policy & Procedure (Pg 80); Wrap Connections Process Checklist (Pg 34)
2.2 Improved School Functioning
Fred Finch Wraparound tracks and supports improved school functioning through monitoring attendance, performance, and engagement. Educational and vocational functioning is monitored as a core outcome of Fred Finch Wraparound services. Facilitators collaborate with youth, caregivers, schools, and educational partners to track attendance, academic engagement, IEP/504 participation, and vocational development. Educational progress is reviewed during Child and Family Team (CFT) meetings and incorporated into the Plan of Care as goals, strategies, and outcomes.
School functioning data is documented in the youth’s record and reviewed through supervisory oversight and CQI outcome monitoring to identify trends, barriers, and opportunities for cross-system coordination.
Evidence: Wrap Plan / Care Plan Templates (Pg 37 & 39); Documentation Certification Policy & Procedure (Pg 80); Continuous Quality Improvement (CQI) Plan (Pg 67)
2.3 Improved Functioning in the Community
Fred Finch Wraparound promotes and evaluates improved community functioning through monitoring youth engagement and justice involvement. Monitors youth functioning in the community, including engagement in pro-social activities and reduced involvement with the juvenile justice system. Facilitators work with families and community partners to identify meaningful community activities aligned with youth strengths and interests. Community functioning outcomes are discussed during team meetings and documented in Plans of Care.
Data related to justice involvement, community participation, and behavioral stability is reviewed through CQI processes to assess effectiveness of strategies and inform plan adjustments.
Evidence: Wrap Plan / Care Plan Templates (Pg 37 & 39); Wrap Connections Process Checklist (Pg 34); Continuous Quality Improvement (CQI) Plan (Pg 67)
2.4 Improved Interpersonal Functioning
Fred Finch Wraparound supports improved interpersonal functioning by strengthening family relationships and social connections. Interpersonal functioning outcomes focus on reduced family stress, improved relationships, and strengthened peer connections. Facilitators support families in identifying relational needs and developing strategies that promote healthy communication, conflict resolution, and connection. Progress is reviewed during team meetings and documented in the Plan of Care.
Supervisors and CQI reviews assess whether interpersonal functioning outcomes are addressed through individualized strategies and whether progress is evident over time.
Evidence: Wrap Plan / Care Plan Templates (Pg 37 & 39); Documentation Certification Policy & Procedure (Pg 80); Continuous Quality Improvement (CQI) Plan (Pg 67)
2.5 Increased Caregiver Confidence
Fred Finch Wraparound enhances caregiver confidence by building skills, strengthening supports, and improving access to resources. Services aim to increase caregiver’s confidence and capacity to manage future challenges independently. Facilitators support caregivers in identifying skills, resources, and supports that enhance confidence and crisis preparedness. Caregiver confidence is discussed during planning and transition and documented as an outcome within the Plan of Care.
CQI processes review caregiver-related outcomes to ensure services are building sustainable skills and connections to community resources.
Evidence: Wrap Plan / Care Plan Templates (Pg 37 & 39); Training Policy & Procedure (Pg 153); Continuous Quality Improvement (CQI) Plan (Pg 67)
2.6 Stable and Least Restrictive Living Environment
Fred Finch Wraparound promotes stability in least restrictive environments by monitoring placements and supporting community-based living. Prioritizes permanency and stability in the least restrictive, community-based living environments. Placement stability is monitored throughout service delivery, with team-based problem-solving used to prevent unnecessary placement changes or institutionalization. Placement changes, when they occur, are documented and reviewed to identify contributing factors.
CQI dashboards and discharge reviews monitor trends in placement stability and inform program-level improvements.
Evidence: Continuous Quality Improvement (CQI) Plan (Pg 67); Internal Quality Records Review Policy (Pg 94); Documentation Certification Policy & Procedure (Pg 80)
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Fred Finch Wraparound reduces inpatient and emergency department utilization by supporting behavioral health stability and early intervention. Behavioral health stability is measured through monitoring inpatient admissions and emergency department visits. Facilitators coordinate with behavioral health providers and caregivers to identify triggers, enhance crisis planning, and implement preventative strategies. Hospital utilization data is reviewed during team meetings and incorporated into plan revisions.
CQI outcome analysis tracks trends in inpatient and emergency utilization to evaluate program effectiveness and guide training and service improvements.
Evidence: Safety Planning (Pg 35); Continuous Quality Improvement (CQI) Plan(Pg 67); Documentation Certification Policy & Procedure (Pg 80); Incident Reporting Policy & Procedure (Pg 89)
2.8 Reduction in Crisis Visits
Fred Finch Wraparound reduces crisis involvement by strengthening natural supports and proactive crisis planning. Emphasizes proactive crisis prevention and natural support utilization. Crisis frequency, intensity, and professional involvement are documented and reviewed. Facilitators work with families to strengthen natural supports and crisis response strategies, reducing reliance on professional crisis services over time.
Crisis data is reviewed through CQI processes and supervision to ensure crisis plans are effective and individualized.
Evidence: Safety Plan (Pg 35); Wrap Connections Process Checklist (Pg 34); Continuous Quality Improvement (CQI) Plan (Pg 67); Incident Reporting Policy & Procedure. (Pg 89)
2.9 Positive Exit from HFW
Fred Finch Wraparound ensures positive exits by supporting needs-based transitions and avoiding discharge due to adverse events. Youth and families exit Fred Finch Wraparound services based on stabilization and sufficient progress in meeting identified needs. Discharges do not occur due to adverse events or administrative requirements. Transition readiness is determined collaboratively by the team and family and documented in the youth’s record.
CQI discharge reviews evaluate reasons for exit, outcomes achieved, and sustainability of supports to ensure fidelity to Wraparound principles.
Evidence: Transition Planning Documentation (RTWB slide 12 )(Pg 12), Wrap Connections Process Checklist (Pg 34); Continuous Quality Improvement (CQI) Plan (Pg 67); Documentation Certification Policy & Procedure (Pg 80)
Engagement
3.1 Orientation
Fred Finch Wraparound ensures comprehensive orientation to the HFW process, including roles, expectations, and legal considerations:
(A) The High-Fidelity Wraparound (HFW) process is fully explained to every family at the outset of services. Facilitators provide an overview of the Wraparound principles and phases, ensuring families understand the structure and purpose of the model and how services will be delivered. Orientation is conducted in a developmentally appropriate and culturally responsive manner.
Evidence: Wrap Connections Process Checklist, p.34; RTWB Training (Engagement), p.9.
(a) Legal and ethical considerations are clearly explained to families during orientation, including confidentiality, mandated reporting, informed consent, and family rights and responsibilities. These expectations are reviewed with families and documented in the youth’s record.
Evidence: Documentation Certification Policy & Procedure, p.80; Training Policy & Procedure, p.153.
(b) The roles and responsibilities of all team members are explained, including the central role of the youth and family, the importance of natural supports, and the collaborative nature of the Child and Family Team (CFT). In cases involving Indian children, the role of the Tribe is explained and incorporated as an equal partner on the team.
Evidence: RTWB Training (Engagement), p.9; Training Policy & Procedure, p.153.
(c) Orientation is documented in the youth’s file, and supervisors review documentation to ensure orientation was completed and that families demonstrate understanding of the Wraparound process, expectations, and their rights.
Evidence: Documentation Certification Policy & Procedure, p.80; New Hire Orientation Checklist, p.189.
3.2 Safety and Crisis stabilization
Fred Finch Wraparound addresses immediate safety and crisis needs to support stabilization and engagement in services:
(a) During the Engagement phase, facilitators assess and address immediate safety and crisis concerns with the youth and family. When urgent needs are identified, an immediate crisis response plan is developed collaboratively, provided to the family, and documented in the youth’s chart to support stabilization and ensure safety.
Evidence: Wrap Connections Process Checklist, p.34; Safety Plan Template, p.35; Documentation Certification Policy & Procedure, p.80.
(b) The initial crisis response plan developed during engagement is used to inform, but does not replace, the comprehensive HFW Safety Plan created during the Plan Development phase. This ensures continuity between immediate stabilization efforts and longer-term safety planning.
Evidence: Safety Plan Template, p.35; RTWB Training (Engagement), p.24.
(c) All families are provided with information on how to access 24/7 crisis response services. Facilitators review crisis access procedures identified on safety plan during engagement and ensure families understand how to obtain support outside of scheduled services.
Evidence: Training Policy & Procedure, p.153; Wrap Connections Process Checklist, p.34.
3.3 Strengths, Needs, Culture and Vision Discovery
Fred Finch Wraparound facilitates structured discovery to identify strengths, needs, culture, and family vision to guide planning:
(a) A Family Vision statement is completed collaboratively with every youth and family during the Engagement phase. Facilitators guide structured conversations to identify the family’s goals, values, and desired outcomes, and the Family Vision is documented in the youth’s chart to guide all subsequent planning and decision-making.
Evidence: Care Plan Template, p.37; RTWB Training (Engagement), p.13; Documentation Certification Policy & Procedure, p.80.
(b) A Strengths, Needs, and Culture Discovery document is initiated for every youth and family and is maintained in the youth’s chart. This document is updated at least every 90 days and revised as new strengths, needs, and cultural preferences are identified. It is shared with all team members and provided to new team members to ensure continuity and alignment in planning.
Evidence: Care Plan Template, p.37; Wrap Plan Template, p.39; IP-CANS, p.96; Continuous Quality Improvement (CQI) Plan, p.67.
3.4 Engage All Team Members
Fred Finch Wraparound ensures engagement of formal and natural supports through intentional team building and role clarification:
(a) A natural supports inventory is completed collaboratively with each youth and family and documented in the youth’s case file. This process identifies individuals within the family’s network who can provide ongoing support and are invited to participate as team members.
Evidence: Wrap Connections Process Checklist, p.34; Care Plan Template, p.37.
(b) Children’s System of Care partners are identified and engaged based on the youth and family’s needs. Facilitators ensure that relevant formal providers, community partners, and supports are included on the Child and Family Team (CFT).
Evidence: RTWB Training (Engagement), p.23; Wrap Plan Template, p.39.
(c) Facilitators work collaboratively with youth and families to identify and invite team members, including formal supports, natural supports, and Tribal representatives when applicable. Roles and responsibilities of each team member are clearly defined and discussed to promote active participation and shared ownership.
Evidence: Wrap Connections Process Checklist, p.34; Training Policy & Procedure, p.153.
(d) Engagement and team-building activities are intentionally facilitated to promote a positive, collaborative team culture. These activities and team interactions are documented in meeting minutes and case notes and are reviewed through supervision and CQI processes.
Evidence: Documentation Certification Policy & Procedure, p.80; Continuous Quality Improvement (CQI) Plan, p.67.
3.5 Arrange Meeting Logistics
Fred Finch implements service and support strategies that take place in the most inclusive, most responsive, most accessible, and least restrictive settings:
(a) Staff demonstrate flexibility in scheduling Child and Family Team (CFT) meetings, including adjusting work hours and selecting meeting times and locations that accommodate the youth, family, and team members. Meetings are held in settings that are accessible, culturally responsive, and sensitive to family needs, including use of community-based locations, telehealth, transportation supports, and interpretation services as needed.
Evidence: Wrap Connections Process Checklist, p.34; Documentation Certification Policy & Procedure, p.80.
(b) Staff are trained to collaborate with youth, families, and team members to schedule meetings that align with family voice and choice and maximize participation. Training emphasizes equitable access, cultural responsiveness, and engagement strategies to ensure all team members can meaningfully participate.
Evidence: Training Policy & Procedure, p.153.
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
Fred Finch Wraparound establishes team agreements, identifies strengths, and develops a shared mission to guide collaborative planning:
(a) Prior to development of the initial Wraparound Plan of Care, the facilitator leads the Child and Family Team (CFT) in developing formal team agreements, identifying and updating team strengths, and creating a Team Mission statement aligned with the Family Vision. These foundational elements are completed collaboratively with the youth, family, and team members and are documented in the youth’s file.
Evidence: Wrap Connections Process Checklist, p.34; Care Plan Template, p.37; Documentation Certification Policy & Procedure, p.80.
(b) Strengths identified during the Engagement phase are revisited, expanded, and updated to reflect newly identified strengths of the youth, family, team members, and community supports. These strengths are documented in the youth’s file and actively used to inform planning, decision-making, and development of the Plan of Care.
Evidence: Care Plan Template, p.37; Wrap Plan Template, p.39; Continuous Quality Improvement (CQI) Plan, p.67.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
Fred Finch Wraparound ensures needs-driven planning by prioritizing underlying needs and developing measurable goals and strategies:
(a) Prior to development of the Wraparound Plan of Care, the facilitator leads the team in identifying and prioritizing underlying needs based on information gathered during engagement and ongoing discovery. Needs statements reflect the root causes of challenges and are documented in the youth’s file.
Evidence: Care Plan Template, p.37; IP-CANS, p.96; Documentation Certification Policy & Procedure, p.80.
(b) Measurable goals and outcomes are developed directly from prioritized needs, ensuring that planning is needs-driven rather than behavior- or deficit-based. Goals are clearly defined and aligned with desired outcomes identified by the youth and family.
Evidence: Care Plan Template, p.37; Wrap Plan Template, p.39.
(c) Goals and outcomes are developed collaboratively with the youth, family, and all Child and Family Team (CFT) members to ensure shared understanding, ownership, and alignment with family priorities.
Evidence: Wrap Connections Process Checklist, p.34; Wrap Plan Template, p.39.
(d) Facilitators guide the team in brainstorming multiple individualized and creative strategies to address prioritized needs. These strategies are documented in the youth’s file (e.g., within the Plan of Care, meeting minutes, or progress notes) and remain available for ongoing reference and adaptation.
Evidence: Wrap Plan Template, p.39; Documentation Certification Policy & Procedure, p.80.
(e) Facilitators receive ongoing training and coaching in needs-driven planning, collaborative goal development, and effective facilitation of team-based brainstorming and action planning.
Evidence: Training Policy & Procedure, p.153.
(f) These processes are implemented within a structured, team-based planning environment to develop an individualized Wraparound Plan of Care that reflects prioritized needs, measurable outcomes, and collaboratively selected strategies with assigned responsibilities.
Evidence: Wrap Plan Template, p.39; Continuous Quality Improvement (CQI) Plan, p.67.
4.3 Develop an Individualized Child or Youth and Family Plan
Fred Finch Wraparound develops comprehensive, individualized Plans of Care that integrate strengths, needs, culture, and coordinated supports:
(a) Facilitators receive ongoing training and coaching to lead a high-quality, team-based planning process that elicits multiple perspectives, builds trust and shared vision, and reflects High-Fidelity Wraparound principles. This process includes participation from all relevant Children’s System of Care partners and, when applicable, Tribal representatives.
Evidence: Training Policy & Procedure, p.153; Wrap Connections Process Checklist, p.34.
(b) The Plan of Care comprehensively integrates goals and objectives identified by all team members and is aligned with the Family Vision and Team Mission. The plan reflects strengths, needs, and cultural considerations and addresses prioritized needs across multiple life domains.
Evidence: Care Plan Template, p.37; Wrap Plan Template, p.39.
(c) The Plan of Care is documented in the youth’s file, distributed to all team members, and includes clearly defined strategies and action items with assigned responsibilities and timelines. Plans incorporate a coordinated mix of formal services, natural supports, and community resources, emphasize community-based service delivery, and include strategies to build sustainable supports and benchmarks for gradual transition to less restrictive services.
Evidence: Wrap Plan Template, p.39; Documentation Certification Policy & Procedure, p.80.
(d) Plans of Care are routinely reviewed through supervision, documentation review, and Continuous Quality Improvement (CQI) processes to ensure fidelity to Wraparound principles and alignment with all required elements. Feedback is provided to staff and supervisors to support ongoing training, coaching, and quality improvement.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67; Documentation Certification Policy & Procedure, p.80.
4.4 Develop a Crisis and Safety Plan
Fred Finch Wraparound develops individualized crisis and safety plans that include proactive and reactive strategies and natural supports:
(a) An individualized crisis and safety plan is developed collaboratively with the youth, family, and team and is documented in the youth’s file. The plan identifies potential safety risks, high-risk and crisis situations, and includes proactive and reactive strategies selected by the family. It clearly outlines warning signs, prevention strategies, response steps, and designated contacts for 24/7 support.
Evidence: Safety Plan Template, p.35; Documentation Certification Policy & Procedure, p.80.
(b) Crisis and safety planning occurs within a team-based, collaborative environment. Facilitators receive ongoing training and coaching in developing individualized, strengths-based, and culturally relevant crisis plans that incorporate family voice and maximize the use of natural supports.
Evidence: Training Policy & Procedure, p.153; Wrap Connections Process Checklist, p.34.
(c) Crisis and safety plans are routinely reviewed through supervision, documentation review, and Continuous Quality Improvement (CQI) processes to ensure plans include individualized strategies, demonstrate a progression of proactive and reactive responses, reflect cultural relevance, and effectively incorporate natural supports.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67; Documentation Certification Policy & Procedure, p.80.
Implementation
5.1 Implement The Plan of Care
Fred Finch Wraparound implements Plans of Care through structured team processes, progress monitoring, and reinforcement of successes:
(a) The facilitator leads implementation of the Plan of Care by guiding Child and Family Team (CFT) meetings that review strategies, action items, assigned responsibilities, and progress toward outcomes. Meeting agendas and minutes are used to track completion of action items, monitor timelines, and document progress. Facilitators also check in between meetings as needed to support follow-through, address barriers, and adjust strategies and action items.
Evidence: Wrap Plan Template, p.39; Wrap Connections Process Checklist, p.34; Documentation Certification Policy & Procedure, p.80.
(b) Staff receive ongoing training and coaching on implementing the Plan of Care in alignment with High-Fidelity Wraparound principles, including strengths-based practice, family voice and choice, cultural responsiveness, and use of natural supports. Training and practice emphasize recognizing and celebrating successes to reinforce progress, build engagement, and support positive outcomes.
Evidence: Training Policy & Procedure, p.153; RTWB Training, p.11; Continuous Quality Improvement (CQI) Plan, p.67.
5.2 Review and Update The Plan of Care
Fred Finch Wraparound ensures continuous review and updating of Plans of Care based on progress, feedback, and changing needs:
(a) Reviews of strategies, progress, and action items occur within Child and Family Team (CFT) meetings, where facilitators guide the team in assessing progress toward outcomes and evaluating the effectiveness of current strategies using data, observations, and family feedback.
Evidence: Wrap Plan Template, p.39; Wrap Connections Process Checklist, p.34.
(b) The facilitator leads the team in adjusting the Plan of Care as needed based on progress, emerging needs, or changing circumstances. Updates to goals, strategies, and action items are documented in the youth’s file and reflect collaborative team decision-making.
Evidence: Care Plan Template, p.37; Documentation Certification Policy & Procedure, p.80.
(c) Facilitators document and communicate all updates, including completion of tasks, new assignments, team attendance, use of formal and natural supports, use of flexible funds, and changes to the Plan of Care. This information is shared with all team members, at a minimum, through team meeting minutes and ongoing communication.
Evidence: Documentation Certification Policy & Procedure, p.80; Wrap Plan Template, p.39.
(d) Documentation tools and forms are designed to be flexible and allow for ongoing updates and individualization of the Plan of Care to reflect evolving youth and family needs. Plans are formally updated and redistributed at least every 90 days, or more frequently as needed, and are reviewed through supervision and Continuous Quality Improvement (CQI) processes to ensure fidelity and quality.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67; Internal Quality Records Review Policy, p.94.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
Fred Finch Fred Finch Wraparound maintains team cohesion and trust through ongoing engagement, support of natural supports, and structured team processes:
(a) Team agreements developed during Plan Development are actively utilized and reviewed during Child and Family Team (CFT) meetings to reinforce expectations for collaboration, communication, and shared decision-making. Facilitators monitor team dynamics and revisit agreements as needed to maintain cohesion and trust.
Evidence: Wrap Connections Process Checklist, p.34; Wrap Plan Template, p.39.
(b) Facilitators receive ongoing training and coaching on building, engaging, and sustaining effective teams, including strategies for conflict resolution, inclusive engagement, and maintaining shared ownership among team members.
Evidence: Training Policy & Procedure, p.153; Performance Evaluation – Direct Care Staff, p.203.
(c) The use of natural supports is continuously monitored and strengthened over time. Supervisors and coaches provide feedback to facilitators on engagement and integration of natural and community supports to promote sustainability and reduce reliance on formal services.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67; Documentation Certification Policy & Procedure, p.80.
(d) When new team members are added, facilitators provide orientation to the Wraparound process, review the current Plan of Care, clarify roles and responsibilities, and engage members in team-building activities to support effective participation and cohesion.
Evidence: Wrap Connections Process Checklist, p.34; Training Policy & Procedure, p.153.
Transition
6.1 Develop a Transition Plan
Fred Finch Wraparound develops individualized transition plans to ensure continuity of supports and sustained outcomes:
(a) The facilitator leads the Child and Family Team (CFT) in identifying readiness for transition based on pre-determined benchmarks and indicators of progress toward meeting prioritized needs and achieving the Team Mission. These benchmarks are monitored throughout the Wraparound process and reviewed collaboratively with the youth and family.
Evidence: Wrap Connections Process Checklist, p.34; Wrap Plan Template, p.39.
(b) Once readiness is identified, the facilitator leads the team in developing an individualized transition plan that identifies ongoing needs, services, and supports. The plan is documented in the youth’s file and distributed to all team members to ensure coordinated implementation.
Evidence: Care Plan Template, p.37; Documentation Certification Policy & Procedure, p.80.
(c) Transition planning occurs within a team-based, collaborative process that prioritizes family voice and choice. Facilitators receive training and coaching to support effective transition planning, including identifying sustainable supports and ensuring alignment with Wraparound principles.
Evidence: Training Policy & Procedure, p.153; RTWB Training, p.12.
(d) The team verifies that identified services and supports will persist beyond formal Wraparound services and that the family can access them. For adoptive families, facilitators provide education on post-adoption services (AAP) and incorporate these supports into the transition plan when applicable.
Evidence: Wrap Plan Template, p.39; Continuous Quality Improvement (CQI) Plan, p.67.
6.2 Develop a Post-Transition Safety Plan
Fred Finch Wraparound ensures post-transition safety through updated crisis planning and continued use of natural supports:
(a) The crisis and safety plan is updated to reflect post-transition needs (or a new transition safety plan is developed) and is documented in the youth’s file. The plan identifies potential post-transition crisis situations and includes proactive and reactive strategies selected by the youth and family, with an emphasis on utilizing natural and community supports and clearly identifying who to contact for 24/7 support.
Evidence: Safety Plan Template, p.35; Documentation Certification Policy & Procedure, p.80.
(b) Development of the post-transition crisis and safety plan occurs within a collaborative, team-based process that prioritizes youth and family voice and choice. Facilitators receive training and coaching to support creation of individualized, culturally relevant, and strengths-based safety plans.
Evidence: Training Policy & Procedure, p.153; Wrap Connections Process Checklist, p.34.
(c) Crisis and safety plans are reviewed through supervision, documentation review, and Continuous Quality Improvement (CQI) processes to ensure individualized strategies, appropriate progression of proactive and reactive responses, cultural relevance, and effective integration of natural supports. Feedback from these reviews informs staff training and coaching.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67; Documentation Certification Policy & Procedure, p.80.
6.3 Create a Commencement and Celebrate Success
Fred Finch Wraparound supports meaningful and culturally relevant celebrations to mark successful transition from services:
(a) Transitions out of the Wraparound process are celebrated in collaboration with the youth and family and reflect their culture, values, preferences, and definition of success. Celebrations are individualized and serve to recognize progress, reinforce strengths, and support a positive and empowering transition from formal services.
Evidence: Wrap Connections Process Checklist, p.34; Care Plan Template, p.37.
(b) Administrative structures support transition celebrations by allowing flexibility in staff time, facilitating community-based activities, and providing access to flexible funds when appropriate. These supports ensure that celebrations are meaningful, accessible, and aligned with Wraparound principles.
Evidence: Flex Funds Policy & Procedure, p.84; Continuous Quality Improvement (CQI) Plan, p.67.
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
Fred Finch Wraparound incorporates youth and family feedback into program-level decision-making and quality improvement processes:
(a) Mechanisms are in place to ensure youth and families can participate in decisions regarding local High-Fidelity Wraparound (HFW) implementation. These include satisfaction surveys, quality assurance follow-up, discharge feedback, and review of outcome data, which capture family perspectives on service experience, accessibility, and cultural responsiveness.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67; Internal Quality Records Review Policy, p.94.
(b) Youth and family feedback is systematically reviewed and utilized by supervisors and program leadership to inform service planning and implementation, policy and procedure development, workforce development, and Continuous Quality Improvement (CQI) activities. Aggregated feedback is used to identify strengths, address barriers, and guide training, coaching, and program improvement efforts.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67; Documentation Certification Policy & Procedure, p.80; Wrap Connections Process Checklist, p.34.
7.2 Community Leadership Team
7.3 Eligibility and Equal Access
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
Fred Finch Wraparound aligns funding and fiscal practices to support high-fidelity service delivery, workforce development, and data systems:
(a) Program budgets and contracts allocate funding to support high-fidelity direct services and individualized supports that meet the immediate and unique needs of youth and families. Funding structures allow for flexible, community-based service delivery aligned with Wraparound principles.
Evidence: Statement of Work (SOW), p.106.
(b) Funding supports required workforce development and staffing structures, including key Wraparound roles and supervision functions necessary to maintain fidelity to the model. Resources are allocated for staff training, coaching, and ongoing professional development.
Evidence: Statement of Work (SOW), p.106; Continuous Quality Improvement (CQI) Plan, p.67.
(c) Funding includes support for required data collection and data management systems used to monitor fidelity, track outcomes, and inform Continuous Quality Improvement (CQI) efforts. These systems ensure accountability and alignment with CA Wraparound Standards.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67.
8.2 Equitable Funding Across System Partners
Fred Finch Fred Finch Wraparound collaborates with system partners to leverage funding resources and support equitable access to services:
(a) As a contracted provider, Wrap Connections collaborates with county and Children’s System of Care partners to identify and leverage available federal, state, local, and private funding resources to support High-Fidelity Wraparound (HFW) services. Funding sources such as Medi-Cal are utilized when appropriate to support service delivery and expand access for eligible youth and families.
Evidence: Statement of Work (SOW), p.106.
(b) Wrap Connections participates in system-level collaboration and communication with county partners to support alignment of funding resources and service coordination. Program leadership communicates funding-related needs, gaps, and barriers through Community Leadership Team (CLT) participation and Continuous Quality Improvement (CQI) processes.
Evidence: HFW Community Leadership Team (CLT) Participation Documentation, p.86; Continuous Quality Improvement (CQI) Plan, p.67.
8.3 Cost Savings are Reinvested
Fred Finch Wraparound participates in transparent reporting processes to inform system-level reinvestment of resources:
(a) As a contracted provider, Wrap Connections does not independently retain or reinvest cost savings at the program level; however, the program participates in transparent fiscal reporting and Continuous Quality Improvement (CQI) processes that inform system partners regarding service utilization, outcomes, and resource needs. When applicable, information regarding efficiencies and service outcomes is shared with county partners to support system-level planning and reinvestment decisions that enhance services for youth and families.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67; Statement of Work (SOW), p.106.
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
Fred Finch Wraparound ensures timely access to flex funds through structured approval processes aligned with Wraparound principles:
(a) Flexible funds are available as part of the High-Fidelity Wraparound (HFW) funding structure to meet urgent and individualized youth and family needs that cannot be addressed through other resources. Flex funds are incorporated into program operations to support timely, needs-driven service delivery.
Evidence: Flex Funds Policy & Procedure, p.84; Statement of Work (SOW), p.106.
(b) Processes to access and manage flexible funds are clearly defined and include:
(1) Timely access to flex funds for families with urgent and individualized needs, ensuring responsiveness to emerging situations.
Evidence: Flex Funds Policy & Procedure, p.84.
(2) A structured approval process in which requests are reviewed based on HFW team recommendation and alignment with established criteria, including support of the Team Mission and Plan of Care, alignment with family strengths and identified needs, cultural relevance, use of natural and community supports, cost effectiveness, and sustainability.
Evidence: Flex Funds Policy & Procedure, p.84; Wrap Plan Template, p.39.
(3) A process for communicating decisions, including denial of requests, with clear rationale provided to the team and family, along with information regarding appeal or alternative options.
Evidence: Flex Funds Policy & Procedure, p.84; Documentation Certification Policy & Procedure, p.80.
8.5 Collaborative Oversight of Flex Funds
Fred Finch Wraparound maintains collaborative oversight and transparent tracking of flex fund use:
(a) Flex fund use and availability are documented and transparently communicated through established tracking and reporting processes. Documentation includes the amount requested, purpose of the request, and HFW team recommendation for both approved and denied requests. Flex fund utilization data is reviewed through program oversight and Continuous Quality Improvement (CQI) processes and shared with funders and system partners to ensure accountability and alignment with Wraparound values.
Evidence: Flex Funds Policy & Procedure, p.84; Continuous Quality Improvement (CQI) Plan, p.67.
(b) Flex funds are managed in collaboration with funders and system partners and are pooled to support equitable access for all families served. Program practices ensure that funds are allocated based on individualized need and team recommendation rather than restricted to individual cases or programs.
Evidence: Flex Funds Policy & Procedure, p.84; FF Organizational Code of Ethics Policy & Procedure, p.83.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
Fred Finch Wraparound utilizes braided funding strategies to ensure flexible resources are available to meet family needs:
(a) Flex funds and program resources are supported through the braiding of available System of Care funding streams to ensure availability and flexibility in meeting youth and family needs. Program leadership collaborates with system partners to align multiple funding sources in support of High-Fidelity Wraparound (HFW) services.
Evidence: Statement of Work (SOW), p.106; Flex Funds Policy & Procedure, p.84.
(b) When limitations exist within a specific funding source, alternative funding options are explored and reliance on other funding streams is increased to prevent gaps in services and supports. Program leadership communicates funding barriers through system and Continuous Quality Improvement (CQI) processes to support problem-solving and resource alignment.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67; Statement of Work (SOW), p.106.
(c) Requirements of any single funding source do not prohibit families from accessing flexible funds to meet their individualized needs. Flex fund decisions are guided by Wraparound principles and team-identified needs rather than by restrictions tied to a single funding stream.
Evidence: Flex Funds Policy & Procedure, p.84.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
Fred Finch Wraparound promotes a culturally responsive workforce through intentional hiring, training, and use of supports to meet diverse family needs:
(a) The demographic composition of the population served is routinely monitored through referral data, case documentation, and program-level reporting. This information is used to inform recruitment and hiring practices, with emphasis on building a workforce that reflects the cultural, racial, ethnic, and linguistic diversity of the youth, families, and communities served.
Evidence: Employee Retention Policy & Procedures, p.104; Continuous Quality Improvement (CQI) Plan, p.67.
(b) When direct cultural or linguistic matching is not possible, the program ensures culturally responsive care through alternative strategies, including engagement of natural supports, culturally matched community partners, Parent Partners, Youth Partners, and other formal supports identified by the family.
Evidence: Job Descriptions (Youth Partner, Parent Partner, Facilitator, etc.), p.159; Training Policy & Procedure, p.153.
(c) When a staff member who speaks the family’s primary language is not available, professional interpretation services or trusted natural supports are utilized to ensure full participation, informed decision-making, and equitable access to services.
Evidence: Training Policy & Procedure, p.153; Documentation Certification Policy & Procedure, p.80.
9.2 Tribally Responsive Workforce
Fred Finch Wraparound ensures tribal responsiveness through staff training, respectful collaboration, and integration of tribal supports:
(a) Staff receive training on tribal sovereignty, traditions, values, and ICWA requirements, including how to engage in respectful communication, collaboration, and advocacy with Tribes. Training emphasizes culturally responsive, strengths-based practices that recognize and honor tribal identity and support culturally rooted approaches to care.
Evidence: Training Policy & Procedure, p.153; Statement of Work (SOW), p.106.
(b) When serving an Indian child, the HFW team actively builds partnerships with tribal representatives and includes them as essential members of the Child and Family Team (CFT). Teams encourage participation in tribal traditions and ceremonies as identified by the youth, family, and Tribe, and integrate tribal services, resources, and cultural practices into the Plan of Care.
Evidence: Care Plan Template, p.37; Wrap Plan Template, p.39; Continuous Quality Improvement (CQI) Plan, p.67.
9.3 Flexible and Creative Work Environment
Fred Finch Wraparound fosters a flexible and collaborative work environment that promotes quality improvement, cohesion, and fidelity:
(a) Leadership engages staff in program quality and improvement through structured Continuous Quality Improvement (CQI) processes, supervision, and team meetings. Staff are encouraged to provide input on program practices, identify areas for improvement, and participate in ongoing evaluation of service delivery and fidelity.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67; Clinical Supervision Guidebook, p.41.
(b) Program leadership promotes staff cohesion by fostering a positive team environment through regular team meetings, reflective supervision, and collaborative problem-solving. These structures support shared responsibility, team connection, and a culture of mutual support.
Evidence: Clinical Supervision Guidebook, p.41; Performance Evaluation – Direct Care Staff, p.203.
(c) Open communication is supported through supervision, team meetings, and feedback mechanisms that allow staff to share perspectives, raise concerns, and contribute to program development. Leadership maintains transparent communication channels to support alignment and responsiveness.
Evidence: Clinical Supervision Guidebook, p.41; Continuous Quality Improvement (CQI) Plan, p.67.
(d) Leadership reinforces a clear sense of mission and compliance with High-Fidelity Wraparound principles through training, supervision, and performance evaluation. Staff are supported in applying Wraparound values, principles, phases, and activities in their daily work, while maintaining flexibility and creativity in service delivery.
Evidence: Training Policy & Procedure, p.153; Performance Evaluation – Direct Care Staff, p.203.
9.4 Hiring, Performance Evaluation, and Job Descriptions
Fred Finch Wraparound maintains rigorous hiring and performance evaluation processes aligned with Wraparound competencies and expectations:
(a) All required High-Fidelity Wraparound (HFW) roles and functions are fulfilled through designated positions or clearly defined combined roles, including Youth Partner, Parent Partner, Facilitator, Family Specialist/Skills Coach, Fidelity/Quality support functions, Clinical Supervisor, and Program Manager.
Evidence: Job Descriptions (All HFW Roles), p.159.
(b) Job descriptions for each role clearly define role purpose, core functions, and required qualities, including skills, competencies, and attributes aligned with Wraparound values and practice expectations.
Evidence: Job Descriptions (All HFW Roles), p.159.
(c) Job descriptions are specific to HFW and reflect the attitudes, knowledge, and experience necessary for effective Wraparound practice, including family voice and choice, strengths-based approaches, collaboration, and cultural responsiveness.
Evidence: Job Descriptions (All HFW Roles), p.159.
(d) The hiring process includes structured opportunities for candidates to demonstrate key competencies and alignment with Wraparound principles, including behavioral interviews, scenario-based questions, and assessment of values-based practice.
Evidence: New Hire Orientation (NHO) Checklist, p.189; Job Descriptions, p.159.
(e) Employees are provided with clear performance expectations and receive ongoing feedback and coaching through supervision and formal performance evaluations to support skill development and fidelity to the HFW model.
Evidence: Performance Evaluation – Direct Care Staff, p.203; Clinical Supervision Guidebook, p.41.
9.5 Workforce Stability
Fred Finch Wraparound promotes workforce stability through competitive compensation, manageable workloads, and advancement opportunities:
(a) Compensation structures are designed to be competitive within the local labor market and reflective of cost-of-living considerations to support recruitment and retention of qualified staff.
Evidence: Employee Retention Policy & Procedures, p.104.
(b) Caseload expectations and workload distribution are monitored to maintain manageable workloads that support staff well-being, service quality, and fidelity to the HFW model.
Evidence: Employee Retention Policy & Procedures, p.104; Performance Evaluation – Direct Care Staff, p.203.
(c) The organization maintains clearly communicated and accessible promotion and advancement pathways that value both professional experience and lived experience, ensuring opportunities are not prohibitive for staff with diverse backgrounds.
Evidence: Job Descriptions (HFW Roles), p.159; Employee Retention Policy & Procedures, p.104.
(d) Staff are provided opportunities for wage increases, leadership development, and role specialization that do not require leaving direct service positions, supporting long-term retention and workforce stability.
Evidence: Training Policy & Procedure, p.153; Performance Evaluation – Direct Care Staff, p.203.
9.6 High Fidelity Training Plan
Fred Finch Wraparound implements a comprehensive training plan that includes initial, ongoing, and booster trainings aligned with HFW standards:
(a) All staff receive initial High-Fidelity Wraparound (HFW) training through an internal curriculum aligned with California Wraparound Standards. Internal training materials reflect the statewide Foundational HFW curriculum and are used to ensure consistency in onboarding and foundational knowledge.
Evidence: Training Policy & Procedure, p.153; RTWB / HFW Training Materials, p.1.
(b) Staff receive ongoing training in both general Wraparound practice and role-specific competencies through a combination of formal trainings, team meetings, supervision, coaching, and peer shadowing.
Evidence: Training Policy & Procedure, p.153; Clinical Supervision Guidebook, p.41.
(c) Staff receive booster trainings at least annually to reinforce Wraparound principles, fidelity expectations, and role-specific skills.
Evidence: Training Policy & Procedure, p.153; Continuous Quality Improvement (CQI) Plan, p.67.
(d) Clinical Supervisors and HFW Supervisors/Managers receive additional training specific to leadership and supervisory functions, including initial, ongoing, and booster trainings to support effective oversight and fidelity to the model.
Evidence: Clinical Supervision Guidebook, p.41; Training Policy & Procedure, p.153.
(e) All staff receive training on ICWA and Tribal sovereignty, and processes are in place to identify and provide additional training to address the needs of specific populations and emerging service trends.
Evidence: Training Policy & Procedure, p.153; Continuous Quality Improvement (CQI) Plan, p.67.
9.7 Community-based Training Program
Fred Finch Wraparound incorporates lived experience and community partners into training to support system-wide understanding and collaboration:
(a) Youth, families, and peer partners with lived Wraparound experience are meaningfully incorporated into the delivery of HFW trainings. Youth Partners and Parent Partners participate in training activities to provide real-world perspectives, reinforce family voice and choice, and model application of Wraparound principles.
Evidence: Youth Partner Job Description, p.179; Parent Partner Job Description, p.175; Training Policy & Procedure, p.153.
(b) Community partners and system stakeholders are invited to participate in Wraparound trainings or are offered training opportunities to strengthen their understanding of HFW and their role within the Children’s System of Care. These efforts support cross-system collaboration, shared language, and effective team participation.
Evidence: Community Leadership Team (CLT) Charter, p.86; Training Policy & Procedure, p.153; RTWB / HFW Training Materials, p.1.
9.8 Coaching and Supervision
Fred Finch Wraparound provides ongoing coaching and supervision to support staff skill development and 24/7 service responsiveness:
(a) All staff participate in an initial apprenticeship period that includes training and coaching on High-Fidelity Wraparound (HFW) values, principles, phases, and activities, as well as the effective and appropriate use of flex funds to meet individualized family needs. Ongoing coaching reinforces skill development, fidelity, and application of Wraparound practices.
Evidence: Clinical Supervision Guidebook, p.41; Training Policy & Procedure, p.153.
(b) Staff have access to supervision and coaching as needed, including during crisis situations, to support 24/7 responsiveness consistent with HFW service expectations. Supervisory structures include scheduled supervision, availability of on-call support, and real-time consultation to address emerging needs.
Evidence: Clinical Supervision Guidebook, p.41; Continuous Quality Improvement (CQI) Plan, p.67.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
Fred Finch Wraparound utilizes data to improve practice, program effectiveness, and system-level collaboration:
(a) Data is used to improve practice with youth and families through timely feedback provided to staff via supervision, coaching, and team meetings. Outcome data, fidelity measures, and case reviews are used to identify strengths in practice, areas for improvement, and individualized staff training and coaching needs.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67; Performance Evaluation – Direct Care Staff, p.203; IP-CANS, p.96.
(b) Aggregated data is analyzed to identify program-level trends related to engagement, fidelity, outcomes, service utilization, and transitions. Findings are used to inform program planning, workflow adjustments, resource allocation, and targeted quality improvement initiatives to enhance overall program effectiveness and better serve families.
Evidence: Continuous Quality Improvement (CQI) Plan, p.67; Internal Quality Records Review Policy, p.94.
(c) Data is used to identify and communicate system-level barriers impacting HFW implementation. Findings are shared with leadership structures, including the Community Leadership Team (CLT), to support cross-system collaboration, problem-solving, and alignment with Wraparound standards.
Evidence: Community Leadership Team (CLT) Charter, p.86; Continuous Quality Improvement (CQI) Plan, p.67.
Fidelity Indicators
1.1 Timely Engagement and Planning
(a) Referrals are received by our Intake coordinator. Per LA County guidelines, the requesting individual is contacted within 72 hours of SBHI receiving the referral or 24 hours if it comes from a hospital, ER or PHF. Once the referral has been processed, the intake is scheduled per LACDMH guidelines. Following the intake, the Facilitator schedules the initial meeting with the client and family within no more than 10 days of receiving the referral (SBHI P&P page 13, 4.5).
(b) The Facilitator leads the team in developing a comprehensive initial Plan of Care within 30 calendar days from the start of services (SBHI P&P page 19, 5.3; Plan of Care).
(c) At each meeting, the Facilitator will review the Plan of Care components and document in the meeting minutes and client’s chart updates to the Plan of Care (SBHI P&P page 21, 6-6.2).
(d) The Facilitator updates the Plan of Care in the youth’s chart and distributes it to the members of the team at least every 90 days or when goals are changed, strategies are changed, team members are added, the needs of the youth and family change (SBHI P&P page 23, 6.2-6.3).
(e) The QA Coordinator collects and monitors data on an ongoing basis and provides it to the Program Director, Clinical Director and Executive Director. Leadership reviews the data on a weekly basis. Data collected includes intake data to ensure that timelines are met and to track utilization. Data is then used to provide constructive, strengths-oriented feedback and, if necessary, coaching to staff regarding team-based performance. The goal of feedback and coaching are to reinforce practice expectations, build skills, and increase confidence. (SBHI P&P page 53, 11.3.a.1).
(f) Weekly group supervision meetings incorporate structured skill development aligned with fidelity domains. Topics include but are not limited to engagement strategies for connecting with families when contact with the family is difficult (SBHI P&P page 42, 10.9.a.2).
1.2 Led by Youth and Families
(a) The Facilitator leads the team in developing formal agreements on how the team will engage during meetings and how decisions will be made. They also create a team mission statement that defines the overall purpose of the HFW team in alignment with the family vision which is created with the family during the initial meeting. Particular focus is on the family’s perspectives, including Tribes, in the case of an Indian child. In order to elicit the client and family’s perspectives, they use the Team Agreement Exercise, Team Mission Worksheet, and What Makes a Good Team Activity (SBHI P&P page 13, 4.6(e); page 17, 5.1; page 24, 6.4; Team Agreement Exercise, Team Mission Worksheet, What Makes a Good Team Exercise). Adjustments to the Plan of Care are made collaboratively with the client and family and reflect family voice and choice (SBHI P&P page 23, 6.2(c))
(b) HFW Team engages families in activities to discover their individual and family strengths, needs, culture, and family vision for a better future. The Facilitator may use, but is not limited to, the following: Wraparound Needs and Strengths Summary based on the IP-CANS provided by the intake clinician; The Strengths Discovery Interview Guide. The Facilitator prepares a summary document to clearly communicate strengths, needs, culture, and a vision to all team members, to orient new team members as they are added, and to support the initial plan development process (Strengths, Needs, Culture, Goals Document). The Strengths, Needs, Culture, Goals document is updated every 90 days and provided to new team members as they are added to the team. This document is part of the client’s file (SBHI P&P page 15, 4.9; Strengths, Needs, Culture and Goals Document; Wraparound Needs and Strengths Summary; Strengths Discovery Interview).
(c) Part of staff training is ensuring compentency which is verified by supervisors through direct observation of Child and Family Team Meetings, review of care plans, chart audits, WFI-EZ and satisfaction survey data, and supervisor assessment (SBHI P&P page 34, 10.4.a.4; page 37, 10.8(e); page 38, 10.11). Program data are systematically reviewed by leadership to enhance practice with youth and families and to provide constructive, strengths-oriented feedback and, if necessary, coaching to staff regarding team-based performance. The goal of feedback and coaching are to reinforce practice expectations, build skills, and increase confidence (SBHI P&P page 45, 11.4).
(d) Client and family satisfaction is tracked every 90 days using the WFI-EZ which is completed during team meetings and the SBHI Client Satisfaction Survey which is sent to clients and families via email and text. Paper versions are available during team meetings. A QR code to the survey is accessible in the reception area at any time during the year (SBHI P&P page 45, 11.3.b.4). The data is used as described in c above.
1.3 Strength-Based
(a) HFW Team engages families in activities to discover their individual and family strengths, needs, culture, and family vision for a better future. The Facilitator may use, but is not limited to, the following: Wraparound Needs and Strengths Summary based on the IP-CANS provided by the intake clinician; The Strengths Discovery Interview Guide. The Facilitator prepares a summary document to clearly communicate strengths, needs, culture, and a vision to all team members, to orient new team members as they are added, and to support the initial plan development process (Strengths, Needs, Culture, Goals Document). The Strengths, Needs, Culture, Goals document is updated every 90 days and provided to all team members including new team members as they are added to the team. This document is part of the client’s file (SBHI P&P page 15,4.9; Strengths, Needs, Culture and Goals Document; Wraparound Needs and Strengths Summary; Strengths Discovery Interview).
(b) The IP-CANS is used in the activities described above but is only one tool and not the only tool that is used to identify strengths (SBHI P&P, page 17, 5.1(b)).
(c) Weekly group supervision meetings incorporate structured skill development aligned with fidelity domains. Topics include using a strengths-based, solution-focused approach to services (SBHI P&P page 39, 10.6.a.1)
(d) Client and family experience of strengths based services is tracked every 90 days using the WFI-EZ which is completed during team meetings and the SBHI Client Satisfaction Surveywhich is sent to clients and families via email and text. Paper versions are available during team meetings. A QR code to the survey is accessible in the reception area at any time during the year. Program data are systematically reviewed by leadership to enhance practice with youth and families and to provide constructive, strengths-oriented feedback and, if necessary, coaching to staff regarding team-based performance. The goal of feedback and coaching are to reinforce practice expectations, build skills, and increase confidence (SBHI P&P page 45, 11.3.b.4, 11.4).
1.4 Needs Driven
(a) The Facilitator reviews with the team needs that were identified during Engagement. The team adds any additional needs beyond those from the IP-CANS, and prioritizes them. Based on the identified needs, the team develops specific, measurable goals and outcomes. The Facilitator leads the team in brainstorming multiple creative strategies for meeting prioritized needs, goals and outcomes once they are established. The team will then select strategies and assign action items to the responsible team member (SBHI P&P page 15, 4.9).
(b) Weekly group supervision meetings incorporate structured skill development aligned with fidelity domains. Topics may include but are not limited to: Identifying needs, developing needs statements that are reflective of the underlying reasons why problematic situations or behavior occur and Utilizing needs-focused planning over problematic planning (SBHI P&P page 39, 10.6.a).
(c) As mentioned in a above, the IP-CANS is used to identify needs but is not the only source (SBHI P&P page 15, 4.9(b)).
(d) When the family has reached pre-determined benchmarks indicating sufficient progress towards completing the team mission and goals, and the youth, family, and team agree the family is ready for transition, the HFW team begins developing a formal individualized transition plan. Readiness for transition is determined through a combination of objective data and team consensus, with strong emphasis on family voice and choice. (SBHI P&P page 27, 7.2(a)).
1.5 Individualized
(a) All HFW documentation templates (e.g., Plan of Care, meeting minutes) are designed to allow open-ended, narrative, and customizable entries. Facilitators individualize documentation to reflect the youth and family’s strengths and needs, culture and preferences, and natural supports and community resources. Documentation is updated continuously to reflect changing needs and team composition. Supervisors review documentation via chart review and QA tools to ensure it reflects individualized, family-driven planning rather than standardized or generic responses. SBHI P&P page 53, 11.2)
(b) Weekly group supervision meetings incorporate structured skill development aligned with fidelity domains. Topics include providing flexible, creative, and highly individualized services and strategies for youth and families (SBHI P&P page 43, 10.9.a.5)
(c) Role Specific Training ensures clarity of function and prevention of role drift. Additional role specific training is required and can be obtained via formal trainings, meetings, coaching, peer shadowing, and/or supervision. Facilitators receive training in effective team leadership, care coordination and phase management, and customizing wraparound to individual needs, strengths, culture and preferences (SBHI P&P page 43, 10.10).
(d) The QA Coordinator collects and monitors data on an ongoing basis and provides it to the Program Director, Clinical Director and Executive Director weekly. Plans of Care are reviewed for use of individualized strengths, needs, culture and preference; balance across natural and formal supports; inclusion and active assignment of natural supports; strategies that are individualized, strengths based and culturally relevant; and a clear linkage between needs–>goals–>strategies–>action items–>outcomes (SBHI P&P page 54, 11.3, 11.3.a.3).
(e) Client and family experience of receiving customized services is tracked every 90 days using the WFI-EZ which is completed during team meetings and the SBHI Client Satisfaction Survey which is sent to clients and families via email and text. Paper versions are available during team meetings. A QR code to the survey is accessible in the reception area at any time during the year. Program data are systematically reviewed by leadership to enhance practice with youth and families and to provide constructive, strengths-oriented feedback and, if necessary, coaching to staff regarding team-based performance. The goal of feedback and coaching are to reinforce practice expectations, build skills, and increase confidence. Programmatic issues are also addressed, policies and procedures are updated if necessary, and new innovations are implemented and tracked over time (SBHI P&P page 55, 11.3(b), 11.3.b.1, 11.3.c.5; 11.4).
1.6 Use of Natural and Community Based Supports
(a) Natural supports and sustainable community resources are included in the Plan, or the Plan includes strategies developed by the team to identify and develop community and natural supports before the client and family transition out of the HFW Program. The client and family complete the Circle of Support and Natural Supports Worksheet to help them consider who provides support and comfort in different areas of their life and how they can meaningfully engage those supports during the HFW process (SBHI P&P page 13, 5.4; Circle of Support Worksheet; Natural Supports Worksheet).
(b) Weekly group supervision meetings incorporate structured skill development aligned with fidelity domains. Topics include providing identification, engagement and integration of natural supports in the HFW process (SBHI P&P page 23, 10.7.1.6).
(c) The QA Coordinator collects and monitors data on an ongoing basis and provides it to the Program Director, Clinical Director and Executive Director weekly. Plans of Care are reviewed for use of individualized strengths, needs, outcomes, and strategies; inclusion of natural supports and for natural supports in assigning of strategies and action items; and shared ownership and follow through on strategies and action items (SBHI P&P page 28, 11.2.1.3).
(d) Client and family experience of having natural supports involved is tracked every 90 days using the WFI-EZ which is completed during team meetings and the SBHI Client Satisfaction Survey which is sent to clients and families via email and text. Paper versions are available during team meetings. A QR code to the survey is accessible in the reception area at any time during the year. Program data are systematically reviewed by leadership to enhance practice with youth and families and to provide constructive, strengths-oriented feedback and, if necessary, coaching to staff regarding team-based performance. The goal of feedback and coaching are to reinforce practice expectations, build skills, and increase confidence (SBHI P&P page 44, 11.3(b), 11.3.c.2, 11.3.c.4).
1.7 Culturally Respectful and Relevant
(a) Facilitator prepares a summary document using the Wraparound Needs and Strengths Summary and Strengths Discovery Interview as well as input from the team to clearly communicate strengths, needs, culture, and a vision to all team members, to orient new team members as they are added, and to support the initial plan development process (Strengths, Needs, Culture, Goals Document). The Strengths, Needs, Culture, Goals document is updated every 90 days and provided to new team members as they are added to the team. This document is part of the client’s file (SBHI P&P page 15, 4.9; Strengths, Needs, Culture, Goals Document; Wraparound Needs and Strengths Summary, Strengths Discovery Interview).
(b) Weekly group supervision meetings incorporate structured skill development aligned with fidelity domains. Topics include use of family and culture in planning and service delivery, and providing culturally respectful and relevant strategies (SBHI P&P page 42, 10.9(a), 10.9.a.9, 10.9.a.10).
(c) Client and family experience of culturally relevant and respectful services is tracked every 90 days using the WFI-EZ which is completed during team meetings and the SBHI Client Satisfaction Surveywhich is sent to clients and families via email and text. Paper versions are available during team meetings. A QR code to the survey is accessible in the reception area at any time during the year. Program data are systematically reviewed by leadership to enhance practice with youth and families and to provide constructive, strengths-oriented feedback and, if necessary, coaching to staff regarding team-based performance. The goal of feedback and coaching are to reinforce practice expectations, build skills, and increase confidence (SBHI P&P page 55, 11.3(b); 11.4).
1.8 High-Quality Team Planning and Problem Solving
(a) The Facilitator leads the team in developing formal agreements on how the team will engage during meetings and how decisions will be made. They also create a team mission statement that defines the overall purpose of the HFW team in alignment with the family vision. These are documented in the client’s file. Particular focus is on the family’s perspectives, including Tribes, in the case of an Indian child. In order to elicit the client and family’s perspectives, they use the Team Agreement Exercise, Team Mission Worksheet, and What Makes a Good Team Activity (SBHI P&P page 17, 5.1; Team Agreement Exercise, Team Mission Worksheet, What Makes a Good Team Exercise).
(b) All team members complete standardized measures every 90 days to assess fidelity to the HFW model, outcomes, and experience of care. The QA lead and Clinical Director conduct follow up phone calls to gather qualitative feedback. The results inform staff coaching and program improvement. The Wraparound Fidelity Index-Short Form (WFI-EZ) is completed by caregivers, youth and Wraparound team members and the SBHI Satisfaction Survey is completed by families and clients to assess the experience of team based collaboration, cohesiveness and communication (SBHI P&P page 55, 11.3(b)).
(c) Program data is systematically used to improve practice, ensure fidelity and drive outcomes. The QA Coordinator collects data on an ongoing basis. This data is provided to leadership weekly. It is reviewed with staff monthly to provide constructive, strengths-oriented feedback and coaching by supervisors. Additional focused coaching is provided when fidelity scores fall below benchmarks, documentation is not compliant, and/or family feedback indicates concerns for three months or longer. Leadership review may lead to program level improvements such as addressing service gaps, workflow issues, or revising policies and procedures. (SBHI P&P page 56, 11.4)
(d) The QA Coordinator collects, monitors, and analyzes data through a structured QA tracking and audit tool designed to assess fidelity to the High Fidelity Wraparound (HFW) model, documentation compliance, service quality, and outcomes. Data is reviewed on a weekly basis and reported to the Program Director, Clinical Director, and Executive Director. Aggregate data is trended and reviewed quarterly as part of the Continuous Quality Improvement (CQI) process. Plans of Care are reviewed for alignment with HFW principles and fidelity indicators, including shared ownership and follow through on strategies and action items across team members (SBHI P&P page 55, 11.3, 11.3.a.3).
1.9 Outcomes Based Process
(a) The Facilitator leads the team in developing a comprehensive initial Plan of Care. The plan includes strategies and action items that are clearly documented and includes who is responsible for each and with established due dates. The Facilitator guides the team toward selected strategies that are clearly linked to prioritized needs and goals, culturally relevant and individualized, and include a balance of formal services, natural supports, and community and family resources (SBHI P&P page 19, 5.3(d)-(e), Initial Plan of Care).
(b) Prior to each Team meeting or at the outset of the meeting, the Facilitator will provide an agenda and a copy of the prior meeting’s minutes. Based on the prior meeting minutes, at each team meeting, the Facilitator will review the strategies and action items and track completion of tasks and new individual assignments in the minutes. The IP-CANS may be used to inform tracking and decision making, but the team must still maintain their own tracking of needs, goal completion and action item completion to plan for transitions and not rely solely on the IP-CANS. The Team will discuss whether individuals will be able to meet timelines and deliverables and adjust strategies and action items as needed. If changes or adjustments are made to strategies or action items outside of regular team meetings, the Facilitator will document the change or adjustment and communicate that change or adjustment to all team members. (SBHI P&P page 22, 6.1(a)-(b),(f)-(k),(m); Plan of Care)
(c) All HFW documentation templates (e.g., Plan of Care, meeting minutes) are designed to allow open-ended, narrative, and customizable entries. Facilitators individualize documentation to reflect the youth and family’s strengths and needs, culture and preferences, and natural supports and community resources. Documentation is updated continuously to reflect changing needs and team composition or at least every 90 days. Supervisors review documentation via chart review and QA tools to ensure it reflects individualized, family-driven planning rather than standardized or generic responses. (SBHI P&P page 53, 11.2)
(d) The IP-CANS is administered by the clinician who completes the intake as part of the intake process. This is the clinician who will serve the client whenever possible (SBHI P&P page 11, 4.3(e)). During the Strengths, Needs, Culture and Goals Discovery, the clinician provides the team with a Wraparound Needs and Strengths Summary document based on the IP-CANS to assist with the process (SBHI P&P page 15, 4.9(b).; Wraparound Needs and Strengths Summary).
(e) As discussed in b above, the IP-CANS may be used to inform tracking and decision making, but the team must still maintain their own tracking of needs, goal completion and action item completion to plan for transitions and not rely solely on the IP-CANS. The Facilitator uses the Plan of Care to review status of goal completion and action item completion, barriers to completion, and effectiveness of strategies in addressing the identified needs (SBHI P&P page 22, 6.1(f); Plan of Care).
1.10 Persistence
(a) The HFW team works collaboratively to persist with engagement and problem-solving, ensuring that services continue until the youth, family, and team determine that goals have been achieved or that transition from Wraparound services is appropriate. When setbacks occur, the team reviews the current Plan of Care and collaboratively identifies adjustments, new strategies, or additional supports. Services continue until the HFW team, with strong consideration given to family voice and choice, determines that Wraparound services should conclude (SBHI P&P page 25, 6.5(a)-(b)).
(b) When teams encounter challenges that cannot be resolved through routine team problem-solving, clear processes are available to access additional support. These processes may include requesting additional coaching or consultation from supervisors or Wraparound coaches, accessing flexible funds to address barriers identified in the Plan of Care, requesting additional staffing support or consultation when complex needs arise, or utilizing crisis planning and safety planning resources to stabilize situations and support the family. Facilitators are responsible for notifying supervisors when additional support is needed and for documenting the request and resulting plan revisions (SBHI P&P page 25, 6.5(c)-(d)).
(c) Facilitators receive ongoing training and coaching to strengthen skills necessary for crisis planning, including risk assessment and safety planning, eading collaborative crisis planning discussions, developing proactive and reactive strategies, ensuring cultural responsiveness and use of natural support, and post-crisis safety planning. They also receive training necessary for building, engaging, and maintaining effective teams including team engagement and facilitation, conflict resolution and mediation, motivational engagement strategies, building collaborative team environments, leading structured brainstorming, and ongoing plan revision. Supervision and coaching sessions provide ongoing training and coaching to strengthen skills necessary for identifying barriers, developing strategies that help teams maintain engagement with youth and families while continuing to implement the HFW model with fidelity, and effective problem solving and plan adaptation (SBHI P&P page 43, 10.10, 10.11).
1.11 Transitions as a part of the Fourth Phase of HFW
(a) The HFW team creates a formal transition plan for each client and family which is distributed to all Team members and placed in the client’s file (Transition Plan). The client with go through several transitions while in the program as they transition from the highest level of acuity to the lowest level of acuity and ultimately out of the HFW program. The Facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring, adapting and documenting in the Plan of Care. While on the Low Acuity Team, the Facilitator leads the team in identifying needs, services, and supports that will persist past formal HFW. Once on the Low Acuity Team, the youth and families are prepared for transitioning out of HFW well in advance. The Facilitator ensures that concerns are addressed, supports are in place, and services are identified that will meet the needs of the youth and family. The transition is paced to allow the youth and family to adjust to the transition prior to ending HFW services. Prior to transition out of services, the Facilitator schedules a Transition Readiness Review discussion during a team meeting once benchmarks appear to have been met. During this meeting the team discussed progress, remaining needs, and readiness indicators. The family provides input and either confirms readiness or identifies remaining needs. Clients will not experience a sudden transition out of HFW due to adverse events or administrative requirements. (SBHI P&P page 11, 4.4; page 26, 7, 7.1-7.4; Transition Plan)
(b) The team ensures that the transition to each lower level of care and out of HFW is celebrated in a manner that reflects a positive transition. The HFW team ensures that the transition from formal Wraparound services is marked by a meaningful and culturally relevant celebration that reflects the youth and family’s preferences and accomplishments. Celebrations are designed to recognize progress toward goals and completion of the team mission, reinforce strengths and resilience, provide closure to the Wraparound process, strengthen connections with ongoing supports, the youth and family determine the type, tone, and participants of the celebration. Facilitator discusses celebration preferences during transition planning. Team collaborates to plan the event (location, attendees, format). Celebration may occur during a final team meeting or separate event. Strengths, achievements, and progress are acknowledged. Natural supports are included to reinforce ongoing connections. The program maintains administrative and fiscal structures that support meaningful transition celebrations. This includes ensuring that staff have time, resources, and flexibility to participate in and facilitate celebrations. Flexible funds may be used, when appropriate, to support culturally relevant and meaningful activities that align with the transition plan and wraparound principles. (SBHI P&P page 29, 7.12-7.13)
Expected Outcomes
2.1 Youth and Family Satisfaction
For all outcomes listed below, the QA Coordinator collects, monitors, and analyzes data through a structured QA tracking and audit tool designed to assess fidelity to the High Fidelity Wraparound (HFW) model, documentation compliance, service quality, and outcomes. Data is reviewed on a weekly basis and reported to the Program Director, Clinical Director, and Executive Director via standardized reports. Aggregate data is trended and reviewed quarterly as part of the Continuous Quality Improvement (CQI) process.
All team members, including youth and family, complete standardized measures every 90 days to assess fidelity to the HFW model, outcomes, and experience of care. The QA lead and Clinical Director conduct follow up phone calls to gather qualitative feedback. The results inform staff coaching and program improvement. Client and family satisfaction, and in the case of an Indian child, the Tribe’s satisfaction, is tracked using the WFI-EZ and the SBHI Client Satisfaction Survey. The WFI-EZ is completed during team meetings. The SBHI Client Satisfaction Survey is sent to clients, families, and tribal representatives via email and text. Paper versions are available during team meetings. A QR code to the survey is accessible in the reception area at any time during the year.
Data is used to identify staff training and coaching needs, inform booster training topics, improve service delivery and program design, address documentation and compliance issues, identify gaps in access, timeliness, and engagement, and strengthen fidelity to HFW principles. Staff receive individualized feedback during weekly supervision and monthly one-on-one coaching sessions. Feedback is strengths-based and solution-focused, Additional coaching is provided when for >3 months: fidelity scores fall below benchmarks, documentation is not compliant, family feedback indicates concerns, and performance trends are tracked over time. Programmatic issues (e.g., workflow, policies, service gaps, stakeholder-related issues) are addressed through leadership review. Policies and procedures are updated based on findings and innovation cycles are implemented to test and refine improvements. Interventions are implemented based on data findings and outcomes are re-measured to assess effectiveness. Adjustments are made as needed. All CQI activities are documented. Data is used to identify systemic barriers (e.g., access to services, funding limitations), which the Clinical Director communicates to the Community Leadership Team and system partners
(SBHI P&P page 55, 11.3, 11.3(b), 11.4).
2.2 Improved School Functioning
Outcomes indicators including educational and vocational functioning are tracked by the QA Coordinator in an excel spreadsheet every 90 days using chart review of Plans of Care documenting outcomes and progress toward outcomes, the WFI-EZ for caregivers, youth and Wraparound team members, and the IP-CANS. The data is provided to leadership on a quarterly basis. If clients are not improving then adjustments are made and the team is provided with additional coaching (SBHI P&P page 53, 11.3, page 55, 11.3(b), 11.4).
2.3 Improved Functioning in the Community
Outcomes indicators including improved community functioning are tracked by the QA Coordinator in an excel spreadsheet every 90 days using chart review of Plans of Care documenting outcomes and progress toward outcomes, the WFI-EZ for caregivers, youth and Wraparound team members, the SBHI Client Satisfaction Survey, and the IP-CANS. The data is provided to leadership on a quarterly basis. If clients are not improving then adjustments are made and the team is provided with additional coaching (SBHI P&P page 53 11.3, page 55, 11.3(b), 11.4).
2.4 Improved Interpersonal Functioning
Outcomes indicators including improved interpersonal functioning are tracked by the QA Coordinator in an excel spreadsheet every 90 days sing chart review of Plans of Care documenting outcomes and progress toward outcomes, the WFI-EZ for caregivers, youth and Wraparound team members, the SBHI Client Satisfaction Survey, and the IP-CANS. The data is provided to leadership on a quarterly basis. If clients are not improving then adjustments are made and the team is provided with additional coaching (SBHI P&P page 53 11.3, page 55, 11.3(b), 11.4).
2.5 Increased Caregiver Confidence
The IP-CANS is used to monitor if the youth and family’s needs are decreasing and if functional strengths are increasing. Specific survey items on the SBHI Client Satisfaction Survey measure if caregivers feel better able to manage future problems, navigate systems, and handle crises. This information is tracked by the QA Coordinator in an excel spreadsheet and provided to leadership on a quarterly basis. If clients are not improving then adjustments are made and the team is provided with additional coaching. (SBHI P&P page 53, 11.3, page 55, 11.3(b), 11.4).
2.6 Stable and Least Restrictive Living Environment
Stability in the community-based living situation and/or frequency of placement changes is evaluated by the WFI-EZ and the IP-CANS. This information is tracked by the QA Coordinator in an excel spreadsheet and provided to leadership on a quarterly basis. If clients are not improving then adjustments are made and the team is provided with additional coaching. (SBHI P&P page 53, 11.3, page 55, 11.3(b), 11.4).
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Stability with regard to behavior as measured by number of hospital visits is evaluated by the WFI-EZ and the IP-CANS. This information is tracked by the QA Coordinator in an excel spreadsheet and provided to leadership on a quarterly basis. If clients are not improving then adjustments are made and the team is provided with additional coaching. (SBHI P&P page 53, 11.3, page 55, 11.3(b), 11.4).
2.8 Reduction in Crisis Visits
Number of crises and involvement of professional support is evaluated by the WFI-EZ and the IP-CANS. We can also look at the Safety and Support section of the SBHI Satisfaction Survey to see how the client’s feels about their ability to manage crises. This information is tracked by the QA Coordinator in an excel spreadsheet and provided to leadership on a quarterly basis. If clients are not improving then adjustments are made and the team is provided with additional coaching. (SBHI P&P page 53, 11.3, page 55, 11.3(b), 11.4).
2.9 Positive Exit from HFW
When the family has reached pre-determined benchmarks indicating sufficient progress towards completing the team mission and goals, and the youth, family, and team agree the family is ready for transition, the HFW team begins developing a formal individualized transition plan. Clients are not transitioned out of HFW due to adverse events.
The Facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring, adapting and documenting in the Plan of Care. The Facilitator ensures that concerns are addressed, supports are in place, and services are identified that will meet the needs of the youth and family. The transition is paced to allow the youth and family to adjust to the transition prior to ending HFW services (SBHI P&P page 26, 7).
Engagement
3.1 Orientation
The First Meeting/Orientation: The following takes place at the first meeting with the family and all activities are documented:
(a) The HFW team orients the client and family to HFW process, principles and phases (SBHI P&P page 13, 4.6(b))
(b) The HFW team addresses legal and ethical considerations (SBHI P&P page 13, 4.6(b))
(c) The HFW Team explains the role and responsibilities of each team member to the client and family including the family’s role and the role of natural supports. This includes Tribes in the case of an Indian child. The Team works with the family to determine who should be on the team. Children’s System of Care partners who should be included on the HFW team are identified and a plan is made for how to engage those supports. (SBHI P&P page 13, 4.6(c), (e))
3.2 Safety and Crisis stabilization
(a) The HFW Team first addresses pressing needs and concerns so that the family can focus on the HFW process. If immediate response is necessary, the Facilitator initiates a plan for immediate intervention and stabilization which is provided to the family and is documented in the chart (SBHI P&P page 15, 4.8(a)-(b), SBHI Wraparound Immediate Crisis Plan).
(b) This does not replace the Safety Plan the team will create during Plan Development.(SBHI P&P page 15, 4.8(d))
(c) The team designates access to 24/7 crisis response when necessary. (SBHI P&P page 15, 4.8(c)).
3.3 Strengths, Needs, Culture and Vision Discovery
(a) The client and family are engaged in developing a Family Vision. This is a strengths-based statement that reflects how the client and family want their life to look in the future. It serves as the foundation for all planning, decision-making, and strategy development throughout the HFW process. (SBHI P&P page 13, 4.6(e))
(b) The program requires that underlying needs are clearly identified and prioritized prior to development of the Plan of Care, and that all goals, outcomes, strategies, and action items are directly derived from those needs. All planning must be collaborative, strengths-based, and family-driven, and must reflect multiple brainstormed strategies prior to selection. The team engages families in activities to discover their individual and family strengths, needs, culture and goals. For Indian children, Tribal representatives are invited to all meetings and explicitly included in decision-making. Family voice is prioritized in all agenda items; decisions are not finalized without confirming alignment with family preferences. The Facilitator may use, but is not limited to, the following: Wraparound Needs and Strengths Summary based on the IP-CANS provided by the intake clinician and The Strengths Discovery Interview Guide. The Facilitator prepares a summary document using the Wraparound Needs and Strengths Summary and Strengths Discovery Interview as well as input from the team to clearly communicate strengths, needs, culture, and a vision to all team members, to orient new team members as they are added, and to support the initial plan development process (Strengths, Needs, Culture, Goals Document). The Strengths, Needs, Culture, Goals document is updated every 90 days and provided to all team members including new team members as they are added to the team. This document is part of the client’s file (SBHI P&P page 15, 4.9).
3.4 Engage All Team Members
(a) A Natural Supports Inventory is completed with the youth and family using the Circle of Support as an activity to assist the client and family in identifying who they might include. This is documented in the client’s chart. (SBHI P&P page 13, 4.6(d))
(b) Children’s System of Care partners who should be included on the HFW team are identified and a plan is made for how to engage those supports. (SBHI P&P page 13, 4.6(e))
(c) Natural supports and sustainable community resources are included in the Plan, or the Plan includes strategies developed by the team to identify and develop community and natural supports before the child or youth and family transition out of the HFW Program. The client and family complete the Circle of Support and Natural Supports Worksheet to help them consider who provides support and comfort in different areas of their life and how they can meaningfully engage those supports during the HFW process (SBHI P&P page 13, 4.6(d)). As new Team members are added, the Facilitator ensures that they are oriented to the Team. This includes: explaining the HFW process, explaining the roles and responsibilities of all members of the Team, reviewing current Plan of Care, and engaging in team building exercises (SBHI P&P page 24, 6.4(f))
(d) We require all Engagement and team building activities to be documented in the client’s chart. This may be meeting minutes, Plan of Care, Immediate Safety Plan, Engagement Log, or progress notes.
3.5 Arrange Meeting Logistics
(a) Team meetings take place at a time and location convenient and accessible to all team members with priority given to the family needs. (SBHI P&P page 15, 4.7(b))
(b) The HFW Team plans and arranges all meeting logistics such as transportation, interpretation, and telehealth. (SBHI P&P page 15, 4.7(c))
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
(a) Building upon activities completed during Engagement and prior to developing the Plan of Care, the Facilitator leads the team in developing formal agreements. Using the Team Agreement Exercise and the What Makes a Good Team Activity, the team develops norms for how they will engage during meetings and how decision will be made. These agreements define expectations for participation and engagement, communication norms (e.g. respectful communication, confidentiality), and the decision-making processes (e.g. consensus-bases, family driven). (SBHI P&P page 17, 5.1(a), Team Agreement Exercise, What Makes A Good Team Activity, Appendix B)
Facilitator leads the team in identifying and documenting additional strengths of each youth, family, and team member, as well as the local community. The strengths must include, but not be limited to, those identified in the IP-CANS. Strengths are functional and actionable and linked to how they will support the team’s work. Facilitator ensures strengths identified during engagement are incorporated and expanded upon. Strengths are identified along the following domains: Youth (skills, interests, talents, resilience), family (protective factors, cultural strengths, capabilities), natural supports (relationships, informal resources), formal supports (provider expertise and roles), community (programs, organizations, cultural/community assets). (SBHI P&P page 17, 5.1(b), Strengths, Needs, Culture, Goals Document, Appendix A)
Facilitator leads the team in creating a team mission statement using the Team Mission Worksheet and What Makes a Good Team Activity. The Team Mission Statement reflects the team’s commitment to supporting identified needs, defines the shared purpose of the team, and aligns directly with the family’s long-term vision. (SBHI P&P page 17, 5.1(d), Team Mission Worksheet, What Makes A Good Team Activity, Appendix B)
These efforts are documented in the chart in the following documentation: Team Agreements Form, Strengths Needs Culture Goals Document, Family Vision Statement, Team Mission Statement, HFW Team Meeting Minutes (documenting the development process, participation of team members, agreement and consensus). (SBHI P&P page 17, 5.1(e), Team Meeting Minutes Template, Appendix B)
(b) The youth’s and family’s strengths which were identified in engagaement were documented in the Strengths Needs Culture Goals Document. During this phase, that document is updated with the additional strengths that are uncovered in (a) above. As stated these activities are reflected in meeting minutes and in the documentation described above. (SBHI P&P page 17, 5.1(b), 5.1(e))
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
(a) The HFW team reviews needs that were identified during Engagement. In a collaborative process with the client, family, and Tribe, the team identifies and adds any additional needs beyond those from the IP-CANS. Then they prioritizes those needs and document them in the meeting minutes. (SBHI P&P page 18, 5.2(a))
(b) Once prioritized, the team develops specific, measurable goals and outcomes based on those needs. (SBHI P&P page 18, 5.2(b))
(c) This is done in a collaborative process with the client, family and rest of the HFW team as stated above.
(d) The Facilitator leads the team in brainstorming multiple creative strategies for meeting prioritized needs, goals and outcomes. The team is instructed that there is to be no immediate selection or filtering during initial brainstorming. The Facilitator encourages inclusion of ideas from all team members, especially youth and family. Special consideration is given to strengths, culture, and natural supports. Facilitator prompts the team to develop strategies that are individualized to the youth and family, inclusive of natural and community supports, culturally relevant, and flexible and creative. All brainstormed strategies are documented in meeting minutes prior to selecting final strategies, ensuring that there is a clear record of multiple options considered, and the ability to revisit alternative strategies if needed. The team then selects strategies and assigns action items to the responsible team member and documents that in the meeting minutes to prepare for the Initial Plan of Care. The Facilitator guides the team in selecting strategies based on alignment with prioritized needs and goals, feasibility and family preference, use of strengths and natural supports. For each selected strategy, the Facilitator ensures that specific action steps are defined. Each action item includes the responsible person, timeline or due date, and a clear description of the task. The Facilitator confirms that each assigned team member agrees to their role and understands expectations. All of these activities are documented in meeting minutes.
(SBHI P&P page 18, 5.2(c)-(k), Team Meeting Minutes Template-Appendix A)
(e) The Facilitator receives specific training in the Plan of Care skill lab from UC Davis. Weekly group supervision meetings incorporate structured skill development aligned with fidelity domains including identifying, prioritizing, and selecting strategies and developing action items. Role specific training for Facilitators includes identifying and prioritizing underlying needs, writing needs based goals and measureable outcomes, leading structured brainstorming, developing actionable strategies and assignments, and ongoing plan revision (SBHI P&P page 42, 10.8.b.3, page 44, 10.10.b.4, Training Matrix Appendix E)
(f) All of these activities are documented in meeting minutes. The prioritized needs, outcomes, strategies, and action items identified above form the basis of the comprehensive Initial Plan of Care that is developed in SBHI P&P Section 5.3. The activities in Section 5.2 must be completed prior to beginning Section 5.3. Once (d) above is completed, the Facilitator leads the team in developing a comprehensive Initial Plan of Care (POC) within 30 calendar days from the start of services. The Plan of Care is based on the prioritized needs, goals, outcomes, and strategies identified in (d). The POC is in alignment with the family vision and team mission and it is based on the strengths, needs, and culture of the youth and family as identified in the Engagement activities. (SBHI P&P page 19, 5.3, Plan of Care-Appendix B)
4.3 Develop an Individualized Child or Youth and Family Plan
(a) Facilitators are required to take the Plan of Care Skills Lab and Child and Family Team Facilitation through UC Davis. The Clinical Director and Supervisors are responsible for ensuring Facilitators receive initial and ongoing training aligned with California High Fidelity Wraparound standards. Skill development is reinforced through formal Wraparound training and skills labs, internal booster trainings, weekly individual supervision, group supervision and case consultation, direct observation and feedback, and fidelity tools. Facilitators are trained and coached in building, engaging and maintaining effective teams, facilitation skills including eliciting multiple perspectives (youth, family, SOC partners, natural supports, Tribe if applicable), building trust and shared vision among team members, and applying HFW principles and maintaining family voice and choice. (SBHI P&P page 41, 10.8.b.3, 44, 10.10.b.3)
(b) The Plan of Care includes an array of services and supports that are well-coordinated across Children’s System of Care partners. The team addressess needs across multiple life domains (Behavioral Health, Education, Family Relationships, Safety, Physical Health, Social/Community Functioning) and includes Children’s System of Care partners in this process. The Facilitator guides the team toward selected strategies are clearly linked to prioritized needs and goals, cultutrally relevant and individualized, and that include a balance of formal supports, natural supports, and community and family resources. (SBHI P&P page 19, 5.3(c)-(g); Plan of Care-Appendix B)
(c) The Facilitator leads the team in a collaborative process developing a comprehensive initial Plan of Care (POC) within 30 calendar days from the start of services. The Plan of Care is based on the prioritized needs, goals, outcomes, and strategies identified in 5.2. The POC is in alignment with the family vision and team mission and it is based on the strengths, needs, and culture of the youth and family as identified in the Engagement activities. The POC addresses needs across multiple life domains and Children’s System of Care partners as identified and prioritized by the HFW team. Domains include but are not limited to Behavioral Health, Education, Family Relationships, Safety, Physical Health, and Social/Community Functioning. Facilitator ensures that POC has strategies and action items clearly documented and includes who is responsible for each and with established due dates. Facilitator guides team toward selected strategies that are clearly linked to prioritized needs and goals, culturally relevant and individualized, include a balance of formal services, natural supports, and community and family resources. Each team member understands their role. Facilitator ensures all services and supports are coordinated across CSOC partners, avoid duplication or fragmentation, are delivered in the family’s community whenever possible, and reflect family voice, schedule, culture, and trauma history. Facilitator ensures access and engagement barriers are addressed. Facilitator ensures the Plan includes existing natural supports and community resources and identifies strategies to develop additional natural supports if needed. Facilitator promotes increasing reliance on natural supports over time. Facilitator ensures the Plan includes graduated transition strategies toward less restrictive and less formal services, benchmarks or indicators of readiness for transition, and consideration of the family’s pace and readiness. The Plan of Care is distributed to all members of the Team and placed in the client’s file. (SBHI P&P page 19, 5.3, Plan of Care, Appendix B)
(d) The QA Coordinator collects, monitors and analyzes data through a structured QA tracking tool on an ongoing basis. Plans of Care are reviewed for alignment with HFW principles and fidelity indicators including: full alignment with the 10 Wraparound Principles, use of individualized strengths, needs, culture, and preferences, evidence that strengths are actively used in planning (not just listed), needs-driven planning (not problem-focused), cear linkage: Needs → Goals → Strategies → Action Items → Outcomes, strategies are individualized, strengths-based, and culturally relevant, balanced across formal and natural supports, inclusion and active assignment of natural supports, shared ownership and follow through on strategies and action items across team members, coordination across Systems of Care (SOC) partners, presence of transition planning and sustainability strategies, ongoing updating of strengths and needs based on new information, documentation reflects continuous discovery process, multiple strategies explored and documented, and action items are specific, assigned, and time-bound. Data is shared with leadership on a weekly basis to identify training needs and improve overall program effectiveness. Staff receive individualized feedback during weekly supervision meetings and monthly one-on-one coaching sessions. Additional coaching is provided when for three months or longer fidelity scores fall below benchmark, documentation is not compliant, or family feedback indicates concerns (SBHI P&P page 53, 11.3, page 54, 11.3.a.3, page 44, 11.4).
4.4 Develop a Crisis and Safety Plan
(a) The program requires that every youth and family has a documented Crisis and Safety Plan developed through a team-based, collaborative process prior to or concurrent with the initial Plan of Care. Facilitator leads the team in identifying potential high risk and crisis situations (e.g. behavioral escalation, placement instability, family conflict, medical or mental health crises), early warning signs and triggers, and individualized proactive strategies designed to prevent escalation and maintain safety and stability. Proactive atrategies must be selected by the youth and family, reflect strengths, culture, and preferences, and utilize natural supports and community resources whenever possible. The Facilitator leads the team in identifying individualized reactive (crisis response) strategies which are organized in a progressive sequence from least restrictive to more intensive interventions- What actions to take during a crisis, Who is responsible for each step, and De-escalation techniques and safety responses.
A Safety Plan Worksheet is provided to the client as a collaborative planning tool that centers the youth’s lived experience, preferences, and strengths. The plan includes clearly documented contact information and both natural supports (family, friends, community members) and formal supports (providers, crisis lines, emergency services)
This includes names, phone numbers, availability (including who is available 24/7). Natural supports are prioritized when possible and appropriate. The safety plan is reviewed at each team meeting or when new risks emerge for clarity of roles and responsibilities, family agreement with all strategies, and cultural relevance and appropriateness. The plan is updated immediately following a crisis event or significant change in risk. (SBHI P&P page 15, 4.8, page 20, 5.4; Crisis and Safety Plan Template, Safety Plan Client Worksheet – Appendix A)
(b) As stated above, the Safety Plan is created by the team, in a collaborative setting. The Clinical Director and Supervisors are responsible for ensuring Facilitators receive initial and ongoing training aligned with California High Fidelity Wraparound standards. Facilitators are required to take the Safety and Crisis Skills Lab through UC Davis. Skill development is reinforced through internal booster trainings, weekly individual supervision, group supervision and case consultation, direct observation and feedback, and fiidelity tools. Facilitators are trained and coached in:
o Risk assessment and safety planning
o Leading collaborative crisis planning discussions
o Developing proactive and reactive strategies
o Ensuring cultural responsiveness and use of natural supports
o Post-crisis safety planning
(SBHI P&P page 41, 10.8.b.2, 44, 10.10.b.1)
(c) The QA process has been described in detail elsewhere. With regard to crisis and safety plans, the QA Coordinator collects, monitors and analyzes data through a structured QA tracking tool on an ongoing basis. Crisis and Safety Plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, use of natural supports, and support contacts including who is available 24/7, as well as the clarity, usabilitym and family ownership of the plan. Data is shared with leadership on a weekly basis to identify training needs and improve overall program effectiveness. Staff receive individualized feedback during weekly supervision meetings and monthly one-on-one coaching sessions. Additional coaching is provided when for three months or longer fidelity scores fall below benchmark, documentation is not compliant, or family feedback indicates concerns. (SBHI P&P page 53, 11.3, 11.3.a.2)
Implementation
5.1 Implement The Plan of Care
(a) Facilitator schedules and leads regular monthly (or more frequently as needed) HFW team meetings using a standardized agenda that includes review of all active strategies and action items, status updates (completed, in progress, barriers), and assessment of effectiveness in addressing identified needs. Prior to each meeting, Facilitator provides a copy of the agenda and prior meeting’s minutes to all team members. Attendance at each meeting is documented in the meeting minutes. At each team meeting, Facilitator uses structured, strengths-based questioning to identify new strengths, including recent successes or accomplishments, newly identified skills or supports, and cultural or community resources not previously identified. Facilitator ensures newly identified strengths are added to the Strengths Inventory, referenced during strategy development and linked explicitly to meeting identified needs. Based on the prior meeting minutes, at each team meeting, the Facilitator reviews the strategies and action items and tracks completion of tasks and new individual assignments in the minutes. The IP-CANS may be used to inform tracking and decision making, but the team must still maintain their own tracking of needs, goal completion and action item completion to plan for transitions and not rely solely on the IP-CANS. The review includes status of completion (completed, in progress, not started), barriers to completion, and effectiveness of strategies in addressing identified needs. Each team member, including the youth and family, reports on assigned tasks. The team collaboratively determines whether strategies should continue as planned, require modification, or should be replaced with alternative strategies. The Facilitator actively tracks timelines and deliverables, prompting team members to meet deadlines and offering problem-solving support when barriers arise. Updated or new action items are clearly assigned with specific responsible parties and timelines before the close of each meeting.
Between meetings, the Facilitator conducts follow-up check-ins (via phone, text, or collateral contacts) to support completion of action items and maintain momentum.
If changes or adjustments are made to strategies or action items outside of regular team meetings, the Facilitator documents the change or adjustment and communicates that change or adjustment to all team members via an updated Care Plan. At each meeting, the Facilitator will also document in the minutes and client’s chart the use of formal and natural supports, use of Flex Funds, and updates to the Plan of Care. TThe Plan of Care is updated in the client’s chart and distributed to the members of the team at least every 90 days or when goals are changed, strategies are changed, team members are added, or the needs of the youth and family change.
The Facilitator leads the team in real-time evaluation of strategy effectiveness during meetings. Based on team input, the Facilitator guides the team to modify or discontinue ineffective strategies, develop new strategies aligned with updated needs, and revise goals when needs evolve. All changes are made collaboratively with the youth and family and reflect family voice and choice. The Plan of Care is formally updated during the team meeting, not outside of it. Updated Plans are completed and distributed to all team members at least every 90 days, or more frequently when changes occur.
The Facilitator completes detailed HFW Team Meeting Minutes within required timelines, documenting completion of tasks and status of action items, new assignments with responsible parties and timelines, team attendance (including natural and formal supports), use of formal and natural supports in strategies, use of flex funds (if applicable), including purpose and linkage to needs, and all updates to the Plan of Care. Meeting minutes are distributed to all team members following each meeting to ensure shared understanding and accountability. The Facilitator maintains ongoing communication between meetings (phone, email, text, collateral contacts) to support task completion and reinforce updates. (SBHI P&P page 21, 6-6.3)
(b) There are a few ways in which staff receive training and coaching in implementing the Plan of Care in alignment with HFW principles. The UCD Plan of Care Skills Lab is one of the booster trainings offered and it is also required for all Supervisors and Facilitators. There are several topics in the ongoing trainings related to the Plan of Care such as: Identifying needs and developing needs statements that are reflective of the underlying reasons why problematic situations or behavior occur; Identifying, prioritizing, and selecting strategies and developing action items; Use of family and culture in planning and service delivery; Providing culturally respectful and relevant strategies; and Revising and strengthening Plans of Care when strategies are not producing the desired outcomes. Training and coaching explicitly address the importance of recognizing and celebrating successes. In addition, the QA Coordinator collects and monitors information from chart reviews. For the Plan of Care that includes use of individualized strengths, needs, outcomes, and strategies; iInclusion of natural supports and for natural supports in assigning of strategies and action items; shared ownership and follow through on strategies and action items. This information is collected in a QA tool and provided to the Program Director, Clinical Director and Executive Director. Staff are provided with constructive, strengths-oriented feedback to enhance practice and, if necessary, coaching when training needs are identified. (SBHI P&P page 42, 10.8.f.2; 41, 10.8.b.3; page 42, 10.9; page 43, 10.11(i); page 54, 11.3.a.3; page 45, 11.4)
5.2 Review and Update The Plan of Care
(a) Based on the prior meeting minutes, at each team meeting, the Facilitator reviews the strategies and action items and tracks completion of tasks and new individual assignments in the minutes. The IP-CANS may be used to inform tracking and decision making, but the team must still maintain their own tracking of needs, goal completion and action item completion to plan for transitions and not rely solely on the IP-CANS. The review includes status of completion (completed, in progress, not started), barriers to completion, and effectiveness of strategies in addressing identified needs. Each team member, including the youth and family, reports on assigned task. The team collaboratively determines whether strategies should continue as planned, require modification or should be replaced with alternative strategies. The Facilitator actively tracks timelines and deliverables, prompting team members to meet deadlines and offering problem-solving support when barriers arise. Updated or new action items are clearly assigned with specific responsible parties and timelines before the close of each meeting. Between meetings, the Facilitator conducts follow-up check-ins (via phone, text, or collateral contacts) to support completion of action items and maintain momentum. If changes or adjustments are made to strategies or action items outside of regular team meetings, the Facilitator documents the change or adjustment and communicates that change or adjustment to all team members via an updated Care Plan.
(SBHI P&P page 22, 6.1(f)-(k))
(b) The Facilitator leads the team in real-time evaluation of strategy effectiveness during meetings. Based on team input, the Facilitator guides the team to modify or discontinue ineffective strategies, develop new strategies aligned with updated needs, or revise goals when successes occur or needs evolve. All changes are made collaboratively with the youth and family and reflect family voice and choice. The Plan of Care is formally updated during the team meeting, not outside of it.
Updated Plans are completed and distributed to all team members and placed in the client’s file at least every 90 days, or more frequently when changes occur.
(SBHI P&P page 23, 6.2, 6.3(b))
(c)At each meeting, the Facilitator documents in the minutes completion of tasks and status of action items, new assignments with responsible parties and timelines, meeting attendance including natural and formal supports, the use of formal and natural supports in strategies, use of Flex Funds including purpose and linkage to need, and updates to the Plan of Care. Meeting minutes are distributed to all team members following each meeting to ensure shared understanding and accountability. c) The Facilitator maintains ongoing communication between meetings (phone, email, text, collateral contacts) to support task completion and reinforce updates.(SBHI P&P page 24, 6.3))
(d) All forms are computer-based and adaptable so that they can be updated and individualized for the client and family. They are not pre-filled.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
(a) Facilitator brings team agreements (Norms, Strengths Inventory, Family Vision and Team Mission) to every meeting. These agreements are reviewed when a new member is added to the team, when challenges occur, during key transitions, or at least every 60-90 days depending on how frequently the team meets. (SBHI P&P page 24, 6.4(a))
(b) Facilitators must complete the Foundational Wraparound training through UC Davis as well as the Wraparound Training Passport. a) Additional role specific training is required and can be obtained via formal trainings, meetings, coaching, peer shadowing, group supervision, direct observation of team meetings, and/or individual supervision. Facilitators receive initial and ongoing training and coaching on building, engaging, and maintaining effective teams including team engagement and facilitation, conflict resolution and mediation, motivational engagement strategies, building collaborative team environments, facilitation skills including eliciting multiple perspectives (youth, family, SOC partners, natural supports, Tribe if applicable), building trust and shared vision among team members, and applying HFW principles and maintaining family voice and choice.
(SBHI P&P page 41, 10.8; page 43, 10.10(a), 10.10.b.3)
(c) The Supervisor monitors the inclusion and utilization of natural supports through chart review, supervision, and fidelity data. Feedback is provided to ensure plans prioritize natural and community-based supports and reduce reliance on formal services over time. (SBHI P&P page 45, 10.12(h))
(d) As new team members are added, the Facilitator ensures that they are oriented to the Team. This includes: explaining the HFW process and principles, explaining the roles and responsibilities of all members of the team, reviewing the current Plan of Care, and engaging in team building exercises as a group. (SBHI P&P page 24, 6.4(f))
Transition
6.1 Develop a Transition Plan
(a) The HFW team creates a formal transition plan for each client and family which is distributed to all Team members and placed in the client’s file (Transition Plan). The client with go through several transitions while in the program as they transition from the highest level of acuity to the lowest level of acuity and ultimately out of the HFW program.
The Facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring, adapting and documenting in the Plan of Care (refer to Section 4.4). Once a youth is ready for transition, their graduation from the High Acuity Team is celebrated and they join the Moderate Acuity Team. This process is repeated again as the youth and family transition from the Moderate Acuity Team to the Low Acuity Team. While on the Low Acuity Team, the Facilitator leads the team in identifying needs, services, and supports that will persist past formal HFW. This process includes strategies to transition any remaining support being provided by HFW staff to those ongoing supports. Once on the Low Acuity Team, the youth and families are prepared for transitioning out of HFW well in advance. The Facilitator ensures that concerns are addressed, supports are in place, and services are identified that will meet the needs of the youth and family. The transition is paced to allow the youth and family to adjust to the transition prior to ending HFW services. (SBHI P&P page 11, 4.4; page 26, 7.1; Transition Plan)
The HFW Facilitator, in collaboration with the Child and Family Team (CFT), leads a structured review of progress toward the family vision, team mission, and prioritized needs. Readiness for transition is determined through a combination of objective data and team consensus, with strong emphasis on family voice and choice.
Transition readiness is assessed using the following indicators: sustained progress on prioritized needs and goals in the Plan of Care, reduction in intensity or frequency of crises, increased caregiver confidence and ability to manage future challenges, stability in placement, school, and community functioning, demonstrated use of natural and community supports, and improvement in standardized measures (e.g., CANS, WFI-EZ, satisfaction surveys). The Facilitator schedules a Transition Readiness Review discussion during a Child and Family Team meeting once benchmarks appear to be met. The team collaboratively determines readiness.
Facilitator reviews data prior to the meeting (CANS, Plan of Care progress, crisis logs) and places “Transition Readiness Review” on the team meeting agenda. Team discusses progress, remaining needs, and readiness indicators. Family provides input and confirms readiness (or identifies remaining needs). Decision is documented in meeting minutes. (SBHI P&P page 27, 7.2-7.4)
(b) Upon agreement that the youth and family are ready for transition, the Facilitator leads the development of a formal Individualized Transition Plan. The plan ensures continuity of care and sustainability of outcomes by clearly identifying remaining needs to be monitored post-transition, ongoing formal services (if applicable), natural and community supports, crisis and safety supports, roles and responsibilities of individuals post-transition, and specific steps to transition responsibilities from HFW staff to natural supports and/or other providers. The plan is reviewed, finalized, and approved during a CFT meeting and reflects team consensus and family preferences.
Facilitator drafts the Transition Plan based on team input. Plan is reviewed and refined during a team meeting. Final plan is signed/approved (if applicable). Facilitator distributes the plan to all team members within established timelines. Plan is uploaded and maintained in the client record. (SBHI P&P page 28, 7.6)
(c) The HFW Facilitator, in collaboration with the Child and Family Team (CFT), leads a structured review of progress toward the family vision, team mission, and prioritized needs. Readiness for transition is determined through a combination of objective data and team consensus, with strong emphasis on family voice and choice. (SBHI P&P page 27, 7.2(a)) Facilitators are required to complete the UC Davis Transition Skills Lab. They also receive ongoing training aligned with CA HFW standards. Skill development is reinforced through booster trainings, weekly individual supervision, group supervision and case consultation, direct observation and feedback, and fidelity tools. Facilitators are trained in transition planning, including determining transition readiness using data and team consensus, building high quality, individualized transition plans, and transitioning responsibility from formal supports to natural supports (SBHI P&P page 41, 10.8.b.4, page 43, 10.10, 10.10.b.2)
(d) The HFW team ensures that all services and supports identified in the Transition Plan are accessible, sustainable, and actively connected prior to discharge. This includes confirming appointments are scheduled with ongoing providers, natural supports understand their roles, community connections are established, crisis contacts are current and understood, and families receiving Adoption Assistance Program (AAP) funding are educated on and connected to post-adoption services. The Facilitator verifies access and readiness through direct confirmation with the family and service providers. (SBHI P&P page 28, 7.9)
6.2 Develop a Post-Transition Safety Plan
(a) Facilitator leads the team in updating the existing Crisis and Safety Plan or developing a Transition-Specific Crisis and Safety Plan. The plan reflects anticipated risks following discharge from formal Wraparound and ensures that the youth and family are equipped with clear, actionable, and individualized strategies. The plan includes early warning signs of crisis specific to the youth, proactive (preventative) strategies identified by the family, reactive strategies to manage escalating situations, clearly identified natural supports and their roles, crisis contacts and emergency resources, culturally relevant strategies aligned with family values. The youth and family play a primary role in identifying strategies to ensure the plan is usable and meaningful post-transition. Facilitator reviews existing crisis plan prior to transition phase. Facilitator schedules dedicated discussion during a team meeting. Team identifies likely post-transition crisis scenarios. Youth and family identify preferred coping strategies and supports. Facilitator ensures inclusion of natural supports and community resources. Plan is updated or newly developed and reviewed with the team. Final plan is documented in the client record and shared with all team members. (SBHI P&P page 29, 7.11, Crisis and Safety Plan)
(b) Facilitators are required to complete the UC Davis Safety and Crisis Skills Lab. They also receive ongoing training aligned with CA HFW standards. Skill development is reinforced through booster trainings, weekly individual supervision, group supervision and case consultation, direct observation and feedback, and fidelity tools. Facilitators are trained in crisis planning, including risk assessment and safety planning, leading collaborative crisis planning discussions, developing proactive and reactive strategies, ensuring cultural responsiveness and use of natural supports, and post-crisis safety planning. (SBHI P&P page 41, 10.8.b.2, page 44, 10.10.b.1)
(c) The QA Coordinator collects, monitors, and analyzes data through a structured QA tracking and audit tool designed to assess fidelity to the High Fidelity Wraparound (HFW) model, documentation compliance, service quality, and outcomes. Data is reviewed on a weekly basis and reported to the Program Director, Clinical Director, and Executive Director. Aggregate data is trended and reviewed quarterly as part of the Continuous Quality Improvement (CQI) process. Crisis and Safety Plans are reviewed for individualized strategies, clear proactive and reactive progression of strategies, cultural relevancy and alignment with family values, inclusion and utilization of natural supports, inclusion of support contacts and 24/7 resources, clarity, usability, and family ownership of the plan. (SBHI P&P page 53, 11.3.a.2)
6.3 Create a Commencement and Celebrate Success
(a) The HFW team ensures that the transition from formal Wraparound services is marked by a meaningful and culturally relevant celebration that reflects the youth and family’s preferences and accomplishments. Celebrations are designed to recognize progress toward goals and completion of the team mission, reinforce strengths and resilience, provide closure to the Wraparound process, and strengthen connections with ongoing supports. The youth and family determine the type, tone, and participants of the celebration. Facilitator discusses celebration preferences during transition planning. Team collaborates to plan the event (location, attendees, format). Celebration may occur during a final team meeting or separate event. Strengths, achievements, and progress are acknowledged. Natural supports are included to reinforce ongoing connections. (SBHI P&P page 29, 7.12)
(b) The program maintains administrative and fiscal structures that support meaningful transition celebrations. This includes ensuring that staff have time, resources, and flexibility to participate in and facilitate celebrations. Flexible funds may be used, when appropriate, to support culturally relevant and meaningful activities that align with the transition plan and wraparound principles. (SBHI P&P page 29, 7.13-7.14)
Process for Requesting Flex Funds and scheduling Celebrations
1. Facilitator identifies celebration needs with the family
2. Flexible Funds Request Form is completed if needed
3. Supervisor reviews and approves request
4. Program Director reviews and approves request
5. Request is sent to Accounts Payable for processing
6. Staff schedules are adjusted to allow participation
7. Community resources and partnerships are leveraged when appropriate
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
(a) Youth and family are key decision-makers. Youth and family feedback is utilized to inform all levels of the HFW Program, including service planning and implementation, policy and procedure development, workforce development, and quality improvement of the Wraparound model. Feedback is elicited via satisfaction surveys, informal check ins after meetings, and using the WFI-EZ. (SBHI P&P page 30, 8.1-8.2)
Client, family satisfaction, and Tribal satisfaction, is tracked every 90 days using the WFI-EZ is completed during team meetings and SBHI Client Satisfaction Survey is sent to clients, families, and tribal representatives via email and text. Paper versions are available during team meetings. A QR code to the survey is accessible in the reception area at any time during the year. QA follow up calls for qualitative feedback. (SBHI page 56, 11.3.b.5)
(b) Data is reviewed quarterly by leadership to informed decision making. Data is used to identify staff training and coaching needs, inform booster training topics, improve service delivery and program design, address documentation and compliance issues, identify gaps in access, timeliness, and engagement, and strengthen fidelity to HFW principles. (SBHI P&P page 56, 11.4(b))
7.2 Community Leadership Team
(a) System-Level Advocacy: Data is used to identify systemic barriers (e.g., access to services, funding limitations). The Clinical Director communicates findings to the Community Leadership Team and system partners. SBHI participates in system-level problem solving and advocacy efforts. (SBHI P&P page 57, 11.4(f))
7.3 Eligibility and Equal Access
(a) Eligibility and Equal Access. All youth referred for HFW services that meet established eligibility criteria are offered an appointment despite severity or nature of their needs.
b) Case loads are assigned mindfully so that staff can meet the complex needs of families and support those that require 24/7 crisis availability.
SBHI P&P page 31, 8.4
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
SBHI maintains fiscal practices that ensure compliance with California High Fidelity Wraparound (HFW) standards and support the effective delivery of services. Financial resources are allocated and managed to sustain essential program operations, including staffing, workforce development, data collection and management, service delivery, and flexible funding to meet individualized family needs. SBHI ensures that fiscal practices support family voice and choice, individualization, and access to resources, and that financial structures do not create barriers to meeting the needs of youth, families, Tribes, and communities.
Annual Budget Development: The Chief Executive Officer (CEO) prepares an annual operating budget prior to the start of each fiscal year based on total contract allocation and funding streams (e.g., LACDMH), historical spending trends and prior year utilization, projected staffing model and caseload capacity, anticipated program expansion or service changes, and equired investments in training, data systems, and quality assurance.
The budget includes detailed line items for personnel costs (salaries, benefits, overtime), workforce development (training, certification, coaching), data systems and technology (EHR, QA tools, reporting systems), operational costs (rent, supplies, administrative support), direct service costs (transportation, interpretation, community-based services), and flexible Funds allocation to support individualized family needs.
The budget is structured to ensure adequate resources to meet HFW fidelity requirements, including staffing ratios, frequency of contact, and access to natural and community-based supports. The CEO, Program Director and Clinical Director review the budget against quarterly expenses.
Ongoing Budget Monitoring and Review: The CEO, Program Director, and Clinical Director conduct formal quarterly budget reviews comparing budgeted vs. actual expenditures, cost per client and cost per service unit, staffing expenditures relative to productivity and service delivery, and utilization of contract funds across funding categories. In addition to quarterly reviews, monthly financial check-ins are conducted to monitor spending trends across funding sources, monitor contract utilization and remaining balance, identify early variances or risks, and ensure alignment between service delivery and financial performance. Variances from the budget are analyzed and may result in adjustments to staffing or caseload distribution, reallocation of resources across budget categories, implementation of cost containment strategies, increased utilization of alternate funding, or requests for additional funding (when appropriate).
Alignment of Fiscal Management with Service Delivery: Fiscal decisions are directly aligned with program operations to ensure that funding supports timely access to services, required frequency and intensity of HFW contacts, adequate staffing to maintain fidelity, and engagement of natural and community supports. The Program Director and Clinical Director provide input on service delivery needs to ensure that financial decisions do not compromise care quality, access, or fidelity.
SBHI P&P page 32, 9.1-9.3
8.2 Equitable Funding Across System Partners
8.3 Cost Savings are Reinvested
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
a) Teams can request access to flexible funds to meet urgent and individualized needs when these needs are not readily met by other resources. Requests for flexible funds are evaluated based on recommendation of the HFW team and whether the use of funds adds value to the team mission and supports the individualized care plan, builds on family strengths, meets identified youth and family needs, are culturally relevant, builds on natural support and/or community capacity, represents a good deal for the investment, includes a plan for sustainability. (SBHI P&P page 34, 9.5(a)-(b))
(b) A Flex Fund Request Form is completed by the Facilitator and submitted to Supervisor for review and approval. Once the Supervisor approves the request, it is sent to the Program Director for final review and approval. Once the Program Director approves the request, the form is sent to the CEO to release the funds. If the Team decides the need is urgent, a decision must be made within 3 days of receiving the Flex Fund Request Form. In the case of an Indian child, flex funds may be used to pay the Tribe for activities that address youth and family needs. If the request is denied, the Team will receive a written explanation for the denial may appeal the decision by scheduling a meeting with the Program Director and CEO. (SBHI P&P page 34, 9.5(c)-(h))
8.5 Collaborative Oversight of Flex Funds
(a) All Flex Fund requests whether approved or denied are documented in our QA tracking log. This excel file includes the following information: facilitator/HFW Team that requested the funds, purpose of the funds, amount of the funds, whether the funds were approved or denied. Information regarding Flex Fund use is provided to LACDMH per their guidelines. (SBHI P&P page35, 9.6(a)-(b))
(b) Flex funds are pooled and held to meet the needs of all families served. When funding limitations exist in a single funding source, alternate funding options are explored and those efforts are documented in the youth’s chart. (SBHI P&P page 35, 9.6(d))
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
(a) SBHI ensures that the requirements of any single funding source do not limit the availability of flexible funding or the resources necessary to meet the individualized needs of youth, families, and Tribes. Flexible Funds and program resources are supported through a braided funding approach, which includes combining multiple System of Care funding sources (e.g., LACDMH, BHSA, Title IV-E, CalWORKs, and other eligible funding streams), and allocating funds in a manner that maximizes flexibility and responsiveness to family-identified needs. (SBHI P&P page 33, 9.4-9.4.a.1)
(b) Funding streams are tracked and managed to ensure compliance with each funding source’s requirements while maintaining flexibility at the service delivery level.
The availability of Flexible Funds is not restricted by the limitations of any single funding source. When funding limitations exist within a specific funding stream alternate funding options are actively explored, reliance on other available funding sources is increased, and leadership collaborates to identify solutions that maintain service continuity. (SBHI P&P page 33, 9.4.a.2-9.4.b.2)
(c) Decisions regarding Flexible Fund use are based on youth and family needs identified through the HFW process, alignment with HFW principles (individualization, strengths-based, culturally relevant), and sustainability and effectiveness of the proposed support. Under no circumstances are families denied access to appropriate Flexible Funds solely due to restrictions within a single funding source. (SBHI P&P page 33, 9.4.b.3-9.4.b.4)
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
(a) The QA Coordinator extract and compiles demographic data from the HER including: race and ethnicity, primary language, cultural identity, and special populations (e.g. Tribal affiliation). Workforce demographic data is compiled by HR and includes: Staff race/ethnicity, language fluenty spoken, and cultural competencies and lived experience (when disclosed). On a quarterly basis, leadership reviews the alignment between the workforce and client demographics to identify gaps in language capacity, cultural representation, and any other areas of high unmet need. Based on identified gaps, recruitment strategies are adjusted and may include: Targeted job postings in culturally specific networks and organizations, outreach to community-based organizations, universities, and training programs, use of bilingual and culturally specific job boards, partnerships with community leaders and cultural organizations, and job descriptions are updated to reflect the preferred or required language skills, cultural competencies, and experience working with specific populations. HR tracks applicant demographics, language capacity, and hiring outcomes relative to identified needs. (SBHI P&P page 36, 10.1)
(b) When SBHI is unable to recruit or hire staff that fully reflect the cultural, racial, or linguistic needs of the population served, alternative strategies are implemented to ensure culturally responsive care. During Engagement and Discovery, the team identifies cultural identity and values, language preferences, cultural or community connections important to the family, and need for cultural representation on the team. This information is documented in the Strengths Needs Culture Discovery document and the Plan of Care. The Facilitator works with the family to identify natural supports who share the family’s cultural background, speak the family’s preferred language, and provide culturally relevant guidance and support. Natural supports are invited to participate in Child and Family Team meetings, assigned meaningful roles within the Plan of Care and are supported in actively contributing to strategies and decision making. When natural supports are not available or sufficient, the team identifies and engages cultural brokers, community leaders, faith-based supports, tribal representatives (when applicable), and culturally specific service providers. These supports are integrated into the HFW team and planning process. (SBHI P&P page 38, 10.4(a)-(c))
(c) When staff do not speak the family’s preferred language professional interpretation services are arranged for all meetings and key interactions. Translated materials are provided when available. The Facilitator ensures that interpretation is scheduled in advance of meetings, the family is comfortable with the interpreter, and communication remains clear and accessible. The HFW team ensures that strategies are culturally relevant and aligned with family values, services are adapted to reflect cultural practices and beliefs, and amily preferences guide all planning decisions. Supervisors monitor cultural responsiveness through chart reviews, team observation, and feedback from families. The following must be documented in the client record: Identified cultural and linguistic needs, efforts to match staff or provide representation, use of interpreters or cultural supports, integration of cultural elements into the Plan of Care, and participation of natural or cultural supports in team meetings. (SBHI P&P page 38, 10.4(d)-(f))
9.2 Tribally Responsive Workforce
(a) All new staff complete the training: Indian Child Welfare Act (ICWA) Overview & Tribal Engagement in Teaming Best Practices. (SBHI P&P page 40, 10.6.a.2) Staff receive annual training in cultural competency including training on tribal sovereignty, traditions, and values offered by LACDMH (SBHI P&P page 40, 10.6.d.1)
(b) Tribal representatives are invited to all meetings and explicitly included in decision-making as a valued member of the HFW team (SBHI P&P page 15, 4.9(a)). The Team works with the family to identify natural supports and include them on the Team. The Facilitator continuously assesses the presence and participation of natural supports on the team. During team meetings, the Facilitator prompts discussion of opportunities to identify, invite, and engage additional natural supports
When working with Indian children, the Team builds partnerships with tribal representatives, encouraging participation in traditions and ceremonies. (SBHI P&P page 24.6.4 (b)-(e))
9.3 Flexible and Creative Work Environment
SBHI engages in a data-driven continuous quality improvement program model. Policy and procedure revisions are informed by CQI data, including but not limited to:
Wraparound Fidelity Index (WFI-EZ) results, IP-CANS trends and outcomes data, Client satisfaction surveys, Chart audits and documentation reviews, and Timeliness and access metrics. Input from staff, youth, families, caregivers, and Tribal representatives is actively solicited and incorporated into policy revisions when appropriate. Feedback mechanisms include staff surveys, supervision discussions, team meeting feedback, and formal satisfaction surveys. Data is reviewed weekly and aggregated quarterly by leadership and used to identify gaps, trends, and opportunities for program improvement. (SBHI P&P page 53 11.3(b), 11.4, page 58, 12.3, 12.4)
9.4 Hiring, Performance Evaluation, and Job Descriptions
(a) SBHI implements rigorous hiring practices, clearly defined role expectations, and ongoing performance management processes to ensure that all staff demonstrate competency in High Fidelity Wraparound principles, values, phases, and activities. All required Wraparound functions are fulfilled through defined roles or appropriately combined positions with clear responsibilities. SBHI ensures that the following roles/functions are fulfilled within the program: Youth Partner, Parent Partner, HFW Facilitator, Family Specialist, Fidelity Coach, Clinical Supervisor (licensed), and HFW Supervisor/Manager. The Program Director maintains a Role Coverage Matrix identifying each required HFW function, assigned staff member(s), whether roles are combined or separate, and role combination (if applicable). When roles are combined responsibilities are clearly delineated in job descriptions, supervisors ensure workload remains manageable, and role expectations are reviewed during supervision. Annually leadership reviews role coverage annually to ensure all functions are fulfilled and staffing structure supports fidelity. (SBHI P&P page 36, 10.1, Role Coverage Matrix)
(b) Each job description includes: Role purpose, Core functions and responsibilities, Required competencies (skills, knowledge, attributes), and HFW-specific expectations.
(SBHI P&P page 37, 10.2, Job Descriptions)
(c) Job descriptions are aligned with HFW principles, Wraparound phases and activities, UC Davis Wraparound Standards Toolkit. Competency Areas Include engagement and teaming, needs-driven planning, cultural responsiveness, collaboration with natural supports, and documentation and outcomes tracking. (SBHI P&P page 37, 10.2(b)-(c))
(d) All candidates are encouraged to have an in person interview to allow them to get a feel for the work environment and to allow potential Team members to meet them prior to hiring. All applications are screened by the Program Director based on experience with family-centered care and alignment with HFW values. Those that pass the initial screening are reviewed by the Clinical Director, Clinical Supervisor, and Executive Director to assess ability to engage families, strengths-based thinking, problem solving and flexibility, and cultural responsiveness. Candidates complete at least one of the following mock Child and Family Team scenario, case-based problem-solving exercise, or role-play demonstrating engagement or facilitation. (SBHI P&P page 38, 10.4(a)-(d))
(e) Staff certification status is directly linked to fidelity and performance data. Data sources used for certification monitoring include the Wraparound Fidelity Index (WFI-EZ), Team Observation Measure (TOM 2.0) or internal equivalent, chart audits, Plan of Care quality reviews, timeliness metrics, and client satisfaction surveys. Staff are expected to meet established program benchmarks for fidelity and documentation quality. Staff falling below benchmarks will receive targeted coaching, increased supervision, and/or booster training assignments. Staff who do not meet certification or recertification standards will be supported through a structured remediation process. Remediation may include increased frequency of supervision, live or recorded session review, shadowing high-performing staff, targeted skill-based coaching, re-completion of specific UC Davis Skills Labs (as appropriate). A formal Fidelity Improvement Plan will be developed and tracked. Progress is reviewed weekly to bi-weekly until competency is demonstrated. (SBHI P&P page 47, 10.15-10.16) Nevertheless, all benchmark data is reviewed by leasdership weekly. Staff receive individualized feedback during weekly supervision and monthly one-on-one coaching sessions. Feedback is strengths-based and solution-focused. (SBHI P&P page 53, 11.4(c))
9.5 Workforce Stability
(a) SBHI makes all efforts to offer competitive wages and compensation to our employees. We work with a Professional Employment Organization to ensure that employees’ salaries meet the requirements of California labor law. The Hiring Manager and/or Chief Executive Officer researches local salary benchmarks for other community-based mental health agencies in our service area annually to ensure that we are in alignment with the current market. (SBHI P&P page 48, 10.19)
(b) SBHI is committed to maintaining manageable workloads for staff.
Our agency will determine it’s maximum capacity based on its contract with LACDMH. The number of clients per team will be based on a combination of funding and team structure requirements by the County. We will also consider staff experience, client complexity, and service intensity. (SBHI P&P page 48, 10.20)
(c) SBHI utilizes a leadership structure that allows for advancement in position and pay as employees demonstrate leadership skills, increased responsibility, and desire to promote. SBHI uses a competency-based advancement framework. Advancement is tied to demonstrated fidelity competency, measurable family outcomes, documentation quality, leadership behaviors, training completion, and certification milestones. (SBHI P&P page 49, 10.21, Organization Chart, Advancement Milestone by Role)
(d) We aim to provide wage increases on an annual basis to adjust for increases in cost of living. Wage increases do not require a change in position. Leadership opportunities are also available that do not require a change of position. Staff are able to participate in peer supervision, trainings during supervision, and participate on the IMPACT Committee which is a committee that meets quarterly to discuss issues that impact the organization and strategies and implements solutions. They act as the employee voice for the organization. We also promotes internal capacity building through advanced certification pathways. Advanced certification opportunities include participation in Training for Trainers (UC Davis), certification as internal Wraparound Coach or Supervisor, and advanced facilitation and fidelity monitoring training. The eligibility criteria is demonstrated high fidelity scores, strong outcomes and family feedback, consistent documentation quality, and leadership and mentorship behaviors, (SBHI P&P page 48, 10.17)
9.6 High Fidelity Training Plan
(a) All new staff complete foundational training. Wraparound 101: Foundations for Fidelity training offered by the Resource Center for Family-Focused Practice at UC Davis Human Services and Indian Child Welfare Act (ICWA) Overview & Tribal Engagement in Teaming Best Practices. The Clinical Director, Facilitators, and any Clinical Supervisor follow the Foundational Wraparound Training Passport to gain a thorough understanding of the Wraparound process. At least one staff member is identified to enroll in Foundational Wraparound Training for Trainers to build internal sustainability capacity. All direct staff complete training on medical necessity requirements, linking CANS actionable items to Plans of Care goals, writing functionally focused progress notes, documenting time, location, and mode of service, and linking interventions directly to identified needs. (SBHI P&P page 41, 10.8)
(b) In addition to Foundational Training there are four additional layers of trainings that are required and provided for our staff–annual training, ongoing training, booster trainings and role specific training. Annual training reinforces fidelity and compliance standards. Staff receive annual training in cultural competency including training on tribal sovereignty, traditions, and values offered by LACDMH. Staff complete annual refresher training in Wraparound 101 or equivalent fidelity reinforcement training. Clinical supervisors including HFW supervisors also complete fidelity training specific to their supervisory role. Weekly group supervision meetings incorporate structured skill development aligned with fidelity domains. Role specific training ensures clarity of function and prevention of role drift. Additional role specific training is required and can be obtained via formal trainings, meetings, coaching, peer shadowing, group supervision, direct observation of team meetings, and/or individual supervision (SBHI P&P page 42, 10.8(d); page 43, 10.10; Training Matrix in Appendix E)
(c) Booster Trainings are provided monthly and topics are determined based on supervision themes, WFI-EZ results, client satisfaction data, chart audit findings, CANS trends, staff survey input (collected twice annually), and staff role. A Booster Training calendar is maintained on Sharepoint. Booster training may also include UC Davis Skills Labs. (SBHI P&P page 42, 10.8(e)-(g))
(d) As stated earlier, all new staff including the Clinical Director, Facilitators, and any Clinical Supervisor follow the Foundational Wraparound Training Passport to gain a thorough understanding of the Wraparound process. Annual training reinforces fidelity and compliance standards. Clinical supervisors including HFW supervisors complete fidelity training specific to their supervisory role. Booster Trainings are provided monthly and topics are determined based on supervision themes, WFI-EZ results, client satisfaction data, chart audit findings, CANS trends, staff survey input (collected twice annually), and staff role. (SBHI P&P page 41, 10.8(b), 42, 10.8.d.2, 10.8(e))
(e) Staff receive annual training in cultural competency including training on tribal sovereignty, traditions, and values offered by LACDMH. The Clinical Director tracks special populations as part of the QA process. Booster trainings may include trainings that support special populations that have specific needs. (SBHI P&P page 41, 10.7.a.3, page 42, 10.8(e))
9.7 Community-based Training Program
(a) SBHI administers its High Fidelity Wraparound training program in collaboration with youth, families, peer partners, and community stakeholders to ensure that training reflects lived experience, promotes meaningful system collaboration, and strengthens the effectiveness of the Children’s System of Care.
Training efforts are designed to be inclusive, accessible, and responsive to the needs of both internal staff and external partners who participate in or support the Wraparound process. Identification and Recruitment of Training Partners. SBHI identifies youth, caregivers, Parent Partners, Youth Partners, and individuals with prior Wraparound experience who are interested in participating in training delivery. Recruitment sources include current and former HFW participants (with consent and readiness), Parent Partners and Youth Partners employed by SBHI, and community-based peer organizations. Individuals are selected based on lived experience with Wraparound, ability to share experiences in a constructive and strengths-based manner, and readiness to participate in a training environment. (SBHI P&P page 50, 10.22(a)) Youth, families, and peer partners are actively incorporated into training, not used in a symbolic or tokenized role. Their involvement may include co-facilitating training sessions, participating in panel discussions, sharing personal Wraparound experiences, providing examples of effective engagement, family voice and choice, and what helped vs. what did not help. Lived experience content is integrated into key training areas, including Engagement (“Hello”), teaming and collaboration, strengths-based planning, cultural responsiveness, and transition and outcomes. Trainers ensure that lived experience perspectives are directly tied to HFW principles, used to enhance staff understanding and empathy, and integrated into skill-building exercises. (SBHI P&P page 50, 10.22(c))
(b) SBHI identifies key System of Care partners, including schools (e.g., LAUSD or equivalent), child welfare agencies, probation/juvenile justice partners, healthcare providers, community-based organizations, and cultural and faith-based organizations. SBHI maintains a Community Partner Contact List for outreach. Community partners are invited to attend SBHI Wraparound trainings on a quarterly basis, or offered targeted trainings tailored to their role in supporting HFW. Invitations are distributed via email, formal letters or direct outreach by Program Director or designee. When appropriate, SBHI offers joint trainings that include SBHI staff, community partners, and youth and family representatives. These trainings are designed to build shared understanding of HFW, strengthen cross-system collaboration, and improve team functioning. SBHI tracks community partner attendance, type of organizations participating, and requency of participation. This participation data is reviewed quarterly to identify gaps in system engagement and adjust outreach strategies. (SBHI P&P page 51, 10.23)
The training content reinforces cross-system collaboration, shared responsibility for outcomes, and use of natural and community supports. Trainings ensure that external team members understand their role in Wraparound, can actively participate in team meetings, and align their services with the Plan of Care. Feedback from community partners is used to improve training relevance, strengthen collaboration, and address system barriers. (SBHI P&P page 52, 10.24)
9.8 Coaching and Supervision
(a) All staff undergo an initial apprenticeship that covers values, skills and knowledge related to HFW principles, phases, activities and the effective use of flex funds to meet a family’s needs. (SBHI P&P page 44, 10.11(a))
(b) An on-call supervisor is available 24/7. The contact information for the Supervisor of the Day is posted on-site and also emailed to all providers at the beginning of the month. (SBHI P&P page 45, 10.11(b))
Coaching is strength-based and solution-focused which is a model for the type of service provided to SBHI’s clients. Feedback is provided using fidelity tools and structured coaching methods. All clinical staff are assigned a clinical supervisor who provides frequent feedback, including real-time, targeted feedback, and coaching through supervision including case consultation, review of Plans of Care, direct observation of team meetings, team dynamics, and facilitation effectiveness, documentation review, and feedback from family and team. Supervisors provide ongoing training and coaching to strengthen skills necessary for identifying barriers, developing strategies that help teams maintain engagement with youth and families while continuing to implement the HFW model with fidelity and effective problem-solving and plan adaptation.
Crisis and safety plans are reviewed during supervision for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and use of natural supports. The Supervisor monitors the inclusion and utilization of natural supports through chart review, supervision, and fidelity data. Feedback is provided to ensure plans prioritize natural and community-based supports and reduce reliance on formal services over time.
Training and coaching explicitly address the importance of recognizing and celebrating successes, including Facilitators prompting teams to identify progress toward needs and outcomes at each meeting, acknowledging completion of action items and milestones, and highlighting youth and family achievements, strengths, and efforts.
If teams or individuals feel they need additional coaching or supervision, a request is made to the immediate supervisor. If coaching and/or supervision needs continue beyond what the immediate supervisor is able to provide, the Team/individual may contact the Clinical Director for additional support. (SBHI P&P page 45, 10.11(c)-(k))
In addition to the above, SBHI has ongoing training and competency requirements. All staff must complete annual competency evaluations to ensure continued fidelity. Requirements include direct observation, documentation audit, and review of fidelity data. Information regarding fidelity based performance monitoring can be found at SBHI P&P page 47, 10.14-10.18)
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
(a) Data is collected on an ongoing basis and reviewed on a weekly basis by leadership. Staff competency status is directly linked to fidelity and performance data. The QA Coordinator collects, monitors, and analyzes data through a structured QA tracking and audit tool designed to assess fidelity to the High Fidelity Wraparound (HFW) model, documentation compliance, service quality, and outcomes. Data is reviewed on a weekly basis and reported to the Program Director, Clinical Director, and Executive Director. Aggregate data is trended and reviewed quarterly as part of the Continuous Quality Improvement (CQI) process. Program data is systematically used to improve service delivery and program design, identify staff training and coaching needs, inform booster training topics, address documentation and compliance issues, identify gaps in access, timliness and engagement, strengthen fidelity to HFW principles, and drive outcomes.
Staff receive individualized feedback during weekly supervision and monthly one-on-one coaching sessions. Feedback is strengths-based and solution-focused. Staff are expected to meet established program benchmarks for fidelity and documentation quality. Staff falling below benchmarks for three months or longer receive targeted coaching, increased supervision, and booster training assignments. Remediation may also include live or recorded session review, shadowing skill-based coaching, re-completion of specific UC Davis Skills Labs. A formal Performance Improvement Plan is developed to track and monitor progress. (SBHI P&P page 47, 10.16, page 53, 11.3, 11.4)
(b) Based on the weekly review of data, leadership addresses programmatic issues (e.g., workflow, policies, service gaps, stakeholder-related issues) and policies and procedures are updated based on findings. Innovation cycles are implemented to test and refine improvements. Interventions are implemented based on data findings. Outcomes are re-measured to assess effectiveness. Adjustments are made as needed. All CQI activities are documented. (SBHI P&P page 56, 11.4)
(c) Data collected by the QA Coordinator and reviewed by leadership in weekly meetings is used to identify systemic barriers (e.g., access to services, funding limitations). The Clinical Director communicates findings to the Community Leadership Team and system partners. (SBHI P&P page 57, 11.4(f))
Fidelity Indicators
1.1 Timely Engagement and Planning
(a) Within 24 business hours of assignment to a team, the Facilitator or another member of the Wraparound team attempts to contact both the referring person and caregiver (and youth if they are over 18 years old) to introduce services, begin engagement, assess for any urgent needs, and set up an initial meeting. The initial in-person meeting is held within 10 days of the program receiving the Wraparound referral, unless an alternative timeline is requested by the referring party or family. See Intake & Engagement Protocol, pg 2.
(b) The Plan of Care must be completed within 30 days. Once the document is complete, it must be distributed to team members and put in the youth and family’s file. It is the Facilitator’s responsibility to ensure this is done. See Wraparound Manual, pg 38.
(c) The Child and Family Team convenes at least every 30-45 days to review progress and strategy as it relates to the Plan of Care. Routine can be helpful in terms of setting up a recurring day and time for the Child and Family Team to meet. That said, meeting logistics may need to be revisited and adjusted throughout the process. The Facilitator will need to stay present to these evolving needs and support the team in adjusting, while keeping the youth and family at the center of the process. See Wraparound Manual, pg 30.
(d) The Wraparound Plan of Care is a living document to be brought to and used as a guide in all Child and Family Team meetings. It must be updated to reflect progress, shifts in need, and newly acquired strengths at least every 90 days. It is the Facilitator’s responsibility to ensure this is done. See Wraparound Manual, pg 36.
(e) Wraparound program leaders monitor the timeliness of services for CQI purposes on a quarterly basis. Staff and Supervisors are provided feedback on their ability to meet timelines for CQI purposes and engage in brainstorming to identify alternate engagement strategies that can be utilized in the future in individual supervision or program team meetings. Wraparound program leaders also collaborate with county partners around ongoing themes that impact the timeliness of services that can be addressed at the systems level. See Intake & Engagement Protocol, pg. 5.
(f) If the caregiver is not responsive, the Facilitator or Wraparound team member attempts three (3) more times by phone over a period of 5-7 business days and consults with the referring worker on alternate engagement strategies including joining the referring worker or another existing provider in an already scheduled meeting or attempts through other forms of contact such as text messaging or email. The Wraparound team also considers leveraging the Family Partner or Youth Partner’s unique ability to engage youth and families. See Intake & Engagement Protocol, pg. 3.
1.2 Led by Youth and Families
(a) The Facilitator, Support Counselor, Parent Partners, and/or Youth Partner are all responsible during the engagement phase for collecting information on natural and formal supports. If a youth is tribally enrolled, eligible for tribal enrollment, or has a tribally enrolled parent, and is ICWA eligible, special efforts are made to ensure a tribal representative is on the team and at the first Child and Family Team meeting to confirm the Family Vision and participate in the creation of the Team Mission. See Wraparound Manual, pg. 29-30, 32
(b) The Facilitator and Parent Partner are primarily responsible for meeting with the caregiver(s) and team members while the Support Counselor and Youth Partner meet with the youth to gather information about the family’s values, culture, expertise, capabilities, interests and skills. The Facilitator should also be meeting with the youth during the engagement phase to gather information directly. This collection of information will be documented in our IP-CANS assessment and our Clinical Assessment. The key points should also be shared at the first Child and Family Team meeting as part of the Wraparound Plan of Care. See Wraparound Manual, pg. 25.
(c) Wraparound supervisors conduct in-field supervision of child and family team meetings for each Facilitator annually and review Wraparound Plans of Care at initiation and every 6 months thereafter. Safety plans are also reviewed by a supervisor at initiation and discharge. See Supervisory Support in Wraparound, pgs. 3-4.
(d) Feedback from families is routinely elicited through the following methods.
• WFI-EZ: Administered once at 6 months of enrollment (or at discharge if enrolled between 3 and 6 months) and again annually to assess fidelity to HFW standards from the youth and family’s perspective.
• Pediatric Symptoms Checklist (PSC-35) or Patient Outcome Questionnaire (POQ): Completed within the first 30 days during intake, every 6 months, and at discharge to assess child emotional and behavioral functioning.
• Satisfaction Surveys: Collected from youth, caregivers, and, when applicable, Tribes after major service milestones and discharge.
• Program and System Data: Includes demographic data, placement stability, school attendance/functioning, functioning in the community, interpersonal functioning, caregiver confidence, crisis incidents, hospitalizations, justice involvement, and positive exit from HFW.
See SFA Performance Improvement Policy Addendum for High Fidelity Wraparound Programs, pg. 2.
1.3 Strength-Based
(a) The Seneca Wraparound Plan of Care includes a section called Network of Support. The documents prompts for all team members to be added in this section along with “Type of Support and Functional Strengths” they offer. This document is brought to, updated, and distributed after every Child and Family Team meeting. Anyone from the team can add new members to the list but it is the Facilitator’s job to ensure that the list is up to date. See Wraparound Care Plan Training Tool, pg. 3.
(b) The CANS assessment is used to support service planning by identifying priority needs, building existing strengths, and tracking progress toward goals. The CANS Assessment does not replace tracking of needs, goal completion, and action item completion within the Child and Family Plan of Care. These elements remain essential to planning for transition and ensuring youth and families are supported in achieving last change. See CANS Policy for CA Programs, pg. 3.
(c) Supervisors provide ongoing support in the core principles and activities of Wraparound across the phases, including providing strengths-based, hope-based, solution-focused services. They adjust training and coaching content to meet the needs of staff depending on their role, the particulars of the youth and families served, and that staff’s professional development arc. This is achieved via a combination of: Weekly supervision that is individualized and role specific; Recurrent role-specific group supervision or Wraparound team meetings that offer model and role-specific boosters; Adherence to the agency Wraparound training plan; Supervisor and staff-identified training opportunities via The Seneca Institute for Advanced Practice and UC Davis’ Resources Center for Family Focused Practice. See Supervisory Support in Wraparound, pg. 3.
(d) Feedback regarding experience of strengths-based service is routinely elicited through the following methods:
• WFI-EZ: Administered once at 6 months of enrollment (or at discharge if enrolled between 3 and 6 months) and again annually to assess fidelity to HFW standards from the youth and family’s perspective.
• Satisfaction Surveys: Collected from youth, caregivers, and, when applicable, Tribes after major service milestones and discharge.
Data is then reviewed quarterly by Wraparound leader, resulting in:
• Practice Improvement efforts: Supervisors provide staff with timely, case-specific feedback based on data. Training and coaching plans are updated based on identified practice gaps.
• Workforce Development: Data is used to identify staff training needs (e.g., need-based planning, cultural relevance, engagement strategies).
See SFA Performance Improvement Policy Addendum for High Fidelity Wraparound Programs, pg. 2-3.
1.4 Needs Driven
(a) Led by the Facilitator and in consultation with the Wraparound Supervisor(s), the Seneca Wraparound team works together to understand what needs may be underlying the observable needs identified via administration of the CANS and youth, family and team member interview. Consultation with the supervisor(s) also includes how to introduce these ideas to the family to see if they resonate and ensure alignment before moving on to goal development with the family and Wraparound team. See Wraparound Manual, pg 27-28.
(b) Supervisors provide ongoing support in the core principles and activities of Wraparound across the phases, including identifying needs and developing an understanding of the underlying drivers. They adjust training and coaching content to meet the needs of staff depending on their role, the particulars of the youth and families served, and that staff’s professional development arc. This is achieved via a combination of: Weekly supervision that is individualized and role specific; Recurrent role-specific group supervision or Wraparound team meetings that offer model and role-specific boosters; Adherence to the agency-wide wraparound training plan; Supervisor and staff-identified training opportunities via The Seneca Institute for Advanced Practice and UC Davis’ Resources Center for Family Focused Practice. See Supervisory Support in Wraparound, pg. 3.
(c) The CANS assessment is used to support service planning by identifying priority needs, building existing strengths, and tracking progress toward goals. The CANS Assessment does not replace using tracking of needs, goal completion, and action item completion within the Child and Family Plan of Care. These elements remain essential to planning for transition and ensuring youth and families are supported in achieving last change.
See CANS Policy for CA Programs, pg. 3.
(d) The Facilitator leads the team in identifying when the youth and family are ready for transition based on their progress toward achieving the team mission and goals. The youth, family, and team will have a collaborative conversation about their readiness for transition. See Wraparound Manual, pg. 44.
1.5 Individualized
(a) The format of the Seneca Wraparound Plan of Care includes prompts consistent with the model but allows space for the content creation and evolution of document to be reflective of the individual youth, family and team. See Wraparound Care Plan Training Tool.
(b) Supervisors provide ongoing support in the core principles and activities of Wraparound across the phases, including designing flexible, creative, evolving, and highly individualized strategies. They adjust training and coaching content to meet the needs of staff depending on their role, the particulars of the youth and families served, and that staff’s professional development arc. This is achieved via a combination of: Weekly supervision that is individualized and role specific; Recurrent role-specific group supervision or Wraparound team meetings that offer model and role-specific boosters; Adherence to the agency Wraparound training plan; Supervisor and staff-identified training opportunities via The Seneca Institute for Advanced Practice and UC Davis’ Resources Center for Family Focused Practice. See Supervisory Support in Wraparound, pg. 3.
(c) Supervisors provide ongoing support in the core principles and activities of Wraparound across the phases. They adjust training and coaching content to meet the needs of staff depending on their role, the particulars of the youth and families served, and that staff’s professional development arc. Supervisors ensure that Facilitators are trained specifically and coached in guiding the team-based, collaborative development of a unique and effective plan of care. See Supervisory Support in Wraparound, pg. 3.
(d) Supervisors routinely review documents that reflect the Wraparound process, including the Plan of Care. The initial Plan of Care is reviewed and then reviewed again every 6 months. Review of the Plan of Care includes assessment for:
• Needs, strengths, goals, and strategies that are individualized to the youth and family
• Follow through on action steps
• Cultural relevancy
• Inclusion of natural supports
See Supervisory Support in Wraparound, pg. 4.
(e) Feedback regarding experience of individualized service is routinely elicited through the following methods:
• WFI-EZ: Administered once at 6 months of enrollment (or at discharge if enrolled between 3 and 6 months) and again annually to assess fidelity to HFW standards from the youth and family’s perspective.
Data is then reviewed quarterly by Wraparound leader, resulting in:
• Practice Improvement efforts: Supervisors provide staff with timely, case-specific feedback based on data. Training and coaching plans are updated based on identified practice gaps.
• Workforce Development: Data is used to identify staff training needs (e.g., need-based planning, cultural relevance, engagement strategies).
See SFA Performance Improvement Policy Addendum for High Fidelity Wraparound Programs, pg. 2-3.
1.6 Use of Natural and Community Based Supports
(a) Natural supports and active community resources are included in the “Network of Support” portion of Seneca’s Wraparound Plan of Care. This list is fluid and updated throughout services. Any member of the team can add to the list but it is the Facilitator’s job to make sure the Wraparound Plan of Care is up to date. See Wraparound Care Plan Training Tool, pg. 3.
(b) Supervisors provide ongoing support in the core principles and activities of Wraparound across the phases, including ongoing identification, engagement, and integration of natural supports for long-term stability. They adjust training and coaching content to meet the needs of staff depending on their role, the particulars of the youth and families served, and that staff’s professional development arc. This is achieved via a combination of: Weekly supervision that is individualized and role specific; Recurrent role-specific group supervision or Wraparound team meetings that offer model and role-specific boosters; Adherence to the agency Wraparound training plan; Supervisor and staff-identified training opportunities via The Seneca Institute for Advanced Practice and UC Davis’ Resources Center for Family Focused Practice. See Supervisory Support in Wraparound, pg. 3.
(c) Supervisors routinely review documents that reflect the Wraparound process, including the Plan of Care. This review is intended to support staff development and strengthen model fidelity. The initial Plan of Care is reviewed and then reviewed again every 6 months. Review of the Plan of Care includes assessment for the inclusion of natural supports. See Supervisory Support in Wraparound, pg. 3.
(d) Feedback regarding the engagement of natural supports is routinely elicited through the following methods:
• WFI-EZ: Administered once at 6 months of enrollment (or at discharge if enrolled between 3 and 6 months) and again annually to assess fidelity to HFW standards from the youth and family’s perspective.
Data is then reviewed quarterly by Wraparound leader, resulting in:
• Practice Improvement efforts: Supervisors provide staff with timely, case-specific feedback based on data. Training and coaching plans are updated based on identified practice gaps.
• Workforce Development: Data is used to identify staff training needs (e.g., need-based planning, cultural relevance, engagement strategies).
See SFA Performance Improvement Policy Addendum for High Fidelity Wraparound Programs, pg. 2-3.
1.7 Culturally Respectful and Relevant
(a) During the Engagement phase, the Wraparound team meets with the youth, family, and team members to collect information related to the strengths and needs of the youth and family, as well as the family story. The Facilitator and Parent Partner are primarily responsible for meeting with the caregiver(s) and team members while the Support Counselor and Youth Partner meet with the youth to gather this information. This collection of information will be documented into our IP-CANS assessment and our Clinical Assessment and stored in the chart. See Wraparound Manual, pg. 25.
(b) Supervisors provide ongoing support in the core principles and activities of Wraparound across the phases, including ongoing eliciting and applying family values and culture to planning and service delivery. They adjust training and coaching content to meet the needs of staff depending on their role, the particulars of the youth and families served, and that staff’s professional development arc. This is achieved via a combination of: Weekly supervision that is individualized and role specific; Recurrent role-specific group supervision or Wraparound team meetings that offer model and role-specific boosters; Adherence to the agency Wraparound training plan; Supervisor and staff-identified training opportunities via The Seneca Institute for Advanced Practice and UC Davis’ Resources Center for Family Focused Practice. See Supervisory Support in Wraparound, pg. 3.
(c) Feedback regarding the engagement of culturally relevant and respectful services and strategies are routinely elicited through the following methods:
• WFI-EZ: Administered once at 6 months of enrollment (or at discharge if enrolled between 3 and 6 months) and again annually to assess fidelity to HFW standards from the youth and family’s perspective.
Data is then reviewed quarterly by Wraparound leader, resulting in:
• Practice Improvement efforts: Supervisors provide staff with timely, case-specific feedback based on data. Training and coaching plans are updated based on identified practice gaps.
• Workforce Development: Data is used to identify staff training needs (e.g., need-based planning, cultural relevance, engagement strategies).
See SFA Performance Improvement Policy Addendum for High Fidelity Wraparound Programs, pg. 2-3.
1.8 High-Quality Team Planning and Problem Solving
(a) The Seneca Wraparound Plan of Care has a specific space for Group Agreements. Group Agreements are collaboratively developed with the team in the initial meeting and updated if needed. A copy of Wraparound Plan of Care is always put in the youth’s file. See Wraparound Care Plan Training Tool, pg. 1.
(b) Feedback regarding team engagement and collaboration are routinely elicited through the following methods:
• WFI-EZ: Administered once at 6 months of enrollment (or at discharge if enrolled between 3 and 6 months) and again annually to assess fidelity to HFW standards from the youth and family’s perspective.
See SFA Performance Improvement Policy Addendum for High Fidelity Wraparound Programs, pg. 2.
(c) Data is reviewed quarterly by Wraparound leader, resulting in:
• Practice Improvement efforts: Supervisors provide staff with timely, case-specific feedback based on data. Training and coaching plans are updated based on identified practice gaps.
• Workforce Development: Data is used to identify staff training needs (e.g., need-based planning, cultural relevance, engagement strategies).
See SFA Performance Improvement Policy Addendum for High Fidelity Wraparound Programs, pg. 3.
(d) Supervisors routinely review documents that reflect the Wraparound process, including the Plan of Care and the Safety Plan. The initial Plan of Care is reviewed and then reviewed again every 6 months. Review of the Plan of Care includes assessment for:
• Needs, strengths, goals, and strategies that are individualized to the youth and family
• Follow through on action steps
• Cultural relevancy
• Inclusion of natural supports
See Supervisory Support in Wraparound, pg. 4.
1.9 Outcomes Based Process
(a) The Seneca Wraparound Plan of Care is brought to every meeting and updated in real-time as a living document. The format of the Plan of Care includes a section titled, Specific and Observable Action Steps Toward Goal and Vision. This section prompts for what the strategy/action step is, who will do it, and when. There is also space to track when it is completed. See Wraparound Care Plan Training Tool, pg. 2.
(b) The Seneca Wrap Plan of Care includes a section titled, Specific and Observable Action Steps Toward Goal and Vision. This section prompts for what the strategy/action step is, who will do it, when it is due, and when it is completed. It is the Facilitators job to ensure that the Wrap Plan of Care is updated after every meeting and distributed to all team members. See Wraparound Care Plan Training Tool, pg. 2.
(c) The Seneca Wraparound Plan of Care is brought to every meeting and updated in real-time as a living document. The format of the Plan of Care allows for narrative to be captured around progress and effectiveness of strategies as well as specific actions steps and strategies to be documented and tracked. It is the Facilitator’s job to ensure that the Plan of Care is updated after every meeting and distributed to all team members. See Wraparound Care Plan Training Tool.
(d) The CANS is completed by a certified staff member (e.g., clinician, Wraparound Facilitator) who has direct knowledge of the youth and family. Staff must maintain current CANS certification through approved training and annual recertification. Supervisors who supervise staff who facilitate CANS or who approve CANS assessments must maintain a current CANS certification.
Sharing the CANS:
• With Families: After completion, staff review the finalized CANS with the youth and family, highlighting strengths, identified needs, and how the information will inform the care plan. Staff promote transparency by ensuring the ratings reflect the youth’s and family’s perspectives and by keeping discussion of the ratings open throughout the course of treatment. Youth and families are offered a copy of the CANS in a format that is understandable and accessible.
• With the Child and Family Team (CFT): CANS ratings are presented in CFT meetings to guide care planning, goal setting, and service prioritization. The team uses the CANS to track changes over time, celebrate progress, and address emerging needs quickly.
• With Other Providers: The CANS may be shared with other providers, if in a manner that aligns with HIPAA law, 42 CFR Part 2 (if applicable), and Seneca’s General Privacy Policy.
See CANS Policy for CA Programs, pg. 1-3.
(e) The CANS assessment is used to support service planning by identifying priority needs, building existing strengths, and tracking progress toward goals. Changes in ratings help determine whether interventions are effective or need adjustment. The CANS Assessment does not replace using tracking of needs, goal completion, and action item completion within the Child and Family Plan of Care. These elements remain essential to planning for transition and ensuring youth and families are supported in achieving last change. See CANS Policy for CA Programs, pg. 3.
1.10 Persistence
(a) Cancelling of meetings, missed meetings, and failing to return phone calls or messages is expected to occur during enrollment. Any break in engagement that leads to difficulty providing Wraparound services each week is communicated directly by Wraparound staff to their Wraparound Supervisor(s). Teams are supported in the ongoing engagement of enrolled youth and families by taking steps to re-engage the family. See Intake & Engagement Protocol, pg. 4.
(b) Supervisors provide ongoing support in the core principles and activities of wraparound across the phases. They adjust training and coaching content to meet the needs of staff depending on their role, the particulars of the youth and families served, and that staff’s professional development arc. This is achieved via a combination of weekly supervision that is individualized and role specific; recurrent role-specific group supervision or Wraparound team meetings that offer model and role-specific boosters; adherence to the agency Wraparound training plan; Supervisor and staff-identified training opportunities via the Seneca Institute for Advanced Practice and UC Davis Resource Center for Family Focused Practice See SFA Supervisory Support in Wraparound, pg. 3.
(c) Supervisors provide ongoing support in the core principles and activities of Wraparound across the phases. They adjust training and coaching content to meet the needs of staff depending on their role, the particulars of the youth and families served, and that staff’s professional development arc. Building and sustaining effective, collaborative teams and leading those teams to address safety needs is part of this ongoing training for Facilitators. See SFA Supervisory Support in Wraparound, pg. 3.
1.11 Transitions as a part of the Fourth Phase of HFW
(a) The Facilitator leads the team in identifying when the youth and family are ready for transition based on their progress toward achieving the team mission and goals. The youth, family, and team will have a collaborative conversation about their readiness for transition. See Wraparound Manual, pg. 44.
(b) Led by the Facilitator, the team plans for a graduation that offers opportunities to acknowledge and celebrate achievement and growth and includes all team members. Inquiry with the family is made as to what sort of celebration would be reflective of their values and traditions. The Seneca Wraparound staff consult with their supervisor(s) to understand what resources (including Flex Funds) are available to support transition-related celebrations. See Wraparound Manual, pg. 47-48.
Expected Outcomes
2.1 Youth and Family Satisfaction
WFI surveys (which include youth and family satisfaction) are offered to anyone involved on a Wraparound team for a youth who has been enrolled for a minimum of 6 months. If the program has a large number of youth who discharge prior to 6 months, the Program Director and/or Regional Executive Director can discuss with the Wraparound Fidelity Director a plan to offer the WFI at discharge. If the program chooses to offer the WFI at discharge for youth who discharge before 6 months, this is consistent expectation for the program.
Four types of WFI surveys are available. At least one Youth (if at least 11 years old), Caregiver, and Facilitator survey must be completed for each family. The Team Member survey is optional. The exception to this is in the case of children eligible under the Indian Child Welfare Act (ICWA). A representative of the Tribe must be included in survey administration.
With the support of local program administrators and Seneca’s data team, that information is gathered to be viewed in aggregate via a reporting template used across Wraparound programs. See WFI Program Implementation Guide, pg. 5 and SFA CQI Reporting Template.
2.2 Improved School Functioning
The CANS is used to monitor school and vocational functioning (Life Functioning Domain). The CANS is completed within 30 days of intake or program enrollment for Wraparound programs. The CANS Assessment is then completed at least every 6 months and at discharge (unless the most recent CANS was completed within 1 month prior to the date of discharge), or sooner if there is a significant change in the youth’s needs, strengths, or circumstances. With the support of local program administrators and Seneca’s Data Team, that information is gathered to be viewed in aggregate via a reporting template used across Wraparound programs. See CANS Policy for CA Programs, pg. 2 and SFA CQI Reporting Template.
2.3 Improved Functioning in the Community
The CANS is used to monitor improved functioning in the community (Strengths Domain). The CANS is completed within 30 days of intake or program enrollment for Wraparound programs. The CANS Assessment is then completed at least every 6 months and at discharge (unless the most recent CANS was completed within 1 month prior to the date of discharge), or sooner if there is a significant change in the youth’s needs, strengths, or circumstances. With the support of local program administrators and Seneca’s Data Team, that information is gathered to be viewed in aggregate via a reporting template used across Wraparound programs. See CANS Policy for CA Programs, pg. 2 and SFA CQI Reporting Template.
2.4 Improved Interpersonal Functioning
The CANS is used to monitor improved interpersonal functioning (Life Functioning and Strengths Domains). The CANS is completed within 30 days of intake or program enrollment for Wraparound programs. The CANS Assessment is then completed at least every 6 months and at discharge (unless the most recent CANS was completed within 1 month prior to the date of discharge), or sooner if there is a significant change in the youth’s needs, strengths, or circumstances. With the support of local program administrators and Seneca’s Data Team, that information is gathered to be viewed in aggregate via a reporting template used across Wraparound programs. See CANS Policy for CA Programs, pg. 2 and SFA CQI Reporting Template.
2.5 Increased Caregiver Confidence
WFI Caregiver surveys (which include an item on Caregiver confidence) are offered to anyone involved on a Wraparound team for a youth who has been enrolled for a minimum of 6 months. If the program has a large number of youth who discharge prior to 6 months, the Program Director and/or Regional Executive Director can discuss with the Wraparound Fidelity Director a plan to offer the WFI at discharge. If the program chooses to offer the WFI at discharge for youth who discharge before 6 months, this is a consistent expectation for the program.
Four types of WFI surveys are available. At least one Youth (if at least 11 years old), Caregiver, and Facilitator survey must be completed for each family.
With the support of local program administrators and Seneca’s Data Team, that information is gathered to be viewed in aggregate via a reporting template used across Wraparound programs. See WFI Program Implementation Guide, pg. 5 and SFA CQI Reporting Template.
2.6 Stable and Least Restrictive Living Environment
All changes to placement (planned and unplanned) are discussed and recorded in the context of the Child and Family Team meeting. With the support of local program administrators and Seneca’s Data Team, that information is gathered to be viewed in aggregate via a reporting template used across Wraparound programs. See Wraparound Care Plan Training Tool, pg. 2 and SFA CQI Reporting Template.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
If reportable incidents, including the hospitalization of a youth, occurs, staff members notify program leadership as soon as possible and the incident is documented in an Incident Report. Incident Reports are completed by the end of the day the incident occurred, or knowledge of the incident was learned, unless otherwise indicated. With the support of local program administrators and Seneca’s Data Team, that information is gathered to be viewed in aggregate via a reporting template used across Wraparound programs. See Incident Reporting Policy pg. 1-2 and SFA CQI Reporting Template.
2.8 Reduction in Crisis Visits
Crises that involve professional support (police intervention, mobile response, Seneca’s Rapid Response, etc.) are discussed and recorded in the context of the Child and Family Team meeting. With the support of local program administrators and Seneca’s Data Team, that information is gathered to be viewed in aggregate via a reporting template used across Wraparound programs. See Wraparound Care Plan Training Tool, pg. 2 and SFA CQI Reporting Template.
2.9 Positive Exit from HFW
When a youth discharges from the program, a Discharge Summary is completed. Information regarding the youth and their family’s exit from the program, including reason for discharge, progress towards goals, treatment goal attainment, and client level of risk is documented in the Discharge Summary. With the support of local program administrators and Seneca’s Data Team, that information is gathered to be viewed in aggregate via a reporting template used across Wraparound programs. See SFA Agency-wide Documentation Manual pg. 13 and SFA CQI Reporting Template.
Engagement
3.1 Orientation
(a) During the initial in-person meeting, the Facilitator or Wraparound team member orients the youth and family to the Wraparound process, including explaining the Wraparound principles and phases, addressing legal and ethical considerations, and explaining the role of each member of the team including the family’s role and the role of natural supports, community-based supports, and formal supports, including Tribes in the case of an ICWA-eligible child. See Intake & Engagement Protocol, pg 3.
(a) During the initial in-person meeting, the Facilitator or Wraparound team member orients the youth and family to the Wraparound process, including explaining the Wraparound principles and phases. See Intake & Engagement Protocol, pg 3.
(b) During the initial in-person meeting, the Facilitator or Wraparound team member addresses legal and ethical considerations. See Intake & Engagement Protocol, pg 3.
(c) During the initial in-person meeting, the Facilitator or Wraparound team member explains the role of each member of the team including the family’s role and the role of natural supports, community- based supports, and formal supports, including Tribes in the case of an ICWA-eligible child. See Intake & Engagement Protocol, pg 3.
3.2 Safety and Crisis stabilization
(a) The Risk Screening is completed by the Facilitator upon intake and then as needed for clients throughout treatment. Information is typically gathered from referral documents and conversations with the youth, family, referring party, and any other team members who are familiar with current or historical risks or protective factors. If indicated on the Risk Screening, Safety Plans are completed upon intake and updated as needed throughout the course of treatment. See Agency-wide Documentation Manual, pg. 2-3.
(b) The Facilitator ensures an initial crisis/safety plan is developed with the family as soon as Wraparound begins. This initial plan should be designed to increase the potential for safety and decrease the impact of pressing concerns so that the team can focus on launching the Wraparound process. This plan is returned to in the Plan Development phase and built out with input from the team. See Wraparound Manual, pg. 24 and 36.
(c) The content of the initial in-person meeting includes the Wraparound team providing the family with the necessary information to access Seneca’s Rapid Response Support Line 24/7 when needed. See Intake & Engagement Protocol, pg 3.
3.3 Strengths, Needs, Culture and Vision Discovery
(a) A Family Vision is created with the family in the Engagement phase. This Family Vision is presented at the first Child and Family Team Meeting and recorded in the Wraparound Plan of Care to inform the team throughout the course of Wraparound. See Wraparound Manual, pg. 35 and Wraparound Plan of Care Training Tool, pg. 1.
(b) With the support of the Wraparound Supervisor(s) and input from the full Wraparound staff team, the Facilitator documents Strengths, Needs, and Culture Discovery findings in the Clinical Assessment, which is filed at the close of the Engagement Phase. A briefer summary is also included in the Wraparound Plan of Care, which is updated at each Child and Family Team meeting and shared with all new members. See Wraparound Manual, pg. 25, 35-36 and Wraparound Plan of Care Training Tool, pg. 1.
3.4 Engage All Team Members
(a) Natural supports are included in the “Network of Support” portion of Seneca’s Wraparound Plan of Care. This list is fluid and updated throughout services. Any member of the team can add to the list but it is the Facilitator’s job to make sure the Wraparound Plan of Care in its entirety is up to date. See Wraparound Care Plan Training Tool, pg. 3.
(b) The Facilitator collects information regarding formal supports like system partners (social workers, probations officers, etc.) and reaches out to them. Interviews with these team members are included in the assessment process. See Wraparound Manual, pg. 25, 29.
(c) The Support Counselor, Parent Partner, and Youth Partner are responsible for collecting information from the family regarding their natural and community supports. The Facilitator should collect the information regarding formal supports like system partners (social workers, probations officers, etc.), therapists/psychiatrists, school representatives, medical/health providers, etc. See Wraparound Manual, pg. 29.
(d) Activities to promote team cohesion and effectiveness undertaken during Child and Family Team Meetings are documented un “Additional Discussion Points” in the Wraparound Plan of Care. It is the Facilitator’s role to ensure the Wraparound Plan of Care is accurate. See Wraparound Care Plan Training Tool, pg. 2.
3.5 Arrange Meeting Logistics
(a) Facilitators and Support Counselors are required in their job descriptions to “maintain flexible schedules” to accommodate individual family needs, including Child and Family team meetings. See Seneca HFW Job Descriptions, pgs. 2, 3, 4.
(b) Wraparound staff are trained to take the following into account when scheduling Child and Family Team meetings: Family schedule needs following by natural support and provider availability; Location that prioritizes family culture and comfort. Each family will have a different preference when it comes to meeting in their home, an office setting, or community location. This preference may be based on history with providers, history of trauma, history of resilience, living situation, etc. and should be honored whenever possible; accessibility options, including plans around transportation, language interpretation, and telehealth versus in-person options. See Wraparound Manual, pg. 30.
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
(a) Led by the Facilitator, the first Child and Family team meeting includes the creation of group agreements, a review and youth, family, and team strengths, and the development of a Team Mission that supports the Family Vision. See Wraparound Manual, pg. 35.
(b) Youth and family strengths are initially recorded in the Strengths, Needs and Culture Discovery section of the Seneca Wraparound Plan of Care. Strengths are also pulled out and added to the “Supports Towards Vision” section which is fluid and should evolve over time. The Seneca Wraparound Plan of Care is updated and distributed to team members after each meeting. It is the Facilitator’s responsibility to ensure that the Wraparound Plan of Care is kept up to date. See Wraparound Care Plan Training Tool, pg. 1.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
(a) Developing a theory of the underlying needs is part of the assessment process. The Wraparound team does this in consultation with the Wraparound Supervisor(s) and in conversation with the youth and family. This is documented in the Clinical Assessment. See Wraparound Manual, pg. 25-27.
(b) Goal development follows the completion of the initial assessment, which includes a formulation of the underlying needs. The Facilitator guides the team to develop goals that are measure-able and positive. See Wraparound Manual, pg. 35.
(c) The initial goals for the Wraparound Plan of Care are developed in the first Child and Family team meeting. See Wraparound Manual, pg. 35-36.
(d) Seneca’s Wraparound Plan of Care includes space for evolving ideas/conversation around the Supports and Barriers to meeting the Family’s Vision and Goals. There is also space to create a record of the specific and observable action steps toward taken. It is the Facilitator’s job to make sure the Wraparound Plan of Care in its entirety is up to date. See Wraparound Care Plan Training Tool, pg. 1-2.
(e) Seneca Facilitators attend the UCDavis: Wraparound 101: Foundations of Fidelity as part of their onboarding, which include content selecting affective strategies and actions items. See Wraparound Training Plan, pg. 1.
(f) The Wraparound Plan of Care is informed by the assessment completed in Engagement phase and formally developed in the first Child and Family Team meeting. The Wraparound Plan of Care is then treated as a living document, brought to and updated after each Child and Family Team. See Wraparound Manual, pg. 36.
4.3 Develop an Individualized Child or Youth and Family Plan
(a) Supervisors provide ongoing support in the core principles and activities of Wraparound across the phases. They adjust training and coaching content to meet the needs of staff depending on their role, the particulars of the youth and families served, and that staff’s professional development arc. For Facilitators, this includes eliciting youth, family and team member perspectives as well as the rich and nuanced process of building and sustaining teams. See SFA Supervisory Support in Wraparound, pg. 3.
(b) Gathering information for the initial assessment, which in turn informs the creation of the Plan of Care includes interviews with all systems of care providers. With the support of the Wraparound Supervisor(s), and input from all Wraparound staff, the Facilitator works to prioritize these needs in order of importance and impact to the youth and family’s abilities to function and remain safe. See Wraparound Manual, pg. 27.
(c) Following the first Child and Family Team Meeting(s), the information gathered and generated should be documented in the final Wraparound Plan of Care. Once this document is complete, it must be distributed to team members and put in the youth and family’s file. It is the Facilitator’s responsibility to ensure the Plan of Care is completed, distributed, and filed. See Wraparound Manual, pg. 36 and Wraparound Care Plan Training tool.
(d) Supervisors also routinely review documents that reflect the Wraparound process, including the Plan of Care. The initial Plan of Care is reviewed and then reviewed again every 6 months. The supervisor ensures that any information regarding areas of individual staff strength and growth that flow from these reviews are shared with that staff in a timely way. In collaboration with that staff member, the supervisor adjusts training and coaching plans to support any identified practice gaps. The supervisor also works with the Program Director and Wraparound leadership to notice broader themes across practice observations that may inform group training needs and program improvement steps (workflow, documentation needs, resources/attention reallocation) that could support strengthen practice. See Supervisory Support in Wraparound, pg. 4.
4.4 Develop a Crisis and Safety Plan
(a) The Facilitator ensures an updated Safety Plan, which include all safety risks relevant to that youth and family, proactive and reactive crisis management strategies with specific team members assigned, strategies that involve both informal and formal supports, and information on who to contact for 24/7 support, is present in the youth’s chart by the end of the Plan Development stage. See Wraparound Manual, pg. 36.
(b) Safety Plans can be updated within the context of a Child and Family Team or through individual conversation with the youth, family and team members. They must be created collaboratively. See Wraparound Manual, pg, 36.
(c) Supervisors also routinely review documents that reflect the Wraparound process, including the Safety Plan. The initial Safety Plan is reviewed as is the discharge Safety Plan. Review of the Safety Plan includes assessment for:
• Individualized strategies that exist along the crisis curve (proactive, reactive, recovery)
• Cultural relevancy
• Inclusion of natural supports
The supervisor ensures that any information regarding areas of individual staff strength and growth that flow for the review are shared with that staff in a timely way. In collaboration with that staff member, the supervisor adjusts training and coaching plans to support any identified practice gaps. The supervisor also works with the Program Director and Wraparound leadership to notice broader themes across practice observations that may inform group training needs and program improvement steps (workflow, documentation needs, resources/attention reallocation) that could support strengthen practice. See Supervisory Support in Wraparound, pg. 4.
Implementation
5.1 Implement The Plan of Care
(a) The Facilitator uses the Wraparound Plan of Care in to drive the agenda for the Child and Family Team meeting in Implementation phase. This includes review of goals, action steps status, and next steps as needed. See Wraparound Manual, pg 39-40.
(b) Supervisors provide ongoing support in the core principles and activities of Wraparound across the phases. They adjust training and coaching content to meet the needs of staff depending on their role, the particulars of the youth and families served, and that staff’s professional development arc. Supervisors ensure that all Wraparound staff are trained and coached in: Eliciting and applying family values and culture to planning and service delivery; Providing strengths-based, hope-based, solution-focused services; Identifying needs and developing an understanding of the underlying drivers; Ongoing identification, engagement, and integration of natural supports for long-term stability; Designing flexible, creative, evolving, and highly individualized strategies; Fostering positive team culture and functioning; Recognizing, celebrating, and amplifying successes; Addressing safety needs. This is achieved via a combination of weekly supervision that is individualized and role specific; Recurrent role-specific group supervision or Wraparound team meetings that offer model and role-specific boosters; Adherence to the agency Wraparound training plan; Supervisor and staff-identified training opportunities via the Seneca Institute for Advanced Practice and UC Davis’ Resources Center for Family Focused Practice. See Supervisory Support in Wraparound, pg. 3.
5.2 Review and Update The Plan of Care
(a) Child and Family Team meetings agendas during the implementation phase include a review of progress towards and goals, as well as action steps completion and generation. See Wraparound Manual, pg. 39-40.
(b) Child and Family Team meetings (facilitated by the Facilitator) in implementation phase include a review of previous goals and action steps, re-prioritization of strategies as needed, and development of new strategies and action steps. The Wraparound Plan of Care clearly reflects the decisions and plans made by the team. Plans are distributed the following business day after the meeting. It is the Facilitator’s responsibility to ensure the Plan is distributed. See Wraparound Manual, pg. 39.
(c) The Wraparound Plan of Care is updated after every team meeting to include (among other things) who attended the meeting, what actions steps were completed and by whom, what new action steps were generated, if flex funds were requested. The updated Wraparound Plan of Care is distributed to all team members by the next business day by a Seneca Wraparound staff designated by the team. See Wraparound Care Plan Training Tool and Wraparound Manual, pg. 39.
(d) The Wraparound Plan of Care is brought to every meeting and updated in real-time as a living document. The format of the Plan of Care includes prompts consistent with the model but allows space for the content creation and evolution of the document to be reflective of the individual youth, family and team. See Wraparound Care Plan Training Tool.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
(a) Group agreements are documented in the Wraparound Plan of Care and are utilized and reviewed regularly in Child and Family Team meetings. If new members are added to the team then the Facilitator will explain the team meeting process and group agreements. See Wraparound Plan of Care, pg. 1 and Wraparound Manual, pg. 30.
(b) Supervisors provide ongoing support in the core principles and activities of Wraparound across the phases. They adjust training and coaching content to meet the needs of staff depending on their role, the particulars of the youth and families served, and that staff’s professional development arc. Supervisors ensure that Facilitators are also trained and coached in the rich and nuanced process of building and sustaining teams. This is achieved via a combination of weekly supervision that is individualized and role specific; Recurrent role-specific group supervision or Wraparound team meetings that offer model and role-specific boosters; Adherence to the agency-wide wraparound training plan; Supervisor and staff-identified training opportunities via the Seneca Institute for Advanced Practice and UC Davis’ Resources Center for Family Focused Practice See Supervisory Support in Wraparound, pg. 3.
(c) The supervisor reviews the Plan of Care and Safety Plan at regular intervals with a particular lens for the inclusion of natural supports. The supervisor ensures that any information regarding areas of individual staff strength and growth that flow from these reviews are shared with that staff in a timely way. In collaboration with that staff member, the supervisor adjusts training and coaching plans to support any identified practice gaps. The supervisor also works with the Program Director and Wraparound program leadership to notice broader themes across practice observations that may inform group training needs and program improvement steps (workflow, documentation needs, resources/attention reallocation) that could support strengthen practice. See Supervisory Support in Wraparound, pg. 4.
(d) Each Child and Family Team meeting covers a return to group agreements, goal and action step review, and a review of current Obstacles and Supports to reaching the goal. This serves the purpose of keeping current team members aligned and orienting new team members to the process. See Wraparound Manual, pg. 39-40.
Transition
6.1 Develop a Transition Plan
(a) The Facilitator invites the team through the implementation stage to monitor progress via standardized tools and verbal feedback from the youth, family, and team members. This ongoing conversation is used to inform the team’s decision to enter transition phase. See Wraparound Manual, pg. 44.
(b) The activities included in the Family Team Meetings held during transition phase culminate in the creation of a Transition Plan. The creation and completion of this plan is guided by the Facilitator and must include: identification of any ongoing needs and the individuals, organizations, resources, and services that will provide any ongoing care to the youth and/or family; description of the community and natural support networks that will offer ongoing support; any linkage to a new provider or community support should be established before closure. The Transition Plan must be distributed to the youth, family, and relevant team members and documented in the youth’s file. See Wraparound Manual, pg. 47.
(c) The Facilitator leads the development of the Transition Plan in the final Child and Family Team meetings. Facilitators receive ongoing supervision and coaching related to safety plan development. See Wraparound Manual, pg. 46-47 and Supervisory Support in Wraparound, pg. 3.
(d) The creation and completion of the Transition Plan is guided by the Facilitator and must include a description of the community and natural support networks that will offer ongoing support. Any linkage to a new provider or community support is established before closure. See Wraparound Manual, pg. 47.
6.2 Develop a Post-Transition Safety Plan
(a) The Facilitator leads the team in developing or adjusting the current Safety Plan to respond to potential crisis situations that may occur after transitioning from formal Wraparound. The Safety Plan includes: proactive and reactive crisis management strategies with specific family members, natural supports, and remaining service providers assigned. The Facilitator ensures that the post-transition Safety Plan is shared with the youth, family and relevant supports. It must also be documented in the youth’s file. See Wraparound Manual, pg. 47-48.
(b) The Facilitator leads the team to develop the Post Transition Safety Plan with the youth and family, and all team members present. All team members should have a copy, and one member should be designated responsible for making any necessary updates in the future. Facilitators receive ongoing supervision and coaching related to Safety Plan development. See Wraparound Manual, pg. 47 and Supervisory Support in Wraparound, pg. 3.
(c) Supervisors routinely review documents that reflect the Wraparound process, including the Safety Plan. The initial Safety Plan is reviewed as is the discharge Safety Plan. Review of the Safety Plan includes assessment for:
• Individualized strategies that exist along the crisis curve (proactive, reactive, recovery)
• Cultural relevancy
• Inclusion of natural supports
The supervisor ensures that any information regarding areas of individual staff strength and growth that flow from these reviews are shared with that staff in a timely way. In collaboration with that staff member, the supervisor adjusts training and coaching plans to support any identified practice gaps. The supervisor also works with the Program Director and Wraparound program leadership to notice broader themes across practice observations that may inform group training needs and program improvement steps (workflow, documentation needs, resources/attention reallocation) that could support strengthen practice. See Supervisory Support in Wraparound, pg. 4.
6.3 Create a Commencement and Celebrate Success
(a) Led by the Facilitator, the team plans for a graduation celebration that is reflective of the youth and family’s values and traditions. See Wraparound Manual, pg. 48.
(b) Wraparound staff are trained and supported to make intentional time for celebration at the close of services, to ensure team members can attend, and to take adequate time to plan and resource the celebration. See Wraparound Manual, pg. 47.
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
(a) Seneca recognizes that more formal and consistent mechanisms are needed to strengthen youth and family participation in administrative level decision making related to local HFW implementation. As such, Seneca program leadership is actively collaborating with county partners to co develop and align standardized mechanisms for meaningful youth and family involvement across all Wraparound programs. See SFA HFW Program & Community Leadership Practices, pg. 1.
(b) Methods to collect family feedback to be used in the decision-making regarding service planning and implementation, policy and procedure development, workforce development and quality improvement includes:
• WFI-EZ: Administered once at 6 months of enrollment (or at discharge if enrolled between 3 and 6 months) and again annually to assess fidelity to HFW standards from the youth and family’s perspective.
• Satisfaction Surveys: Collected from youth, caregivers, and, when applicable, Tribes after major service milestones and discharge.
Feedback collected from families directly inform:
• Practice Improvement: Supervisors provide staff with timely, case-specific feedback based on data; training and coaching plans are updated based on identified practice gaps.
• Program Improvement: Wraparound leadership develops targeted improvement projects when data shows gaps in fidelity, outcomes, or satisfaction; improvements may include changes to workflows, documentation tools, or resource allocation.
• Workforce Development: Data is used to identify staff training needs (e.g., need-based planning, cultural relevance, engagement strategies).
• System Advocacy: Aggregate data is shared with system partners to address barriers (e.g., access to natural support, service availability).
See SFA Performance Improvement Policy Addendum for HFW Programs, pgs. 1-3.
7.2 Community Leadership Team
(a) For each Seneca Wraparound program, an identified HFW leader – typically the Program Director or designee – actively participates on the Community Leadership Team when convened by the county. See Seneca HFW Program and Community Leadership Practices, pg. 2.
7.3 Eligibility and Equal Access
(a) Eligibility criteria and referral processes are county specific and most often determined by the county. In some counties, eligibility criteria are pre established by the county, while in others they are co developed in collaboration with Seneca and other system partners. In all counties where Seneca partners, Seneca leaders routinely participate in authorizing or advisory bodies that oversee Wraparound referrals, such as referral authorization committees, care coordination teams, or interagency review groups. Through this participation, Seneca supports transparent, equitable referral decision making and advocates for access to services for youth with complex and intensive needs, consistent with Wraparound principles. Once a youth is determined eligible and referred, Seneca accepts and serves youth in accordance with county criteria and program capacity. Seneca does not impose additional exclusionary criteria beyond those established by the county and works collaboratively with referral sources to clarify eligibility requirements, service expectations, and program fit. See Seneca HFW Program and Community Leadership Practices, pg. 3.
(b) Staffing across Seneca Wraparound programs is intentionally structured to support the intensity and frequency of services required by families with complex needs, including 24/7/365 availability. Programs utilize a combination of regular scheduling, shared team coverage, and on call systems to ensure timely response to family needs and crisis situations. Program Directors and Supervisors work in partnership to ensure caseloads are monitored and adjusted as needed to maintain service quality, staff sustainability, and consistent access to support across all programs. See Seneca HFW Program and Community Leadership Practices, pg. 3.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
(a) Seneca ensures that all budgets and contracts fully support the CA HFW model through inclusion of required Wraparound staffing, 24/7 crisis response, and flex funds access to accommodate diversity in youth and family needs. See Seneca High Fidelity Wraparound Funding Plan, pg. 1-2.
(b) Seneca ensures that all budgets and contracts fully support the CA HFW model through budgeting for required workforce development, including training, coaching,
supervision, and fidelity-related functions. See Seneca High Fidelity Wraparound Funding Plan, pg. 1.
(c) Seneca ensures that all budgets and contracts fully support the CA HFW model through ensuring that data collection and data management systems required by counties and the HFW model are fully funded. Seneca High Fidelity Wraparound Funding Plan, pg. 1.
8.2 Equitable Funding Across System Partners
8.3 Cost Savings are Reinvested
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
(a) Seneca budgets specifically for flex funds and works with counties to ensure appropriate funding and that there are no funding source barriers to access flex funds. See Wrap Fiscal Report Template, row 65 and Seneca High Fidelity Wraparound Funding Plan, pg. 1.
(b) 1) Requests/Recommendations for Flex Funds are evaluated through the Child and Family Team (CFT) meeting and documented in the Wraparound Care Plan. The Facilitator guides the CFT to determine if the use of Flex Funds: (1) adds value to the team mission & supports the individualized care plan; (2) builds on family strengths; (3) meets identified child, youth, and family needs; (4) is culturally relevant and realistic for the family; (5) builds on natural supports and/or community capacity; (6) represents a good deal for the investment and; (7) includes a plan for sustainability. See Flex Funds Program Implementation Guide, pg 5.
(b) 2) If the Wraparound team recommends the use of Flex Funds based on the criteria in #1, the Facilitator or Wraparound staff contact their Supervisor or Program Director to describe the need and Wraparound team’s recommendation as documented in the Wraparound Care Plan.
The Supervisor or Program Director reviews the request/recommendation and documents the request/recommendation and expense in the Flex Funds Tracker. If the Supervisor or Program Director determines the request/recommendation meets the criteria above, then it may be approved. If it is determined the request/recommendation does not meet the criteria above, then it may be denied. Individual funding partners may implement unique procedures around the approval of Flex Funds. In these situations, Wraparound leaders should clarify and implement additional steps for approval as needed. See Flex Funds Program Implementation Guide, pg 6.
(b) 3) If the reason for denial was due to not meeting the criteria for Flex Funds, the Wraparound Team may reconvene and resubmit the request/recommendation with the necessary adjustments to meet the criteria. If approval to access Flex Funds is required by the program’s funding partner, the funding partner’s appeal process is followed for denied requests. See Flex Funds Program Implementation Guide, pg 8.
8.5 Collaborative Oversight of Flex Funds
(a) The Supervisor or Program Director is responsible for the documentation of all requests/recommendations for Flex Funds including whether approved or denied, the amount, purpose, and the client for whom the Wraparound team is recommending the Flex Funds for in the program’s Flex Funds Tracker. Program leaders may decide for Wraparound staff to directly enter information in the Flex Funds Tracker or complete other documentation to aid program leaders or administrative support staff in effectively tracking and accounting for Flex Funds. Individual funding partners may require the completion and submission of a Flex Funds report. In these regions, Wraparound leaders may update the Flex Funds Tracker template to include any additional information to more easily meet the needs of the funding partner or use a tracking document provided by the funding partner. See Flex Funds Program Implementation Guide, pg 8.
(b) Seneca leadership collaborates with county partners to ensure transparent and accountable oversight of Flex Funds. This includes participating in pooled funding structures when required by the county. When limitations reflect county or state policy, Seneca leadership collaborates with partners to explore alternate claiming pathways, bridge funding, pooled resources, or policy clarification, ensuring systemic constraints do not impede family access. See Seneca High Fidelity Wraparound Funding Plan, pg. 2, 3.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
(a) Consistent with state guidance on braided/blended funding, Seneca coordinates multiple distinct funding sources—each retaining its own rules, documentation, and accountability requirements—to support a single coordinated plan of care. Seneca operationalizes braided funding by mapping Care Plan needs to allowable sources, identifying alternatives when restrictions apply, using Flex Funds as a safety net when no other source can support the need, and applying Supervisor ($500) thresholds for timely oversight. See Seneca High Fidelity Wraparound Funding Plan, pg. 2.
(b) Seneca references a publicly-available funding source map/matrix via the RCFFP Wraparound Toolkit: Potential Funding Sources to Support Families Participating in California Wraparound to quickly identify backup options when restrictions are encountered, ensuring compliance while preventing disruption to the Care Plan. See Seneca High Fidelity Wraparound Funding Plan, pg. 3.
(c) When limitations reflect county or state policy, Seneca collaborates with partners to explore alternate claiming pathways, bridge funding, pooled resources, or policy clarification, ensuring systemic constraints do not impede family access. See Seneca High Fidelity Wraparound Funding Plan, pg. 3.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
(a) Seneca’s Program Directors and Regional Executive Directors in partnership with Human Resources, routinely review program-level demographic and language data alongside staffing patterns to ensure the workforce reflects the population served and to inform targeted recruitment, hiring and retention strategies. See Seneca HFW Program and Community Leadership Practices, pg 3.
(b) When the Wraparound program is unable to recruit or hire staff who fully match the cultural, racial, and linguistic needs of families, Program Directors and Regional Executive Directors implement alternative strategies that support families’ needs for cultural representation on the HFW team- such as engaging natural supports, partnering with trusted community leaders/organizations, and securing formal supports. See Seneca HFW Program and Community Leadership Practices, pg 3.
(c) Seneca staff will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) or sensory disabilities (i.e. blind, deaf, hard of hearing etc.) have meaningful access and an equal opportunity to participate in our services, activities, programs and other benefits….Clients and their families will be informed of the availability of such assistance free of charge. Clients and families shall receive language assisted services from 1) bilingual staff persons who demonstrate general professional language proficiency and can provide services directly in the client/family’s preferred language, 2) qualified Seneca staff interpreters and translators, and/or 3) through contracts or formal arrangements with qualified external translation and interpreting service providers. See SFA Language Assisted Services Policy, pg. 1.
9.2 Tribally Responsive Workforce
(a) All Wraparound staff and managers are required to attend the SFA ICWA Training through Seneca’s Institute for Advanced Practice within 6 months of hire. It is also available for SFA employees to take again at any time. See Wraparound Training Plan, pg. 1.
(b) During engagement the Facilitator assesses ICWA-eligibility or tribal affiliation. They then engage all team members across all Children’s System of Care partners (including formal, informal, and natural supports) and Tribes, in the case of an ICWA-eligible child, who care about and can aid in the youth and family. See Intake and Engagement Protocol, pg. 2-4.
9.3 Flexible and Creative Work Environment
(a) The following is an outline of the Roles and Responsibilities for program quality and improvement: HFW Facilitators will complete required assessments, review results with youth, families, and Child and Family Teams, and update the Plan of Care. Supervisors will ensure timely completion of assessments, review data and provide feedback during supervision, and support staff skill-building. Wraparound Leadership (including Wraparound Fidelity Director) will aggregate, analyze, and report program data; lead CQI activities to identify and address program needs to better serve families and improve program effectiveness; and engage in CQI activities by participation in SFA system workgroups and collaboratives (i.e. CORE, Wraparound Collaborative) See SFA Performance Improvement Policy Addendum for HFW Programs, pg. 3.
(b) Supervisors provide ongoing support in the core principles and activities of Wraparound across the phases. Supervisors ensure that all Wraparound staff are trained and coached in fostering positive team culture and functioning. See Supervisory Support in Wraparound, pg. 3.
(c) Supervisors set the stage by modeling and fostering healthy team culture, grounded in openness, curiosity, and collaboration. In partnership with the broader leadership team, Wraparound Supervisors support effective communication and cohesion across roles. See Supervisory Support in Wraparound, pg. 1.
(d) Supervisors provide ongoing support in the core principles and activities of Wraparound across the phases. They adjust training and coaching content to meet the needs of staff depending on their role, the particulars of the youth and families served, and that staff’s professional development arc. The supervisor also ensures that any information regarding areas of individual staff strength and growth, identified via supervision or practice observation, are shared with that staff in a timely way. In collaboration with that staff member, the supervisor adjusts training and coaching plans to support any identified practice gaps. See Supervisory Support in Wraparound, pg. 3, 4.
9.4 Hiring, Performance Evaluation, and Job Descriptions
(a) Seneca’s High Fidelity Wraparound job descriptions reflect best practices regarding Wraparound skills and expertise and have clear expectations for performance. While some job titles differ from those on the UC Davis Wraparound Toolkit, alignment is maintained with the functions described in the High Fidelity Wraparound standards. See Seneca HFW Job Descriptions, pg. 1.
(b) Each job description includes a summary of the role, a list of responsibilities specific to the role, and the minimum qualifications. See Seneca HFW Job Descriptions, pgs. 2-17.
(c) Each job description includes expectations in each section (summary, responsibilities, and qualification) that are reflective of HFW Wraparound standards. These are the job descriptions used across all HFW programs at Seneca. See Seneca HFW Job Descriptions, pgs. 2-17.
(d) Once applicants have applied and undergone a phone screening, they are invited to a first interview that provides an opportunity to evaluate a candidate’s skills, experience, and alignment with the role and the organization. If the first interview goes well, a second interview is schedule and allows for a deeper evaluation of a candidate’s expertise, problem-solving abilities, and fit with the role. See SFA Application Process, pg. 1.
(e) Employees are given job descriptions that provide clear expectations for their role, which they sign during onboarding. In addition to ongoing feedback in supervision, supervisors are also responsible for providing annual evaluations specific to the expectations of the job description. See Performance Review and Evaluation (Employee Handbook)
9.5 Workforce Stability
(a) Seneca’s base wages are based on market alignment, service contracts, and fiscal sustainability, and are evaluated regularly to maintain competitive positioning (within the nonprofit industry). See Seneca High Fidelity Wraparound Compensation Philosophy, pg. 1.
(b) Seneca’s Human Resources department collaborates with program leaders to support sustainable staffing and to help ensure workloads remain manageable. Day-to-day responsibility for monitoring workload distribution and addressing capacity concerns rests with Regional Executive Directors. See Seneca High Fidelity Wraparound Compensation Philosophy, pg. 2.
(c) Advancement opportunities are promoted in program as well as posted and shared agency-wide. As outlined in the Compensation Guide, staff may advance within established job tracks (e.g., entry level to associate, senior, or lead roles) or move into supervisory and management positions based on program need, readiness, and demonstrated competencies. See SFA HFW Compensation Philosophy, pg. 4.
(d) All employees receive an annual increase which consists of two parts: a percentage-based increase in the employee’s current salary, and a base wage increase that is consistently applied to all employees with the same job title and pay region assignment. Annual increases are not tied to performance to remove the subjectivity of merit-based increases. Seneca’s New and Emerging Managers Orientation (NEMO) is also available to all staff who either express interest or are identified as potentially transitioning into leadership roles at Seneca. See SFA HFW Compensation Philosophy, pg. 2-3.
9.6 High Fidelity Training Plan
(a) Wraparound staff are trained externally by attending the UC Davis Resource Center for Family Focused Practice training Wraparound 101: Foundations of Fidelity training. See SFA Wraparound Training Plan, pg. 1.
(b) Staff are matched with a peer mentor at onboarding and the receive ongoing training and coaching via the following: weekly supervision that is individualized and role specific; recurrent role-specific group supervision or Wraparound team meetings that offer model and role-specific boosters; adherence to the agency Wraparound training plan; supervisor and staff-identified training opportunities via The Seneca Institute for Advanced Practice and UC Davis’ Resources Center for Family Focused Practice See Supervisory Support in Wraparound, pg. 2, 3.
(c) The supervisor team facilitates recurrent role-specific group supervision or Wraparound team meetings that offer model and role-specific boosters. See Supervisory Support in Wraparound, pg. 3.
(d) Seneca’s Wraparound Fidelity Director facilitates the agency Wraparound Collaborative, a space for connection, shared learning, consultation, and collaboration among Wraparound program leaders. The Wraparound Collaborative takes place every other Friday and includes topics relevant to Wraparound program and practice leadership. See Wraparound Collaborative Scope & Sequence 2026, pg. 1-3.
(e) All Wraparound staff serving child-welfare connected youth are required to take the SFA ICWA training within 6 months of hire. The training is asynchronous and can be accessed immediately by any Wraparound staff. Supervisors also work with supervisees to identify training needs specific to the families they serve and identify additional applicable training resources via the The Seneca Institute for Advanced Practice and the UC Davis Resource Center for Family Focused Practice See Wraparound Training Plan, pg. 2. and Supervisory Support in Wraparound, pg. 3.
9.7 Community-based Training Program
(a) All Seneca Wraparound staff attend the UC Davis Resource Center for Family Focused Practice training, Wraparound 101: Foundations of Fidelity which includes participation from trainers with lived experience. See SFA Wraparound Training Plan, pg. 1.
(b) If members of the formal provider team are unfamiliar with Wraparound or interested in further education, Seneca Wraparound staff encourage participation in the UC Davis Resource Center for Family Focused Practice Wraparound Training offerings. See Wraparound Manual, pg. 22.
9.8 Coaching and Supervision
(a) Following Seneca’s centralized New Employee Orientation, the Supervisor facilitates the new staff’s onboarding over their first week and months in program. Supervisors ensure that new staff receive: An overview of Wraparound values, skills, phases, and activities, and an introduction to the Seneca Wraparound Manual; orientation to their specific role and how it fits within the team; a role-specific peer mentor and opportunities for shadowing; information about local program specifics, including referral partnership, flex fund procedures, and community collaborations and resources. See Supervisory Support in Wraparound, pg. 1.
(b) In addition to the support of program supervisors, all wraparound staff have access to the Rapid Response Administrator On-Call, a rotating group of administrators who are available 24/7 for safety-related supervisory consultation outside of regular business hours or if a supervisor can’t be reached. See Supervisory Support in Wraparound, pg. 1.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
(a) Practice Improvement: Supervisors provide staff with timely, case-specific feedback based on data. Training and coaching plans are updated based on identified practice gaps. See SFA Performance Improvement Policy Addendum for HFW Programs, pg. 2.
(b) Program Level: Wraparound leadership reviews aggregated data quarterly to monitor fidelity to the HFW model; identify trends in strengths, needs, outcomes, and service utilization, and evaluate progress toward the Expected Outcomes listed in Section 2 of the CA HFW Standards. See SFA Performance Improvement Policy Addendum for HFW Programs, pg. 2.
(c) System Level: CQI findings that indicate systemic barriers or cross-agency issues are brought collaboratively to the local Community Leadership Team by Wraparound leadership for review and action. See SFA Performance Improvement Policy Addendum for HFW Programs, pg. 2.
Fidelity Indicators
1.1 Timely Engagement and Planning
a) The assigned case carrying clinician makes contact with the client and/or family supports within 7-10 days of referral. See:
SCFS Policy MHSU 3 – Assessment and Reassessment [Page 1, paragraph 2, section “a”]
SMHS Contract Exhibit A , Sec. E, P.4, i, a (Page 41).
b) Within 30 days of referral the clinician will complete an initial Plan of Care based on assessment materials and with information from client and family, and will use this plan of care as a basis for coordinating and setting agenda for first CFT Meeting. See:
SCFS – MHSU 4 – Service Planning and Monitoring [Page 1, section “I. Initiation”}
SCFS – SMHS Contract – Exhibit A , Sec. D, pt.7 i(F) [page 34)
c) SCFS Wraparound Team will review the Plan of Care at each CFT Meeting which occurs at minimum every 90 days and Wraparound team meetings that include SCFS Staff identified on plan of care occurring Monthly (every 30 days). See:
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, V. Review Process, “A”]
SCFS – SMHS Contract – Exhibit A , Sec. D, pt.7 i(F)[Page 34]
d) At each Child Family Team Meeting the plan of Care will be updated and distributed to team members. See:
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, V. Review Process, “A”]
SCFS – SMHS Contract – Exhibit A , Sec. D, pt.7 i(F)[Page 34]
e) SCFS will include feedback items on CFT satisfaction surveys that speak to timelines and will be measured in PQI. See:
2025-2026 PQI Key Performance Indicators DASHBOARD REPORT MH goals [Page 1, goal 4; Page 2, Goal 5]
f) SCFS staff will have training in timely engagement strategies and active approaches to engaging difficult to contact families. See:
SCFS TS policy – High Fidelity Wrap Training [Page 1]
1.2 Led by Youth and Families
a) SCFS wraparound team will base the strategies and supports provided to youth and families on the needs identified by the youth and families in order to ensure alignment with their preferences. See:
SCFS – MHSU 4 – Service Planning and Monitoring [Page 1, II. “Plan of Care”]
SCFS – MSHU 5.04 Clinical Counseling- Family Therapy [Page 1]
b) SCFS staff receive training in cultural humility and assessment skills in order to provide culturally sensitive services recognizing and honoring each youth and family’s values, culture, expertise, capabilities, interests, and skills. See:
SCFS MHSU 3.03-3.07- Assessment and Reassessment [Page 3, “Standards of Assessment Practice; #3, 4.]
SCFS – SMHS Contract – Exhibit A , Sec. D, pt.2 [page 33]
c) SCFS Supervisors serve as facilitators on High Fidelity Wrap teams, or in cases where they do not review the documentation from team members, and provide feedback and guidance to team members to build skills and increase confidence. See:
SCFS – MHSU 4 – Service Planning and Monitoring; [Page 2, V. Review Process, “A”]
SCFS TS 3, HR 6 Supervision Procedures_Framework [Page 1 “Individual Supervision Procedures”]
d) Feedback from families is elicited at each CFT / HFW team that occurs at a minimum every 90 days through use of the Satisfaction Survey and Service Verification calls. See:
SCFS – SMHS Contract – P.47 – Exhibit A , Sec. F, pt.4(b,c) [ page 47]
2025-2026 PQI Key Performance Indicators DASHBOARD REPORT MH goals
1.3 Strength-Based
a) The SCFS Wraparound team uses assessment materials and plan of care development to develop inventories of functional strengths that will be useful in service planning; inventory of team strengths is included with plan of care and displayed at CFT / HFW team meetings. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 1, II. “Plan of Care”]
SCFS MHSU 3.03-3.07- Assessment and Reassessment [Page 2, “Procedures for Structured Assessments, 1″]
b) SCFS clinicians utilize the IP-CANS to identify individual strengths, in addition to the Medi-Cal 7 Domain assessment and client interview. See
SCFS MHSU 3.03-3.07- Assessment and Reassessment [Page 2, “Procedures for Structured Assessments,” 1]
SCFS – SMHS Contract – Exhibit A , Sec. D, pt.7 i(A-E) [ page 34]
c) SCFS receive ongoing coaching and training through individual and group clinical supervision, agency trainings provided during onboarding and on a recurring basis. See
SCFS TS1 Training and Supervision: Personnel Development [Page 1, “New Hire Training; Page 2, “Ongoing Training and Workforce Development”]
d) Feedback is routinely elicited from families regarding experience of strength based services through Service Verification calls and CFT Satisfaction Surveys. See
SCFS – SMHS Contract – Exhibit A , Sec. F, pt.4(b,c) [page 47] and
2025-2026 PQI Key Performance Indicators DASHBOARD REPORT MH goals
1.4 Needs Driven
a) SCFS staff will use the IP-CANS, PSC-35, and Medi-Cal assessment to identify youth and family needs in the initial assessment period as well as at every 6 month authorization . See
SCFS MHSU 3.03-3.07- Assessment and Reassessment [Page 2, “Procedures for Structured Assessments,” 1-3]
b) SCFS staff receive training at onboarding on assessment; all staff members are required to be CANS certified, and staff additionally receive training in High Fidelity Wrap needs identification and plan development. See
SCFS TS1 Training and Supervision: Personnel Development [Page 1, “New Hire Training]
c) All SCFS staff are CANS certified at onboarding and yearly recertification, See
SCFS TS1 Training and Supervision: Personnel Development [Page 1, “New Hire Training}
d) Transition planning occurs with input from all team members serving youth and family and coordinated closure of services. See
SCFS MHSU Aftercare and Follow Up 12.04, 12.05 [Page 1, “Purpose’]
SCFS- SMHS Contract-9034 -p.34-37, Exhibit A, sec D, pts – 7-9
1.5 Individualized
a) SCFS documentation utilizes standardized formats based on High Fidelity Wraparound Plan of Care and ICPM CFT noting to allow for documentation of individualized plans that include and are informed by the youth and family. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 3-10, Attachment A]
SCFS- SMHS Contract-9034, Exhibit A, sec D, pts – 7-9 [page 34-37]
b) SCFS staff receive training at onboarding on agency practices and orientation to services, and all staff participate in clinical consultation and supervision where creativity and flexibility are encouraged in developing individualized service strategies. See
SCFS TS1 Training and Supervision: Personnel Development [Page 1, “New Hire Training]
SCFS TS 3, HR 6 Supervision Procedures_Framework [Page 1, ‘Individual Supervision Procedures”]
c) SCFS Facilitators are trained in HFW principles for leading needs-focused team meetings that incorporate and review CANS and Plans of Care. See
SCFS-MHSU 10 Care Coordination [Page 2, VII]
SCFS TS1 Training and Supervision: Personnel Development [Page 2, “Supervisor/Leadership Training”]
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, V. Review Process A-D]
d)The SCFS HFW team for each youth and family will routinely review and update Plan of Care as an agenda item at CFT meetings in order to ensure current needs, strengths, and strategies are included. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, V. Review Process A-D]
e)SCFS staff will utilize client and family satisfaction surveys at each CFT as well as service verification calls in order to elicit feedback on staff and services. See:
SCFS – SMHS Contract-9034 – Exhibit A , Sec. F, pt.4(b,c) [page 47] and
2025-2026 PQI Key Performance Indicators DASHBOARD REPORT MH goals
1.6 Use of Natural and Community Based Supports
a) SCFS clinicians will develop an inventory of natural and community supports for each youth and family during assessment process; inventory will be reviewed and updated during HFW CFT meetings. See
SCFS-MHSU 10 Care Coordination [Page 2, VIII, E]
SCFS MHSU 3.03-3.07- Assessment and Reassessment [Page 2, “Procedures for Structured Assessments”]
SCFS – MHSU 4 – Service Planning and Monitoring [Page 1, II. Plan of Care; Page 2, V. Review Process, “A” – “C”]
SCFS MHSU 11- Support Services Referral Procedures [Page 1, “Procedures 2”]
SCFS- SMHS Contract-9034, Exhibit A, sec D, pt 7 [ page 34]
b) SCFS staff will receive ongoing training in identification and engagement with natural supports to reduce dependence on formal supports towards meeting goals. See
SCFS MHSU 3.03-3.07- Assessment and Reassessment [Page 3, “Standards of Assessment Practice” #7 (p.3)]
SCFS TS1 Training and Supervision: Personnel Development; [Page 2, “Ongoing Training and Workforce Development]
SCFS-MHSU 10 Care Coordination [Page 1, Procedure, step II]
SCFS High Fidelity Wraparound Training Plan
c) SCFS HFW/CFT meetings include review of inclusion, utilization, and coordination with natural supports in the plan of care and addressing action items. See
SCFS-MHSU 10 Care Coordination [Page 2, procedure VI.]
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, V. Review Process, B]
d) SCFS staff will utilize client and family satisfaction surveys at each CFT as well as service verification calls in order to elicit feedback on staff and services. See:
SCFS – SMHS Contract – P.47 – Exhibit A , Sec. F, pt.4(b,c) [page 47]
2025-2026 PQI Key Performance Indicators DASHBOARD REPORT MH goals
1.7 Culturally Respectful and Relevant
a) During the assessment process SCFS clinicians include cultural considerations and seek to elicit culturally informed needs and strengths from youth and families. See
SCFS MHSU 3.03-3.07- Assessment and Reassessment [Page 3, “Standards of Assessment Practice; #3, 4.]
SCFS – SMHS SMHS Contract-9034 – Exhibit A , Sec. D, pt.2 [page 33]
b) SCFS Staff participate in training at onboarding as well as on regularly scheduled intervals on cultural concepts and considerations in providing services and ensuring relevant strategies. See
SCFS TS1 Training and Supervision: Personnel Development [Page 1, “New Hire Training; Page 2 “Ongoing Training and Workforce Development” ]
SCFS – SMHS SMHS Contract-9034 – Exhibit A , Sec. D, pt.2 [page 33]
c) SCFS staff will utilize client and family satisfaction surveys at each CFT as well as service verification calls in order to elicit feedback on staff and services. See:
SCFS – SMHS Contract – P.47 – Exhibit A , Sec. F, pt.4(b,c) [page 47]
2025-2026 PQI Key Performance Indicators DASHBOARD REPORT MH goals
1.8 High-Quality Team Planning and Problem Solving
a) SCFS HFW Team agreements will be created at the initial HFW team meeting and development of Wraparound Plan of Care and will be documented in client’s file. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, procedure item III.]
b) SCFS staff will utilize client and family satisfaction surveys at each CFT as well as service verification calls in order to elicit feedback on collaboration and team engagement. See
SCFS – SMHS Contract – Exhibit A , Sec. F, pt.4(b,c) [page 47]
2025-2026 PQI Key Performance Indicators DASHBOARD REPORT MH goals
c)Feedback measures will be reviewed at quarterly PQI meetings and used to provide feedback to staff and supervisors and to inform ongoing training. See
2025-2026 PQI Key Performance Indicators DASHBOARD REPORT MH goals
d) The HFW plan of care will be updated and distributed with meeting minutes following each combined CFT/HFW team meeting. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, V. Review Process, A]
1.9 Outcomes Based Process
a) SCFS HFW teams will develop the plan of care with specific, measurable strategies and action items with timeframes. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, Plan of Care (II), item “E”]
b) HFW Facilitators will track action item completion at each HFW team meeting and/or CFT as needed. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, V. Review Process, “C”]
SCFS-MHSU 10 Care Coordination [Page 2, procedure VII, “E”]
c) Documentation of the HFW Plan of Care and action items will provide for action items to be adjusted and changed as needed throughout the course of treatment; updates will be communicated to team members. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, V. Review Process, “B, C”]
d) The assigned case carrying clinician will be responsible for completion of the initial IP-CANS during assessment, and will coordinate with team members for subsequent IP-CANS updates. See
SCFS MHSU 3.03-3.07- Assessment and Reassessment [Page 1]
SCFS – SMHS Contract – Exhibit A , Sec. D, pt.7 i(A-E)[page 34]
e) The initial IP-CANS will be used in identification of needs and development of associated strategies and action items, and subsequent IP-CANS updates will be incorporated in ongoing team process of tracking progress towards goals. See
SCFS MHSU 3.03-3.07- Assessment and Reassessment [Page 1, page 2 “Procedures for Structured Assessments”]
1.10 Persistence
a) The SCFS HFW team will continue working with youth and families to determine alternative strategies to support progress to goals until the HFW team, with input from the family, agrees services should end. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 1, II. Plan of Care, “C”]
SCFS-MHSU 10 Care Coordination [Page 2, procedure VII, “E”]
SCFS MHSU 11- Support Services Referral Procedures [Page 1, “Procedures, 2”]
b) Teams will be trained, directed, and encouraged to utilize intensive case coordination, group supervision, and supervisor consultation when facing challenges with supporting progress to Plan outcomes. See
SCFS-MHSU 10 Care Coordination [Page 1, procedure II]
SCFS MHSU 11- Support Services Referral Procedures [Page 1, “Procedures”]
SCFS TS 3, HR 6 Supervision Procedures_Framework [Page 1, ‘Individual Supervision Procedures”]
c) SCFS HFW facilitators will receive training and ongoing support in post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision. See
SCFS TS policy – High Fidelity Wrap Training; [Page 2, “Role Specific/Booster Training”]
SCFS TS1 Training and Supervision: Personnel Development [Page 2, “Supervisor/Leadership Training”]
1.11 Transitions as a part of the Fourth Phase of HFW
a) Transitions out of services will be coordinated within the SCFS HFW team to ensure that families do not have adverse outcomes related to sudden cessation of services. See
SCFS MHSU Aftercare and Follow Up 12.04, 12.05; [Page 1, “Purpose’]
SCFS – Contract-9034 – Exhibit A , Sec. D, pt.11 – Discharge Criteria and Process [page 38]
b) The transition out of HFW will incorporate youth and family’s culture and natural supports, as appropriate and with consideration of family voice and choice, into recognition of accomplishment and celebration of needs met.See
SCFS MHSU Aftercare and Follow Up 12.04, 12.05 [Page 1, “Purpose’]
Expected Outcomes
2.1 Youth and Family Satisfaction
SCFS provide opportunities for youth, families, and support systems to give feedback on services delivered and efficacy of the Wraparound Team. See:
SCFS – SMHS Contract – Exhibit A , Sec. F, pt.4(b,c) [page 47]
2025-2026 PQI Key Performance Indicators DASHBOARD REPORT MH goals
2.2 Improved School Functioning
SCFS client care team tracks school functioning in areas of attendance, advancement, and transitions, including to vocational settings, through collation of data from PAF, 3m, and KET forms. See:
SCFS – SMHS Contract – Exhibit A , Sec. F, pt.4(d) [page 47]
SCFS – SMHS Contract – Exhibit A , Attachment A-4 PAF, 3M, KET [page 58-79]
2.3 Improved Functioning in the Community
SCFS staff evaluates youth experience in community through ongoing assessment during treatment, assessment updates with CANS every 6 months, and documents justice involvement through KET form reporting. See:
SCFS MHSU 3.03-3.07- Assessment and Reassessment; [Page 2, “Procedures for Structured Assessments; #1- 5]
SCFS – SMHS Contract – P.47 – Exhibit A , Sec. F, pt.4(d)
SCFS – SMHS Contract – Exhibit A , Attachment A-4 PAF, 3M, KET [page 58-79];
2.4 Improved Interpersonal Functioning
SCFS care team members complete formal reassessment in every 6 month authorization period, wherein use of the IP-CANS and narrative interview elicits updates on interpersonal functioning, and is incorporated into strengths inventories and care plans, and reviewed during CFTs. See:
SCFS MHSU 3.03-3.07- Assessment and Reassessment [Page 2, “Procedures for Structured Assessments; #1- 5]
SCFS – MHSU 4 – Service Planning and Monitoring [Page 1, II. Plan of Care, “C” & page 2, V. Review Process, “D”]
SCFS – SMHS Contract – Exhibit A , Attachment A-4 PAF, 3M, KET [page 58-79]
2.5 Increased Caregiver Confidence
SCFS care team elicits caregiver input during reassessment in every 6 month authorization period, wherein the IP Cans and narrative interview evaluates caregiver strengths; caregiver needs are discussed at each CFT. See
SCFS MHSU 3.03-3.07- Assessment and Reassessment [Page 2, “Procedures for Structured Assessments; #1- 5]
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, Review Process, A-D]
SCFS – SMHS Contract – Exhibit A , Sec. D, pt.7 i(F) [page 34];
2.6 Stable and Least Restrictive Living Environment
SCFS care team tracks placement at time of service initiation as well as any subsequent changes when they occur through completion of the PAF/KET/3M FSP forms and collation of reported data. See
SCFS MHSU 3.03-3.07- Assessment and Reassessment [Page 2, “Procedures for Structured Assessments; #3]
SCFS – SMHS Contract – Exhibit A , Sec. F, pt.4(d) page 47]
SCFS – SMHS Contract – Exhibit A , Attachment A-4 PAF, 3M, KET [page 58-79]
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
SCFS care team tracks acute or inpatient treatment history at time of service initiation as well as any subsequent instances when they occur through completion of the PAF/KET/3M FSP forms and collation of reported data. See
SCFS – SMHS Contract – P.47 – Exhibit A , Sec. F, pt.4(d)
SCFS – SMHS Contract – Exhibit A , Attachment A-4 PAF, 3M, KET [page 58-79];
SCFS MHSU 3.03-3.07- Assessment and Reassessment [Page 2, “Procedures for Structured Assessments; #3]
2.8 Reduction in Crisis Visits
SCFS care team tracks crisis visit history at time of service initiation as well as any subsequent instances when they occur through completion of the PAF/KET/3M FSP forms and collation of reported data. See
SCFS – SMHS Contract – P.47 – Exhibit A , Sec. F, pt.4(d)
SCFS MHSU 3.03-3.07- Assessment and Reassessment [Page 2, “Procedures for Structured Assessments; #3]
SCFS – SMHS Contract – Exhibit A , Attachment A-4 PAF, 3M, KET [page 58-79];
2.9 Positive Exit from HFW
Transitions out of services will be coordinated within the SCFS HFW team to ensure that families do not have adverse outcomes related to sudden cessation of services ; transition out of HFW will incorporate youth and family’s culture and natural supports, as appropriate and with consideration of family voice and choice, into recognition of accomplishment and celebration of needs met. See
SCFS MHSU Aftercare and Follow Up 12.04, 12.05 [Page 1, “Purpose, Procedure’]
SCFS – SMHS Contract – Exhibit A , Sec. F, pt. 11 [ page 38]
Engagement
3.1 Orientation
SCFS HFW Facilitator, during initial HFW/CFT team meeting, explains to all family/youth support members the purpose and function of the HFW team, role and qualifications of each team member, eligibility and rationale for HFW services, and review of legal and ethical considerations consistent with informed consent practices. See
SCFS MHSU 3.03-3.07- Assessment and Reassessment; [Page 3, “Procedures for Structured Assessments; #5]
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, III. HFW Team, “A”]
SCFS Informed Consent Jan 2018
3.2 Safety and Crisis stabilization
a) SCFS clinician will identify safety and crisis concerns during first assessment appointment and develop safety crisis plans which is provided to client and family. See
MSHU 4.02 Crisis Management/ Trauma Informed Care [Page 1, “Procedure A-C”]
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, IV. Safety Crisis Plan]
b) SCFS care team will ensure triggers, warning signs, and supports from safety crisis plan will be included in development of the HFW safety plan. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, IV. Safety Crisis Plan & Page 11, attachment B, Safety Crisis Plan] ;
SCFS MSHU 4.02 Crisis Management/ Trauma Informed Care [Page 1, “Procedure B, C”]
c) Youth and families are provided with information for how to access 24/7 crisis response services when needed. See
SCFS MSHU 4.02 Crisis Management/ Trauma Informed Care [Page 1, “Procedure B, C”]
SCFS Informed Consent Jan 2018
3.3 Strengths, Needs, Culture and Vision Discovery
a) SCFS clinician and/or wraparound team will work with family to develop Family Vision Statement during assessment phase and included in the SCFS Plan of Care. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 1, II. Plan of Care, “A”]
b) SCFS clinician will develop strengths, needs, and culture discovery informed by family and CANS assessment data and will be included with SCFS Plan of Care. See
SCFS MHSU 3.03-3.07- Assessment and Reassessment; [Page 2, “Procedures for Structured Assessments; #1]
SCFS – MHSU 4 – Service Planning and Monitoring [Page 1, II. Plan of Care, “A”]
3.4 Engage All Team Members
a) SCFS clinician will work with client and family to create a natural supports inventory during assessment through completion of the IP-CANS and comprehensive assessment. See
SCFS MHSU 3.03-3.07- Assessment and Reassessment [Page 2, “Procedures for Structured Assessments; #1]
b) SCFS clinician will engage client and caregiver in identification of system of care partners to include in HFW team during assessment, See
SCFS MHSU 3.03-3.07- Assessment and Reassessment [Page 3, “Procedures for Structured Assessments; #5]
c) SCFS HFW team, including clinician and parent partner, will engage client and caregiver in identification of potential partners to include in HFW team during assessment, See
SCFS-MHSU 10 Care Coordination [Page 1, procedure I]
SCFS MHSU 3.03-3.07- Assessment and Reassessment [Page 3, “Procedures for Structured Assessments; #5]
d) Team building activities will be documented in the client chart on CFT meeting notes and appropriate ROI/accounting of disclosures. See SCFS- SMHS Contract-9034, Exhibit A, sec D, pts – 7-9 [page 34-37] and
SCFS – MHSU 4 – Service Planning and Monitoring [ Page 8, Plan of Care, Team Member Strengths]
3.5 Arrange Meeting Logistics
a) SCFS staff and members of the HFW team are flexible in working hours and mobility resources, to include teleconferencing, to coordinate HFW team meetings accommodating child and family needs for participation. See
Sierra Child & Family Services Personnel Manual p. 9-13 – Work Performance; p. 36 “Use of motor vehicles.”
SCFS- SMHS Contract-9034 -p.38, Exhibit A, sec D, pts – 10
b) SCFS staff receive training at onboarding on agency practices and values with respect to collaborative work with families and in promoting child and family participation. See
SCFS TS1 Training and Supervision: Personnel Development [Page 1, “New Hire Training”]
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
a) SCFS clinician and HFW team work with child and family to develop team agreements, strengths inventory , and mission statement to inform development of the HFW Plan of Care. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 1, II. Plan of Care, “A” – “C”]
b) Strengths are continually assessed throughout course of engagement and updated on Plan of Care on routine basis included CFT meetings and documented through plan updates and meeting minutes. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, V. Review Process, “D”]
SCFS MHSU 3.03-3.07- Assessment and Reassessment; [Page 2, “Procedures for Structured Assessments; #1]
SCFS- SMHS Contract-9034, Exhibit A, sec D, pts – 7-9 [page 34-37]
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
a) SCFS clinician will during authorization and engagement in services identify and document needs of child and family through completion of assessment materials. See
SCFS MHSU 3.03-3.07- Assessment and Reassessment; [Page 1, page 2 “Procedures for Structured Assessments]
SCFS- SMHS Contract-9034, Exhibit A, sec D, pts – 7-9 [page 34-37]
b) HFW team develop measurable goals based on identified needs. See
SCFS MHSU 3.03-3.07- Assessment and Reassessment; [Page 1, page 3 “Standards of Assessment Practice]
c) Goals and outcomes are developed in collaboration between HFW team, child, and family. See
SCFS MHSU 3.03-3.07- Assessment and Reassessment; [Page 1, page 3 “Standards of Assessment Practice]
d) Multiple individualized strategies developed by the HFW team are documented in the chart for reference, including in the Plan of Care and CFT meeting minutes.See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, II. Plan of Care, “E” & Page 9, Plan of Care, “Individualized Plan”]
e) SCFS Facilitators are trained to lead teams in identification, prioritization, and selection of strategies and action items to meet goals. See
SCFS TS policy – High Fidelity Wrap Training; [Page 2, “Role Specific/Booster Training”]
SCFS TS1 Training and Supervision: Personnel Development [Page 2, “Supervisor/Leadership Training”]
f) These steps and developed materials are used to develop the HFW plan of Care as a team See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 1-2, “Procedure” items I – V; Page 3-11, attachment A]
4.3 Develop an Individualized Child or Youth and Family Plan
a) SCFS Facilitators receive ongoing training within the agency and with community partners on leading team planning processes that value perspectives, shared vision, and trust in line with HFW principle. See
SCFS TS1 Training and Supervision: Personnel Development [Page 2 “Ongoing Training and Workforce Development” ]
b) SCFS plan of care integrates needs-driven goals and objectives identified by the HFW and children’s system of care. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, II. Plan of Care, “D. E” ]
c) The Plan of Care is documented in the client’s file and is distributed to all team members. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, III. HFW Team]
d) Plans of Care are reviewed for feedback and training opportunities during routine chart audit and review processes. See
SCFS TS 3, HR 6 Supervision Procedures_Framework [Page 1, “Individual Supervision Procedures”]
SCFS TS1 Training and Supervision: Personnel Development [ Page 2 “Ongoing Training and Workforce Development” ]
4.4 Develop a Crisis and Safety Plan
a) Individualized Crisis and safety plans are completed and documented in each youth’s chart where high risk behaviors have been identified and is developed with participation of youth and supports and includes internal and external supports. See
MSHU 4.02 Crisis Management/ Trauma Informed Care [Page 1, “Procedure A-C”]
SCFS – MHSU 4 – Service Planning and Monitoring; [Page 2, IV. Safety Crisis Plan, “A-D”]
SCFS Informed Consent
b) Safety crisis plan development occurs in collaboration between youth, supports, and HFW team members. See
SCFS – MHSU 4 – Service Planning and Monitoring; [Page 2, IV. Safety Crisis Plan, “A-D”]
SCFS MSHU 4.02 Crisis Management/ Trauma Informed Care [Page 1, “Procedure A-C”]
c) Safety crisis plans are reviewed by supervisors with attention to identifying individualized and effective strategies that are relevant and appropriate for youth and family needs. See
SCFS – MHSU 4 – Service Planning and Monitoring; [Page 2, IV. Safety Crisis Plan, “D”]
SCFS MSHU 4.02 Crisis Management/ Trauma Informed Care [Page 1, “Procedure D”]
SCFS TS 3, HR 6 Supervision Procedures_Framework [Page 1, “Individual Supervision Procedures”]
Implementation
5.1 Implement The Plan of Care
a) SCFS facilitators include in HFW team meetings review of the plan of care, including strategies and action items, to track progress and timelines and adjust as needed. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, V. Review Process “A-D”]
SCFS-MHSU 10 Care Coordination; [Page 2, procedure VII, “D, E”]
SSCFS TS policy – High Fidelity Wrap Training; [Page 2, “Role Specific/Booster Training”]
b) Staff receive training and coaching on implementation of Plan of Care with HFW principles. See
SCFS TS policy – High Fidelity Wrap Training; [Page 2, “Role Specific/Booster Training”]
SCFS TS1 Training and Supervision: Personnel Development [Page 1, “New Hire Training; Page 2 “Ongoing Training and Workforce Development” ]
5.2 Review and Update The Plan of Care
a) SCFS facilitators include in HFW team meetings review of the plan of care, including strategies and action items. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, V. Review Process “A-D”]
SCFS-MHSU 10 Care Coordination [Page 2, procedure VII, “D, E”]
b) HFW facilitator supports team in adjusting plans as appropriate to accommodate successes and new needs; new plan is included in client file. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, V. Review Process “C”]
c) HFW meetings as occurring in context of CFT meetings include documentation of plan of care updates, including completed tasks, new strategies, and assigned to-do tasks, and are communicated and documented via meeting notes. See SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, V. Review Process “A-D”];
SCFS-MHSU 10 Care Coordination [Page 2, procedure VI, VII, VIII]
d) Forms are developed to be updated and individualized to meet specific needs of youth, family, and team. See
SCFS – MHSU 4 – Service Planning and Monitoring[Page 3-11, attachments “Plan of Care Template”]
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
a) Team agreements are a part of Plan of Care development and are reviewed at HFW CFT meetings. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, V. Review Process “A-D”]
SCFS-MHSU 10 Care Coordination [Page 2, procedure VIII, D]
b) SCFS Facilitators receive ongoing training within the agency and with community partners on building,engaging, and maintaining effecting HFW teams. See
SCFS TS1 Training and Supervision: Personnel Development [ Page 2 “Ongoing Training and Workforce Development”, “Supervisor/Leadership training” ]
SCFS TS policy – High Fidelity Wrap Training; [Page 2, “Collaborative scope”]
c) Use of natural supports is monitored over time by facilitators during HFW team meetings, feedback is provided to team members. See
SCFS TS1 Training and Supervision: Personnel Development [ Page 2 “Ongoing Training and Workforce Development”
SCFS TS 3, HR 6 Supervision Procedures_Framework [Page 2, “Group Supervision Procedures”]
d) The HFW-CFT meeting includes process for orienting team members to HFW process, current plans, and roles and relevance of each member to the implementation of team plans. See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, III. HFW Team, A]
SCFS TS policy – High Fidelity Wrap Training; [Page 1, “Training emphasis”]
SCFS-MHSU 10 Care Coordination [Page 2, VII]
Transition
6.1 Develop a Transition Plan
a) SCFS team facilitator leads the team in review of benchmarks and addressed needs for indicators of readiness for transition at each team meeting.See
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, V. Review Process “A-D”]
SCFS-MHSU 10 Care Coordination [Page 2, VIII, F]
b) SCFS facilitator leads the team in developing individualized transition plan that identifies and incorporates needs, services, and supports and ensures all team members are included. See
SCFS – MHSU 4 – Service Planning and Monitoring; [Page 2, V. Review Process “A-D”]
SCFS-MHSU 10.01-10.05 Care Coordination [Page 2, VIII, F]
c) Transition plan development occurs in a team based collaborative environment and facilitators are trained to ensure this process. See
SCFS-MHSU 10.01-10.05 Care Coordination [Page 2, procedure VII]
SCFS TS1 Training and Supervision: Personnel Development [ Page 2 “Supervisor/Leadership training” ]
SCFS MHSU Aftercare and Follow Up 12.04, 12.05 [Page 1, “Procedure 1a, 2a”]
d) Facilitator and team members will confirm that services and supports included in the transition plan will continue beyond conclusion of high fidelity wrap team and that youth and family will have access to them. See
SCFS MHSU Aftercare and Follow Up 12.04, 12.05; [Page 1, “Procedure 1a, 2a, 3a”]
SCFS- SMHS Contract-9034, Exhibit A, sec D, pt 11 “Discharge Criteria and Process” [page 38] ;
SCFS- SMHS Contract-9034, Exhibit A, sec E, pt. 9 “Transition of Care Tool” [page 43]
6.2 Develop a Post-Transition Safety Plan
a) With involvement of the team, youth, and family, the individualized crisis and safety plan is updated at time of transition to include supports and strategies relevant at time of and beyond transition out of HFW services, or if not already existing a plan is developed for support post-transiton. See
SCFS MHSU Aftercare and Follow Up 12.04, 12.05 [Page 2, “Procedure 5”]
MSHU 4.02 Crisis Management/ Trauma Informed Care [Page 2, “Procedure L”]
b) SCFS HFW facilitators support development of the crisis and safety transition plan in a team based and collaborative environment and receive training in this. See
SCFS TS1 Training and Supervision: Personnel Development [ Page 2 “Supervisor/Leadership training” ]
SCFS – MHSU 4 – Service Planning and Monitoring [Page 2, IV. Safety Crisis Plan “A-D”]
SCFS MHSU Aftercare and Follow Up 12.04, 12.05 [Page 2, “Procedure 5”]
c) Transition safety crisis plans are reviewed by supervisors/facilitators with attention to identifying individualized and effective strategies that are relevant and appropriate for youth and family needs. See
SCFS MSHU 4.02 Crisis Management/ Trauma Informed Care [Page 2, “Procedure D, L”]
SCFS TS 3, HR 6 Supervision Procedures_Framework [Page 1, ‘Individual Supervision Procedures”]
6.3 Create a Commencement and Celebrate Success
a) Transitions out of care are marked with appropriate, youth-and-family centered recognition and celebration of success. See
SCFS MHSU Aftercare and Follow Up 12.04, 12.05 [Page 2, “Procedure 6”]
b) SCFS agency leadership, including supervisors, are supportive of celebrating transition as a success, including application of flex funds, staff availability, and community partners. See
SCFS MHSU Aftercare and Follow Up 12.04, 12.05 [Page 2, “Procedure 6”]
SCFS TS 3, HR 6 Supervision Procedures_Framework [Page 1, ‘Individual Supervision Procedures”]
SCFS- SMHS Contract-9034, Exhibit B, sec B, pt. 9 “Non-Mental Health Supportive Services and Goods for Clients Enrolled in a FSP Program” [page 82]
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
a) SCFS will work with county to solicit youth and family input and participation in HFW and related services implementation. See
SCFS- SMHS Contract-9034, Exhibit A, sec F, pt. 4 “Reporting And Evaluation Requirements” [page 47]
b) Feedback from youth and families is used in service planning and implementation, workforce development, policy and procedure development, and for quality improvement. See
SCFS- SMHS Contract-9034, Exhibit A, sec F, pt. 4 “Reporting And Evaluation Requirements” [page 47] and 2025-2026 PQI Key Performance Indicators DASHBOARD REPORT MH goals
7.2 Community Leadership Team
a) SCFS Clinical Directors attend and participate in Community Leadership meetings as coordinated by county agencies, including County Behavioral Health, Office of Education, and HHSA. See
SCFS Strategic Plan 22.24 [p. 9-13]
7.3 Eligibility and Equal Access
a)SCFS provides services to all youth and families that meet established eligibility criteria and are not excluded based on severity of needs. See
SCFS MHSU 3.03-3.07- Assessment and Reassessment; [Page 1, page 3 “Standards of Assessment Practice]
b)SCFS staffing procedures include hiring practices based on level of need and utilizing qualifications to meet the demands of the community as well as severity of individual needs. See
SCFS – HR 1 Assessment of Workforce Needs [Page 1, “Assessment of Workforce Needs”]
SCFS – HR 2 Recruitment & Selection Policy and Procedures [Page 1]
SCFS Strategic Plan 22.24 [p. 10]
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
a) SCFS contract with County Behavioral Health includes rates for all provider types on the HFW team employed by the organization, including roles falling under LPHA and MHRS categories. See
SCFS- SMHS Contract-9034 -p.80, Exhibit B, sec A “Rates)
b) SCFS utilizes resources for workforce development and staffing to meet HFW needs. See See
SCFS – HR 1 Assessment of Workforce Needs [Page 1, “Assessment of Workforce Needs”]
SCFS – HR 2 Recruitment & Selection Policy and Procedures [Page 1]
8.2 Equitable Funding Across System Partners
8.3 Cost Savings are Reinvested
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
a) SCFS accesses and utilizes flex funds within conditions set by the county as reimbursable for supporting High Fidelity Wraparound activities benefitting youth and families. See
SCFS- SMHS Contract-9034 -p.82, Exhibit B, sec B, pt. 9 “Non-Mental Health Supportive Services and Goods for Clients Enrolled in a FSP Program”
b) SCFS contract with county includes processes that account for timely access to funds, defined approval process, and appeals process. See
SCFS- SMHS Contract-9034 -p.82, Exhibit B, sec B, pt. 9 “Non-Mental Health Supportive Services and Goods for Clients Enrolled in a FSP Program”
8.5 Collaborative Oversight of Flex Funds
a) SCFS request and use of FSP funds is documented and communicated to the county as outlined in SCFS- SMHS Contract-9034 -p.82, Exhibit B, sec B, pt. 9 “Non-Mental Health Supportive Services and Goods for Clients Enrolled in a FSP Program”
b) Management of flex funds, including pooling and holding, is managed by El Dorado County contract Administrator, see
SCFS- SMHS Contract-9034 -p.82, Exhibit B, sec B, pt. 9 “Non-Mental Health Supportive Services and Goods for Clients Enrolled in a FSP Program”
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
a) SCFS wraparound programs are funded through FSP services contract; additional resources for funding services are actively sought out and coordinated by agency leadership. See
SCFS- SMHS Contract-9034 -p.47, Exhibit A, sec F, pt. 4 “Reporting And Evaluation Requirements’
b) SCFS leadership seeks out community resources to obviate shortcoming and amend gaps in program funding. See
SCFS- SMHS Contract-9034 -p.47, Exhibit A, sec F, pt. 4 “Reporting And Evaluation Requirements’
c) SCFS works with families to explore all available resources to meet needs including funding sources. See
SCFS- SMHS Contract-9034 -p.47, Exhibit A, sec F, pt. 4 “Reporting And Evaluation Requirements’;
SCFS- SMHS Contract-9034 -p.82, Exhibit B, sec B, pt. 9 “Non-Mental Health Supportive Services and Goods for Clients Enrolled in a FSP Program”
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
a) Sierra Child and Family Services hire based on qualifications and recruit/hire staff aligned with population demographics as appropriate among available candidates. See
SCFS – HR 1 Assessment of Workforce Needs; [Page 1, “Assessment of Workforce Needs”]
SCFS – HR 2 Recruitment & Selection Policy and Procedures [Page 1]
b) When recruitment/hiring efforts are unable to be directly reflective of a families cultural, racial, or linguistic needs for representation, alternative means are explored to meet these needs, including community partners and natural supports. See
SCFS-MHSU 10 Care Coordination [Procedure: II (Page1); VI (Page 2)]
SCFS MHSU 11- Support Services Referral Procedures [Page 1, “Procedures, 2”]
SCFS HR 2 Recruitment and Selection; [Page 1, “Identification of Potential Employees Procedures”]
c) Translator services are provided when unable to provide direct staff services in the family’s preferred language. See SCFS Informed Consent Jan 2018
9.2 Tribally Responsive Workforce
a) SCFS staff receive annual cultural competency training which includes tribal relations aimed at ensuring respectful communication, collaboration, and advocacy. See
SCFS TS1 Training and Supervision: Personnel Development [ Page 2 “Ongoing Training and Workforce Development” ]
b) SCFS High Fidelity Wrap team prioritizes building partnerships with tribal representatives and encourages coordination with supports offered by the tribe when serving youth and families with tribal affiliation. See
SCFS-MHSU 10 Care Coordination [Page 1, Procedure IV; Page 2, Procedure V, “E”]
9.3 Flexible and Creative Work Environment
SCFS Leadership including managers and supervisors participate in training and organizing agency activities to engage staff in Program quality and Improvement, Cohesion, Open communication and Creating clear sense of mission and compliance with HFW philosophy. See:
SCFS PQI plan 2024
9.4 Hiring, Performance Evaluation, and Job Descriptions
a) SCFS ensures hiring practices that include positions that meet requirements of all functions described by the HFW program through established roles that match HFW position titles and/or include roles within requirements of existing positions.
– SCFS Job Description: Clinical Supervisor includes roles of supervisor, facilitator; fidelity coach as outlined within HFW standards
– SCFS Parent Partner describes roles fulfilled by HFW Parent Partner
– SCFS Family Specialist describes HFW Family Specialist roles
See
SCFS HR 2 Recruitment and Selection; [Page 1, “Identification of Potential Employees Procedures”]
SCFS HR1 Assessment of Workforce Needs; [Page 1]
SCFS Job Description Clinical Supervisor; SCFS Job Description Family Specialist Supervisor; SCFS Job Description Family Specialist; SCFS Job Description Youth Partner; SCFS Job Description Parent Partner.
b) Job Descriptions include description of purpose, functions, and qualities specific to each role. See Job Descriptions referenced under (a)
c) Job descriptions reflect the attitudes, skills, knowledge, and experience most likely to identify individuals who will be successful in the position. See Job Descriptions referenced under (a)
d) Hiring process allows for candidates to describe and demonstrate attitudes, skills, and qualifications necessary for the position. See:
SCFS HR 2 Recruitment and Selection [Page 2, “Selection Process Procedures”]
e) Employees are provided with clear expectations for role fulfillment and receive regular feedback through supervision and performance review. See:
SCFS TS1 Training and Supervision: Personnel Development [“ Page 2 “Ongoing Training and Workforce Development” ]
SCFS TS 3, HR 6 Supervision Procedures_Framework [Page 1, ‘Individual Supervision Procedures”],
SCFS HR 2 Recruitment and Selection [Page 1, “Identification of Potential Employees Procedures”]
SCFS HR 4 Performance Review Procedures [Page 1]
9.5 Workforce Stability
a) SCFS strives to provide wages commensurate with cost of living and competitive compensatory rates with comparable agencies in the service area. Sierra Child & Family Services Personnel Manual;
SCFS HR1 Assessment of Workforce Needs [Page 1]
b) SCFS Supervision practices include evaluation of staff workloads for purposes of ensuring manageable expectations for meeting client needs. See
SCFS HR1 Assessment of Workforce Needs [Page 1]
SCFS TS 3, HR 6 Supervision Procedures_Framework [Page 3, ‘Workload assignment criteria”]
SCFS MHSU 2.10 Continuity of Care and Case Assignment.[Page 1]
c) Promotion/advancement structures are clearly communicated through the process of supervision and during hiring See
SCFS HR1 Assessment of Workforce Needs [Page 1]
SCFS HR 4 Performance Review Procedures [Page 1]
d) SCFS includes in performance evaluation consideration of wage increase and leadership task addition regardless of position change with consideration of agency based experience independent of external qualification. See
SCFS HR 2 Recruitment and Selection [Page 1, “Identification of Potential Employees Procedures”]
SCFS HR 4 Performance Review Procedures [Page 1]
SCFS HR1 Assessment of Workforce Needs; [Page 1]
9.6 High Fidelity Training Plan
a) All SCFS staff receive initial HFW training through staff member certified through Wraparound 101: Foundations for Fidelity Training for Trainers, See SCFS TS policy – High Fidelity Wrap Training; [Page 1, “Training emphasis, Training Plan”]
b) Staff receive ongoing training in role specific information and practices as determined by supervisors and provided through UC Davis RCFFP. See
SCFS TS policy – High Fidelity Wrap Training; [Page 1, “Training emphasis, Training Plan”]
c) Staff will receive booster training on an annual basis provided via internal trainer or UC Davis RCFFP. See
SCFS TS policy – High Fidelity Wrap Training; [Page 1, “Training emphasis, Training Plan”]
d) Clinical Supervisors will receive initial HFW training through staff member certified through Wraparound 101: Foundations for Fidelity Training for Trainers and booster training on an annual basis provided via internal trainer or UC Davis RCFFP. See
SCFS TS policy – High Fidelity Wrap Training; [Page 2, “Training Plan,Role Specific/Booster Training”]
e) All staff will receive ICWA and Tribal Sovereignty training. See
SCFS TS1 Training and Supervision: Personnel Development [ Page 1, “New Hire Training”; “ Page 2 “Ongoing Training and Workforce Development” ]
9.7 Community-based Training Program
a)SCFS training plan includes efforts to engage system and community partners in training with orientation to High Fidelity Wraparound. See
SCFS TS1 Training and Supervision: Personnel Development [“ Page 2 “Supervisor/Leadership Training” ]
SCFS Strategic Plan 22.24
b) SCFS ensures community partners are invited to attend Wraparound trainings for purposes of promoting effective participation in HFW teams. See
SCFS TS policy – High Fidelity Wrap Training; [Page 2, “Training Plan, Collaborative scope”]
9.8 Coaching and Supervision
a) SCFS Wraparound training includes initial training in HFW that includes approximation of apprenticeship with trained staff. See
SCFS TS policy – High Fidelity Wrap Training; [Page 1, “Training emphasis, Training plan”]
b) Staff have access to supervisory support or coaching 24/7 as needed. See
SCFS TS 3, HR 6 Supervision Procedures_Framework [Page 2, “workload assignment criteria]
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
a) SCFS uses data collected from PQI programs and client feedback to improve practice with youth and families. See:
SCFS – SMHS Contract – Exhibit A , Sec. F, pt.4(b,c) [page 47]
2025-2026 PQI Key Performance Indicators DASHBOARD REPORT MH goals
b) Data is used to identify and address program needs to better serve families and improve program effectiveness. See:
SCFS PQI Plan
c) Data is utilized to identify and communicate system barriers to the community leadership team. See:
SCFS TS 3, HR 6 Supervision Procedures_Framework [Page 2, “workload assignment criteria]
Fidelity Indicators
1.1 Timely Engagement and Planning
(a) WRAP – The WRAP Social worker will attempt to contact and schedule the WRAP Placement with the Child and Family Team within twenty-four (24) business hours of receiving assignment.
WRAP Guidelines 3.1 SLO County Referral Process, page 1
WRAP Guidelines 3.5 Referral and Placement Tracking, page 3
WRAP Guidelines 3.7 Placement, page 6
FSP – The FSP Social Worker will attempt to contact the client/family within twenty-four (24) business hours of receiving assignment to schedule the FSP engagement orientation meeting.
FSP Guidelines 2.2 Initial Client Engagement & Orientation, page 4
(b) WRAP and FSP – The Initial Plan of Care is developed with the Child and Family Team within thirty (30) days of placement/program enrollment.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
(c) WRAP and FSP – The Plan of Care must be reviewed in CFT meetings at least every thirty to forty-five (30–45) days, with formal updates distributed to members at least every ninety (90) days or more frequently as needed.
Direct Service Guidelines 5.1 Child & Family Teams, page 42
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
(d) WRAP and FSP – The Plan of Care must be reviewed in CFT meetings at least every thirty to forty-five (30–45) days, with formal updates distributed to members at least every ninety (90) days or more frequently as needed. Once the Plan of Care is agreed upon and finalized, a copy is provided to all team members by the next business day. Additionally, when new members join the team, they will be provided with a copy of the most recent Plan of Care.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Plan of Care
(e) WRAP and FSP – Each month, five to seven (5-7) charts are selected from clients enrolled for at least thirty (30) days and up to forty-five (45) days. Charts are audited to ensure documentation timelines are met. Staff and supervisors are provided feedback, based on the outcome of the chart audits.
Direct Service Guidelines 12.1 Data Management, page 62
Direct Service Guidelines 12.5 Tools to Support Documentation Compliance, page 67
(f) WRAP and FSP – Staff are provided coaching and training in scheduled training sessions, supervision, and team meetings. They are provided strategies to encourage timely engagement as well as individualized interventions to promote trust and consistency.
Direct Service Guidelines 4.3 Client Scheduling, Timely Engagement & Service Delivery, page 39
Staff Development Guide 7.5 High Fidelity Wraparound Training, page 8
1.2 Led by Youth and Families
(a) WRAP and FSP – Teams are led by youth and family perspectives through Family Vision and Team Mission statements that guide engagement, assessment, planning, monitoring, and transition within the CFT process to ensure culturally responsive, strength-based care and long-term stability. Within the first 30 days, the Family/Youth Vision Statement and Team Agreements are developed and documented within the Plan of Care.
Direct Service Guidelines 2.1 Core Philosophy, page 13
Direct Service Guidelines 2.3 Culturally Competent Care, page 20
Direct Service Guidelines 2.3.1 Serving Spanish Speaking Clients, page 23
Direct Service Guidelines 2.3.2 Serving LGBTQIA+ Clients, page 25
Direct Service Guidelines 2.3.3 Serving Native American Youth, page 29
Direct Service Guidelines 5.2 CFT Facilitation, page 44
Direct Service Guidelines 5.4 Family/Youth Vision, page 47
Direct Service Guidelines 5.5 Team Mission, page 49
Family Vision Worksheet
(b) WRAP and FSP – Teams use the Strengths, Needs, and Cultural Discovery (SNCD) along with the CANS assessment to guide High-Fidelity Wraparound services in a strengths-based, culturally responsive, and individualized manner. These assessments are completed within the first 30 days of enrollment and are maintained in the record.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
WRAP Guidelines 5.4 CANS, page 21
WRAP Guidelines 5.5 Strengths, Needs & Cultural Discovery, page 23
Strengths, Needs and Cultural Discovery
(c) WRAP and FSP – Both the Wraparound Fidelity Coach and staff supervisors conduct observations and regularly review documentation to support ongoing staff skill development.
Direct Service Guidelines 12.7 WrapStat TOM 2.0 Team Observation Measure, page 73
Staff Development Guide 3.2 Field Observation, page 6
(d) WRAP and FSP – Feedback is gathered from youth and families through eliciting input during sessions and CFT meetings, TOM 2.0 observations, Wraparound Fidelity Index surveys, and FCNI Customer Satisfaction Surveys. The Wraparound Fidelity Coach and supervisors review this feedback and provide individualized and team-level coaching to support ongoing staff development, program performance, and continuous quality improvement.
Direct Service Guidelines 12.3 Customer Satisfaction Survey, page 65
Direct Service Guidelines 12.6 WrapStat Wraparound Fidelity Index (WFI-EZ), page 71
Direct Service Guidelines 12.7 WrapStat TOM 2.0 Team Observation Measure, page 73
1.3 Strength-Based
(a) WRAP and FSP – Teams use the Strengths, Needs, and Cultural Discovery (SNCD) along with the CANS assessment to guide High-Fidelity Wraparound services in a strengths-based, culturally responsive, and individualized manner. These assessments are completed within the first 30 days of enrollment and maintained in the record. The Wraparound Team Functional Strengths tool is also used during the CFT process to identify each team member’s strengths, which are incorporated into the Plan of Care and reviewed at each meeting. Team members strengths are included on the Plan of Care, copies are provided and reviewed each meeting.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
WRAP Guidelines 5.4 CANS, page 21
WRAP Guidelines 5.5 Strengths, Needs & Cultural Discovery, page 23
Plan of Care
Strengths, Needs, and Cultural Discovery
Functional Strengths
(b) WRAP and FSP – Team members are provided a copy of the CANS rating sheets, a CANS Quick Guide Tool, as well as a Functional strengths tool to support with identifying strengths. The strengths identified through the CANS are utilized to determine the functional strengths of the youth and family.
WRAP Guidelines 5.4 CANS, page 21
Functional Strengths
CANS Quick Guide
(c) WRAP and FSP – Both the Wraparound Fidelity Coach and staff supervisors provide observations and regularly review documentation, including but not limited to the Plan of Care document, Strengths, Needs, and Cultural Discovery document, CANS, service notes, and Safety Plans to support ongoing staff skill development to support teams with identifying functional strengths and remaining solutions focused.
Direct Service Guidelines 12.1 Data Management, page 62
Direct Service Guidelines 12.5 Tools to Support Documentation Compliance, page 67
Direct Service Guidelines 12.7 WrapStat TOM 2.0 Team Observation Measure, page 73
Staff Development Guide 3.2 Field Observation, page 6
Staff Development Guide 7.5 High Fidelity Wraparound Training, page 8
(d) WRAP and FSP – Feedback is gathered from youth and families through eliciting input during sessions and CFT meetings, TOM 2.0 observations, Wraparound Fidelity Index surveys, and FCNI Customer Satisfaction Surveys. The Wraparound Fidelity Coach and supervisors review this feedback and provide individualized and team-level coaching to support ongoing staff development, program performance, and continuous quality improvement.
Direct Service Guidelines 12.3 Customer Satisfaction Survey, page 65
Direct Service Guidelines 12.6 WrapStat Wraparound Fidelity Index (WFI-EZ), page 71
Direct Service Guidelines 12.7 WrapStat TOM 2.0 Team Observation Measure, page 73
1.4 Needs Driven
(a) WRAP and FSP – Teams use the Strengths, Needs, and Cultural Discovery (SNCD) along with the CANS assessment to guide High-Fidelity Wraparound services in a strengths-based, culturally responsive, and individualized manner. These assessments are completed within the first 30 days of enrollment and maintained in the record. The needs are prioritized along with the information on the IP-CANS is discussed with the team and added to the Plan of Care.
Direct Service Guidelines 2.1 Core Philosophy, page 13
Direct Service Guidelines 2.2 Trauma Informed Care, page 17
Direct Service Guidelines 3.1 Team Members, page 29
Direct Service Guidelines 5.1 Child and Family Teams Overview, page 42
Direct Service Guidelines 5.2 CFT Facilitation, page 44
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
WRAP Guidelines 5.4 CANS, page 21
WRAP Guidelines 5.5 Strengths, Needs & Cultural Discovery, page 23
Plan of Care
Strengths, Needs, and Cultural Discovery
(b) WRAP and FSP – Feedback is gathered from youth and families through eliciting input during sessions and CFT meetings, TOM 2.0 observations, Wraparound Fidelity Index surveys, and FCNI Customer Satisfaction Surveys. The Wraparound Fidelity Coach and supervisors review this feedback and provide individualized and team-level coaching to support ongoing staff development, program performance, and continuous quality improvement.
Direct Service Guidelines 12.3 Customer Satisfaction Survey, page 65
Direct Service Guidelines 12.6 WrapStat Wraparound Fidelity Index (WFI-EZ), page 71
Direct Service Guidelines 12.7 WrapStat TOM 2.0 Team Observation Measure, page 73
Staff Development Guide 3.2 Field Observation, page 6
(c) WRAP and FSP – Teams use the Strengths, Needs, and Cultural Discovery (SNCD) along with the CANS assessment to guide High-Fidelity Wraparound services in a strengths-based, culturally responsive, and individualized manner. These assessments are completed within the first 30 days of enrollment and maintained in the record. The needs are prioritized along with the information on the IP-CANS is discussed with the team and added to the Plan of Care.
Direct Service Guidelines 5.2 CFT Facilitation, page 44
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
WRAP Guidelines 5.4 CANS, page 21
WRAP Guidelines 5.5 Strengths, Needs & Cultural Discovery, page 23
(d) WRAP and FSP – Transition is considered appropriate when the Child and Family Team, in partnership with the youth and family, agrees that identified goals have been met and needs are sufficiently addressed. This decision is based on ongoing assessment during CFT meetings, where progress, strengths, and readiness for transition are consistently reviewed. A formal transition plan is then developed to ensure continued support and maintenance of gains after services conclude.
WRAP Guidelines 6.3 Discharge & Transition Planning, page 27
FSP Guidelines 9.2 Discharge Planning, page 17
1.5 Individualized
(a) WRAP and FSP – Forms are set up to support the team and Facilitator to follow the Wraparound process, however each section is set up as a narrative to allow for flexibility to create individualized plans for each child/family.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
WRAP Guidelines 5.5 Strengths, Needs & Cultural Discovery, page 23
Plan of Care
Strengths, Needs, and Cultural Discovery
(b) WRAP and FSP – Staff receive ongoing training and coaching to support the delivery of flexible, creative, and highly individualized services and strategies. The Wraparound Fidelity Coach and staff supervisors conduct regular observations and review documentation to support continuous skill development, helping staff remain strengths-based, solution-focused, and effective in identifying and building on family and youth strengths.
Staff Development Guide 3.2 Field Observation, page 6
Staff Development Guide 7.5 High Fidelity Wraparound Training, page 8
Direct Service Guidelines 3.4 Internal Team Meetings, page 35
Direct Service Guidelines 12.7 WrapStat TOM 2.0 Team Observation Measure, page 73
(c) WRAP and FSP – Facilitators receive ongoing training and coaching in Child and Family Team (CFT) facilitation using Wraparound principles and philosophies. This includes guidance on how to effectively lead the HFW team and ensure that the process and HFW Plan of Care are individualized and reflective of each youth and family’s unique needs, strengths, values, culture, and preferences.
Staff Development Guide 1.2 Agency Training Requirements – Module A (Clinical Direct Services), page 1
(d) WRAP and FSP – HFW Plans of Care are routinely reviewed through monthly chart audits and quarterly compliance monitoring to ensure they reflect individualized strengths, needs, outcomes, and strategies. These reviews also assess whether plans effectively incorporate and leverage the assets of the family’s community and informal support networks, including natural supports. Findings are used to support ongoing fidelity through documentation feedback, supervision, and coaching as needed.
Direct Service Guidelines 12.1 Data Management, page 62
Direct Service Guidelines 12.5 Tools to Support Documentation Compliance, page 67
(e) WRAP and FSP – Feedback is gathered from youth and families through eliciting input during sessions and CFT meetings, TOM 2.0 observations, Wraparound Fidelity Index surveys, and FCNI Customer Satisfaction Surveys. The Wraparound Fidelity Coach and supervisors review this feedback and provide individualized and team-level coaching to support ongoing staff development, program performance, and continuous quality improvement.
Direct Service Guidelines 12.3 Customer Satisfaction Survey, page 65
Direct Service Guidelines 12.6 WrapStat Wraparound Fidelity Index (WFI-EZ), page 71
Direct Service Guidelines 12.7 WrapStat TOM 2.0 Team Observation Measure, page 73
1.6 Use of Natural and Community Based Supports
(a) WRAP and FSP – A natural and community supports inventory is developed and updated for every family through the use of the Strengths, Needs, and Cultural Discovery (SNCD) and CANS assessment processes. These tools, along with IP-CANS information discussed during CFT meetings, help identify and prioritize needs while ensuring the Plan of Care includes strengths-based strategies that incorporate natural and community supports.
Direct Service Guidelines 2.1 Core Philosophy, page 13
Direct Service Guidelines 2.3 Culturally Competent Care, page 20
Direct Service Guidelines 3.3 Natural Supports, page 35
Direct Service Guidelines 5.1 Child and Family Teams Overview, page 42
Direct Service Guidelines 5.2 CFT Facilitation, page 44
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
WRAP Guidelines 5.4 CANS, page 21
WRAP Guidelines 5.5 Strengths, Needs & Cultural Discovery, page 23
Strengths, Needs, and Cultural Discovery
Plan of Care
(b) WRAP and FSP – Staff receive ongoing training and coaching to support the identification, engagement, and integration of natural supports within the HFW process and to decrease reliance on formal supports. The Wraparound Fidelity Coach and staff supervisors provide regular observations and review documentation to strengthen staff skills in identifying functional strengths and building solution-focused plans that actively incorporate natural and community supports.
Staff Development Guide 1.2 Agency Training Requirements – Module A (Clinical Direct Services), page 1
Staff Development Guide 3.2 Field Observation, page 6
Staff Development Guide 7.5 High Fidelity Wraparound Training, page 8
Direct Service Guidelines 12.7 WrapStat TOM 2.0 Team Observation Measure, page 73
(c) WRAP and FSP – HFW Plans of Care are routinely reviewed through monthly and quarterly audits to ensure the inclusion of natural supports within the plan. These reviews also assess whether community and informal supports are actively used in assigning strategies and action items. Findings are used to support fidelity through feedback, supervision, and coaching as needed.
Direct Service Guidelines 12.1 Data Management, page 62
Direct Service Guidelines 12.5 Tools to Support Documentation Compliance, page 67
(d) WRAP and FSP – Feedback is gathered from youth and families through eliciting input during sessions and CFT meetings, TOM 2.0 observations, Wraparound Fidelity Index surveys, and FCNI Customer Satisfaction Surveys. The Wraparound Fidelity Coach and supervisors review this feedback and provide individualized and team-level coaching to support ongoing staff development, program performance, and continuous quality improvement.
Direct Service Guidelines 12.3 Customer Satisfaction Survey, page 65
Direct Service Guidelines 12.6 WrapStat Wraparound Fidelity Index (WFI-EZ), page 71
Direct Service Guidelines 12.7 WrapStat TOM 2.0 Team Observation Measure, page 73
1.7 Culturally Respectful and Relevant
(a) WRAP and FSP – Teams use the Strengths, Needs, and Cultural Discovery (SNCD) along with the CANS assessment to guide High-Fidelity Wraparound services in a strengths-based, culturally responsive, and individualized manner. These assessments are completed within the first 30 days of enrollment and are maintained in the record.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
WRAP Guidelines 5.4 CANS, page 21
WRAP Guidelines 5.5 Strengths, Needs & Cultural Discovery, page 23
Strengths, Needs, and Cultural Discovery
Plan of Care
(b) WRAP and FSP – Staff receive ongoing coaching and training to support the elicitation and use of family voice, culture, and values in planning and service delivery, and to ensure strategies are culturally respectful and relevant. The Wraparound Fidelity Coach and staff supervisors provide regular observations and review documentation to strengthen staff skills in identifying functional strengths and integrating culturally responsive, family-driven approaches into the HFW process.
Staff Development Guide 1.2 Agency Training Requirements – Module A (Clinical Direct Services), page 1
Staff Development Guide 3.2 Field Observation, page 6
Staff Development Guide 7.5 High Fidelity Wraparound Training, page 8
Direct Service Guidelines 12.7 WrapStat TOM 2.0 Team Observation Measure, page 73
(c) WRAP and FSP – Feedback from families regarding their experience of culturally relevant and respectful services and strategies is routinely elicited through multiple methods, including Wraparound Fidelity Index (WFI) surveys, TOM 2.0 observations, FCNI Customer Satisfaction Surveys, and input gathered during sessions and CFT meetings. This feedback is used for continuous quality improvement, including providing feedback to staff and their supervisors for training, coaching, and ongoing staff development.
Direct Service Guidelines 12.3 Customer Satisfaction Survey, page 65
Direct Service Guidelines 12.6 WrapStat Wraparound Fidelity Index (WFI-EZ), page 71
Direct Service Guidelines 12.7 WrapStat TOM 2.0 Team Observation Measure, page 73
1.8 High-Quality Team Planning and Problem Solving
(a) WRAP and FSP – Team members collaborate in a safe, respectful, strength-based environment by developing Team Agreements within 30 days of intake and at the initial CFT meeting. They are documented in the Plan of Care.
Direct Service Guidelines 5.2 CFT Facilitation, page 44
Direct Service Guidelines 5.3 Team Agreements, page 45
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Plan of Care
Family Vision Worksheet
(b) WRAP and FSP – Feedback is gathered from youth, families, and team members through eliciting input during sessions and CFT meetings, TOM 2.0 observations, Wraparound Fidelity Index surveys, and FCNI Customer Satisfaction Surveys. The Wraparound Fidelity Coach and supervisors review this feedback and provide individualized and team-level coaching to support ongoing staff development, program performance, and continuous quality improvement.
Direct Service Guidelines 12.3 Customer Satisfaction Survey, page 65
Direct Service Guidelines 12.6 WrapStat Wraparound Fidelity Index (WFI-EZ), page 71
Direct Service Guidelines 12.7 WrapStat TOM 2.0 Team Observation Measure, page 73
(c) WRAP and FSP – Teams receive feedback from the HFW Coach and supervisors based on data gathered through team input, observations, and coaching sessions. This feedback is used to support continuous quality improvement by informing staff development, training, and individualized coaching. The HFW Coach also attends internal team meetings to provide targeted coaching and reinforce best practices.
Direct Service Guidelines 3.4 Internal Team Meetings, page 35
Direct service Guidelines 12.1 Data Management, page 62
Direct Service Guidelines 12.5 Tools to Support Documentation Compliance, page 67
(d) WRAP and FSP – The Plan of Care document and meeting minutes are routinely reviewed through monthly and quarterly audits to assess shared ownership of the plan. These reviews also evaluate follow-through on assigned strategies and action items to ensure accountability across the Child and Family Team. Findings are used to support ongoing fidelity through feedback, supervision, and coaching as needed.
Direct service Guidelines 12.1 Data Management, page 62
Direct Service Guidelines 12.5 Tools to Support Documentation Compliance, page 67
1.9 Outcomes Based Process
(a) WRAP and FSP – The Plan of Care includes specific, measurable strategies and action items with defined timeframes, as it is reviewed every 30–45 days in Child and Family Team (CFT) meetings and formally updated at least every 90 days. This structured review process ensures that goals, tasks, and responsibilities are clearly assigned, monitored, and adjusted as needed to support accountability and progress.
Direct Service Guidelines 2.1 Core Philosophy, page 13
Direct Service Guidelines 5.1 Child and Family Teams Overview, page 42
Direct Service Guidelines 5.2 CFT Facilitation, page 44
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Plan of Care
(b) WRAP and FSP – Action item completion is tracked by facilitators and regularly updated through ongoing review of the Plan of Care during Child and Family Team (CFT) meetings. This structured process ensures that goals, tasks, and responsibilities are continuously monitored, with progress updates and adjustments made to support accountability and timely follow-through.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Plan of Care
(c) WRAP and FSP – The Plan of Care is a dynamic document that is routinely reviewed and updated through the Child and Family Team (CFT) process. These updates reflect changes in goals, tasks, and interventions based on the team’s ongoing assessment of needs. Revised Plans of Care are then distributed to all team members, ensuring clear communication and shared understanding of any changes.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Plan of Care
(d) WRAP – The WRAP Facilitator, who must be CANS-certified, is responsible for completing the CANS assessment with input from the Child and Family Team (CFT), and it is reviewed and approved by a supervisor. The results are then shared and discussed with all team members during the CFT process and incorporated into Plan of Care, ensuring all members have a common understanding of the youth’s strengths, needs, and priorities.
WRAP Guidelines 5.4 CANS, page 21
FSP – The FSP Therapist, who must be CANS-certified, is responsible for completing the CANS assessment with input from the Child and Family Team (CFT), and it is reviewed and approved by a supervisor. The results are then shared and discussed with all team members during the CFT process and incorporated into Plan of Care, ensuring all members have a common understanding of the youth’s strengths, needs, and priorities.
FSP Guidelines 8.3 CANS, page 14
(e) WRAP and FSP – The IP-CANS is used to support tracking and team decision-making by identifying actionable needs and strengths that guide care and treatment planning. This information is incorporated into the Child and Family Team (CFT) process and documented in the Plan of Care, where specific goals, strategies, and action items are developed and monitored. While the IP-CANS informs planning, the team also relies on ongoing tracking of needs, goal progress, and action item completion within the Plan of Care to guide decision-making and transition planning.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
WRAP Guidelines 5.4 CANS, page 21
Plan of Care
1.10 Persistence
(a) WRAP and FSP – Teams are supported to maintain engagement with youth and families even when facing setbacks or limited progress, prioritizing continuity of care and avoiding sudden disruption of services. When challenges arise, teams utilize coaching support and internal team meetings to review barriers, adjust strategies, and ensure family voice and choice remain central in decision-making about ongoing services and transition planning.
WRAP Guidelines 6.3 Discharge & Transition Planning, page 27
FSP Guidelines 9.2 Discharge Planning, page 17
Direct Service Guidelines 2.1 Core Philosophy, page 13
Direct Service Guidelines 3.4 Internal Team Meetings, page 35
Direct Service Guidelines 4.3 Client Scheduling, Timely Engagement, and Service Delivery, page 39
(b) WRAP and FSP – Teams participate in regularly scheduled internal team meetings that provide a structured space for support, problem-solving, and resource coordination. During these meetings, staff can identify barriers, request additional support or supervision, access flexible funding, and collaborate on strategies to adjust plans and improve outcomes. High Fidelity Coach and supervisors are available to provide targeted coaching, guidance, and support, including attending team meetings when enhanced training or assistance is needed.
Direct Service Guidelines 3.4 Internal Team Meetings, page 35
(c) WRAP and FSP – Training and coaching is provided to facilitators in post-crisis safety planning, conflict resolution, and effective team leadership to support the CFT process, including effective brainstorming and ongoing, creative, and individualized plan revision.
Staff Development Guide 1.2 Agency Training Requirements – Module A (Clinical Direct Services), page 1
Staff Development Guide 3.2 Field Observation, page 6
Staff Development Guide 7.5 High Fidelity Wraparound Training, page 8
1.11 Transitions as a part of the Fourth Phase of HFW
(a) WRAP and FSP – Teams ensure smooth and adequate transitions, even during adverse events or administrative changes, by prioritizing continuity of care and avoiding any sudden loss of services. They actively coordinate with all parties and provide necessary supports, resources, and hand-offs to maintain ongoing services for families.
WRAP Guidelines 6.3 Discharge & Transition Planning, page 27
FSP Guidelines 9.2 Discharge Planning, page 17
(b) WRAP and FSP – Transitions out of HFW are intentionally celebrated as meaningful milestones, honoring each youth and family’s culture, values, and preferences while reinforcing their progress and achievements. Administrative structures, including access to celebration funds, flexible staff time, and encouragement of community connections, empower teams to actively recognize successes.
Direct Service Guidelines 7.6 Client Celebrations, page 53
Expected Outcomes
2.1 Youth and Family Satisfaction
WRAP and FSP – The WFI-EZ is utilized to collect and evaluate youth and family satisfaction with HFW at set intervals, including enrollment, ongoing service, and discharge. Responses are reviewed in aggregate to support fidelity monitoring and continuous quality improvement. Data is used to inform practice and ensure youth, family, and Tribal voice is reflected in service delivery.
Direct Services Guidelines 12.6 WrapStat Wraparound Fidelity Index (WFI-EZ), page 71
Direct Service Guidelines 12.1 Data Management, page 62
2.2 Improved School Functioning
WRAP and FSP – The WFI-EZ is utilized to gather youth and family feedback at enrollment, during services, and at discharge. This data informs service delivery and ensures supports are aligned with youth voice. Youth are able to report their experiences of improved educational engagement, attendance, and vocational functioning as a result of their involvement in HFW.
Direct Services Guidelines 12.6 WrapStat Wraparound Fidelity Index (WFI-EZ), page 71
Direct Service Guidelines 12.1 Data Management, page 62
2.3 Improved Functioning in the Community
WRAP and FSP – The WFI-EZ is utilized to gather youth and family feedback at enrollment, during services, and at discharge. This data informs service delivery and helps ensure supports are aligned with youth voice and contribute to reduced justice involvement and increased engagement in community activities.
Direct Services Guidelines 12.6 WrapStat Wraparound Fidelity Index (WFI-EZ), page 71
Direct Service Guidelines 12.1 Data Management, page 62
2.4 Improved Interpersonal Functioning
WRAP and FSP – The WFI-EZ is utilized to gather youth and family feedback at enrollment, during services, and at discharge, with responses reviewed in aggregate to support fidelity monitoring and continuous quality improvement. This data informs service delivery and helps ensure supports are aligned with youth and family voice, contributing to improved interpersonal functioning, reduced stress in the home, and strengthened family and peer relationships.
Direct Services Guidelines 12.6 WrapStat Wraparound Fidelity Index (WFI-EZ), page 71
Direct Service Guidelines 12.1 Data Management, page 62
2.5 Increased Caregiver Confidence
WRAP and FSP – The WFI-EZ is utilized to gather caregiver feedback at enrollment, during services, and at discharge, with responses reviewed in aggregate to support fidelity monitoring and continuous quality improvement. This data informs service delivery and helps ensure supports are aligned with the caregiver’s voice, contributing to increased caregiver confidence, improved access to services, and the ability to effectively manage future challenges and crises.
Direct Services Guidelines 12.6 WrapStat Wraparound Fidelity Index (WFI-EZ), page 71
Direct Service Guidelines 12.1 Data Management, page 62
2.6 Stable and Least Restrictive Living Environment
WRAP and FSP – Utilizing the WFI-EZ, caregivers report on whether youth have maintained consistent placements, required transitions to institutional settings (such as detention, psychiatric hospitalization, treatment centers, or STRTPs), and/or experienced moves between residential placements.
Direct Services Guidelines 12.6 WrapStat Wraparound Fidelity Index (WFI-EZ), page 71
Direct Service Guidelines 12.1 Data Management, page 62
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
WRAP and FSP – Utilizing the WFI-EZ, caregivers report on youth behavioral health stability, including whether youth have required hospital visits or experienced a reduction in the need for hospitalization.
Direct Services Guidelines 12.6 WrapStat Wraparound Fidelity Index (WFI-EZ), page 71
Direct Service Guidelines 12.1 Data Management, page 62
2.8 Reduction in Crisis Visits
WRAP and FSP – The WFI-EZ captures data on whether or not youth and natural supports are able to prevent and manage most crises, including averting or responding to impending crises without professional support.
Direct Services Guidelines 12.6 WrapStat Wraparound Fidelity Index (WFI-EZ), page 71
Direct Service Guidelines 12.1 Data Management, page 62
2.9 Positive Exit from HFW
WRAP and FSP – Youth and families exit HFW based on stabilization, goal achievement, or measurable progress as determined by the Child and Family Team, and not due to adverse events alone. All discharge reasons are documented in the EHR, WrapStat and monitored through CQI and fidelity review processes.
WRAP Guidelines 6.3 Discharge & Transition Planning, page 27
FSP Guidelines 9.2 Discharge Planning, page 17
Direct Service Guidelines 12.1 Data Management, page 62
Behavioral Health Guidelines 6.2 Movement Slip, page 1
Engagement
3.1 Orientation
(a) WRAP – During the initial Wraparound Intake meeting with the family, the Wraparound social worker along with other Wraparound team members provide an overview of Wraparound services, including describing the roles of each team member, the principles and phases of Wraparound, and legal and ethical considerations. The Wraparound Process User’s Guide, A Handbook for Families also is provided to the family at the intake meeting, as a supportive tool to inform them of the topics above.
WRAP Guidelines 3.6 Orientation/Intake Meeting Purpose, page 4
Wraparound Intake Checklist
Wraparound Process User’s Guide
FSP – During the initial FSP Engagement meeting with the family, the social worker along with other Wraparound team members provide an overview of FSP services, including describing the roles of each team member, the principles and phases of Wraparound, and legal and ethical considerations. A copy of the Family Guide to FSP handbook is also provided to the family at the engagement meeting, as a supportive tool to inform them of the topics above.
FSP Guidelines 2.2 Initial Client Engagement & Orientation, page 4
FSP Orientation Checklist
Family Guide to FSP, pages 2-3, 5-7 and 12-13
(a) WRAP – During the initial Wraparound Intake meeting with the family, the social worker and other Wraparound team members provide an overview of Wraparound services, including an overview of the principles and phases.
Wraparound Process User’s Guide
Wraparound Intake Checklist
FSP – During the initial FSP Engagement meeting with the family, the social worker along with other Wraparound team members provide an overview of FSP services, including an overview of the Wraparound principles and phases.
Family Guide to FSP, pages 2-3 and 5-7
FSP Orientation Checklist
(b) WRAP – During the initial Wraparound Intake meeting with the family, the social worker and other Wraparound team members provide an overview of Wraparound services, including legal and ethical considerations.
Wraparound Process User’s Guide
Wraparound Intake Checklist
FSP – During the initial FSP Engagement meeting with the family, the social worker along with other Wraparound team members provide an overview of FSP services, including legal and ethical considerations.
Family Guide to FSP, pages 2-3
FSP Orientation Checklist
(c) WRAP – During the initial Wraparound Intake meeting with the family, the social worker and other Wraparound team members provide an overview of Wraparound services, including the role of each team member including the family and natural supports and Tribes in the case of an Indian child.
Wraparound Process User’s Guide
Wraparound Intake Checklist
FSP – During the initial FSP Engagement meeting with the family, the social worker along with other Wraparound team members provide an overview of FSP services, including the role of each team member including the family and natural supports and Tribes in the case of an Indian child.
Family Guide to FSP, page 7
FSP Orientation Checklist
3.2 Safety and Crisis stabilization
(a) WRAP – During the initial Wraparound Intake meeting with the family, the team discusses initial crisis and safety concerns and develops a Safety Plan with the family. A copy of the Safety Plan is provided to the family, and it is also documented in the client’s chart.
WRAP Guidelines 3.6 Orientation/Intake Meeting Purpose, page 4
WRAP Guidelines 5.2 Safety Plan, page 13
FSP – During the FSP Intake meeting with the family, the team discusses initial crisis and safety concerns and develops a Safety Plan/My Plan with the family. A copy of the Safety Plan/My Plan is provided to the family, and it is also included in the client’s chart.
FSP Guidelines 8.1 Safety Planning, page 10
My Plan
(b) WRAP and FSP – The team utilizes the initial Safety Plan/My Plan to help inform, but not replace, any future Safety Plan/My Plan developed with the client/family.
WRAP Guidelines 5.2 Safety Plan, page 13
FSP Guidelines 8.1 Safety Planning, page 10
(c) WRAP and FSP – At the initial intake meeting, all families are provided with information on how to access on-call/after-hours crisis response services (24/7) when needed. All families are also provided with an On-Call Services Flyer at the initial intake meeting, which includes information on how to access on-call/after-hours crisis response services (24/7) when needed.
Direct Service Guidelines 8.2 On-Call Services, page 57
FCNI On-Call Card
3.3 Strengths, Needs, Culture and Vision Discovery
(a) WRAP and FSP – Within thirty (30) calendar days of enrollment, a Family Vision statement is completed with every family. The Family Vision statement is document in the Plan of Care, which is included in the client’s chart and provided to the family and team members. The team utilizes the Family Vision Worksheet to help the family in developing their Family Vision statement.
Direct Services Guidelines 5.4 Family/Youth Vision Statement, page 47
Plan of Care
Family Vision Worksheet
(b) WRAP and FSP – Within thirty (30) calendar days of enrollment, a Strengths, Needs, and Cultural Discovery document is completed with the family and is included in the client’s chart. Updates are included in the Plan of Care at least every ninety (90) days and the Plan of Care is provided to the team, including new team members, as well as included in the client’s chart. The team utilizes the Functional Strengths Flyer to support the family/team in identifying the youth, caregiver, and team members’ strengths.
WRAP Guidelines 5.5 Strengths, Needs, and Cultural Discovery (SNCD), page 23
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Strengths, Needs, and Cultural Discovery
Plan of Care
Functional Strengths Flyer
3.4 Engage All Team Members
(a) WRAP and FSP – Natural supports are active members of the Child and Family Team (CFT). In collaboration with the CFT, a natural supports inventory is completed with all families and is included in the Plan of Care, which is provided to the family and included in the client’s chart.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Plan of Care
(b) WRAP and FSP – Children’s System of Care partners that are relevant to the family are identified and engaged in the CFT and Wraparound process.
Direct Service Guidelines 1.5 System of Care Participation & Interagency Collaboration, page 11
Direct Service Guidelines 2.1 Core Philosophy & Evidenced Based Practices, page 13
Direct Service Guidelines 3.2 Formal Supports, page 33
(c) WRAP and FSP – Natural supports, formal supports, and Tribes in the case of an Indian child are active members of the Child and Family Team (CFT). The role of each team member is developed on an individual basis and in collaboration with the team.
Direct Service Guidelines 3.2 Formal Supports, page 33
Direct Service Guidelines 3.3 Natural Supports, page 35
Direct Service Guidelines 51. CFT Overview, page 42
Direct Service Guidelines 5.2 CFT Facilitation, page 44
(d) WRAP and FSP – Any CFT engagement or team-building activities conducted during team meetings are documented in the client’s chart within individual case notes.
Direct Service Guidelines 5.2 CFT Facilitation, page 44
3.5 Arrange Meeting Logistics
(a) WRAP and FSP – Staff providing services to families have flexible working hours and also use strategies to offer flexible meeting times and locations to best accommodate the needs of the family and team.
Direct Service Guidelines 4.3 Client Scheduling, Timely Engagement, & Service Delivery, page 39
(b) WRAP and FSP – initially upon hire and annually, staff receive training on how to work collaboratively with families and other team members, in order to schedule meetings that are aligned with family needs and preferences and also maximize their participation.
Staff Development Guidelines 1.2 Agency Training Requirements – Module A (Clinical Direct Services), page 1
Staff Development Guidelines 7.5 High Fidelity Wraparound Training, page 8
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
(a) WRAP and FSP – Team agreements, a team strengths inventory, and a team mission statement are developed at the initial CFT meeting, no later than thirty (30) days after intake, prior to the completion of the Plan of Care. All elements are then included on the Plan of Care, which is then provided to the team and included in the client’s chart.
WRAP Guidelines 5.5 Strengths, Needs, and Cultural Discovery (SNCD), page 23
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Direct Service Guidelines 5.3 Team Agreements, page 45
Direct Service Guidelines 5.5 Team Mission Statement, page 49
Strengths, Needs, and Cultural Discovery
Plan of Care
Functional Strengths Flyer
(b) WRAP and FSP – The strengths of the youth and family that are identified during engagement as well as throughout their time in services, are included within the Strengths, Needs, and Cultural Discovery document, as well as ongoing within the Plan of Care. Both of these documents are included in the client’s chart. The team utilizes the Functional Strengths Flyer to support the client and family in identifying their strengths.
WRAP Guidelines 5.5 Strengths, Needs, and Cultural Discovery (SNCD), page 23
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Strengths, Needs, and Cultural Discovery
Plan of Care
Functional Strengths Flyer
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
(a) WRAP and FSP – Within the first thirty (30) days of starting services, the team utilizes the Strengths, Needs, and Cultural Discovery document and the CANS to identify and prioritize the underlying needs of the family. Both the Strengths, Needs, and Cultural Discovery document and the CANS are included in the client’s chart.
WRAP Guidelines 5.5 Strengths, Needs, and Cultural Discovery (SNCD), page 23
WRAP Guidelines 5.4 CANS, page 21
Strengths, Needs, and Cultural Discovery
(b) WRAP and FSP – Based on the identified needs, measurable goals and outcomes are identified and documented on the Plan of Care.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Plan of Care
(c) WRAP and FSP – The goals and outcomes are developed collaboratively with the client, family, and additional team members within the Child and Family Team meeting.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Plan of Care
(d) WRAP and FSP – The team utilizes multiple strategies and tools to help identify the strengths, needs, and goals. The strategies used are documented in progress notes and the Plan of Care.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Direct Service Guidelines 5.2 CFT Facilitation, page 44
Plan of Care
Functional Strengths Flyer
CANS Quick Guide
(e) WRAP and FSP – Facilitators receive initial and ongoing training in how to lead teams in identifying, prioritizing, and selecting strategies and developing action items.
Staff Development Guidelines 1.2 Agency Training Requirements – Module A (Clinical Direct Services), page 1
Staff Development Guidelines 7.5 High Fidelity Wraparound Training, page 8
(f) Facilitators and team members utilize training experiences and tools provided to develop the Plan of Care collaboratively with the child and family team.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Direct Service Guidelines 5.2 CFT Facilitation, page 44
Direct Service Guidelines 2.1 Core Philosophy & Evidenced Based Practices, page 13
Direct Service Guidelines 5.1 Child and Family Teams Overview, page 42
Plan of Care
4.3 Develop an Individualized Child or Youth and Family Plan
(a) WRAP and FSP – Role specific training is provided to facilitators initially and annually on the topics of engaging the team in the planning process with adherence to the HFW principles. Facilitators also receive ongoing coaching to support their development in these areas.
Staff Development Guidelines 1.2 Agency Training Requirements – Module A (Clinical Direct Services), page 1
Staff Development Guidelines 7.5 High Fidelity Wraparound Training, page 8
(b) WRAP and FSP – The Plan of Care is completed with the child and family team, which includes all children’s system of care partners, and integrates goals and objectives identified by all team members.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Direct Service Guidelines 5.1 Child and Family Teams Overview, page 42
Plan of Care
(c) WRAP and FSP – The Plan of Care is documented in the client’s chart and a copy is provided to all team members upon completion and whenever updated (at least every 90 days). It is also inclusive of the defined criteria listed.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Plan of Care
(d) WRAP and FSP – HFW Plans of Care are routinely reviewed through monthly chart audits and quarterly compliance monitoring to ensure they reflect individualized strengths, needs, outcomes, and strategies. These reviews also assess whether plans effectively incorporate and leverage the assets of the family’s community and informal support networks, including natural supports. Findings are used to support ongoing fidelity through documentation feedback, supervision, and coaching as needed.
Direct Service Guidelines 12.1 Data Management, page 62
Direct Service Guidelines 12.5 Tools to Support Documentation Compliance, page 67
4.4 Develop a Crisis and Safety Plan
(a) WRAP – Each client’s file includes an individualized crisis and safety plan that is developed with the client and family. The Crisis and Safety Plan identifies potential crisis situations and proactive and reactive strategies. The Crisis and Safety Plan includes information on who the client and family should call for 24/7 support.
WRAP Guidelines 5.2 Safety Plan, page 13
WRAP Guidelines 5.2.1 Risk Factors to Consider, page 17
FSP – Each client’s file includes an individualized crisis and safety plan that is developed with the client and family. The crisis and safety plan is called a “My Plan”. The My Plan identifies potential crisis situations and proactive and reactive strategies. The My Plan document also includes information on who the client and family should call for 24/7 support.
FSP Guidelines 8.1 Safety Planning, page 10
FSP Guidelines 8.1.1 Risk Factors to Consider, page 13
My Plan
(b) WRAP and FSP – The team develops the Safety Plan in collaboration with the client and family. Facilitators also receive ongoing training and coaching to support their understanding and skills around this process.
WRAP Guidelines 5.2 Safety Plan, page 13
FSP Guidelines 8.1 Safety Planning, page 10
Staff Development Guidelines 1.2 Agency Training Requirements – Module A (Clinical Direct Services), page 1
Staff Development Guidelines 7.5 High Fidelity Wraparound Training, page 8
(c) WRAP and FSP – Safety Plans are reviewed through quarterly compliance monitoring to ensure they include individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports. Findings are used to support ongoing fidelity through documentation feedback, supervision, and coaching as needed.
Direct Service Guidelines 12.1 Data Management, page 62
Direct Service Guidelines 12.5 Tools to Support Documentation Compliance, page 67
Implementation
5.1 Implement The Plan of Care
(a) WRAP and FSP – Facilitator supports team functioning by using the Plan of Care as the primary guiding document. Developed through the CFT process, the Plan of Care identifies goals, tasks, and responsible team members, and is used to track progress and coordinate action items. The facilitator convenes and guides CFT meetings to review progress, monitor assigned tasks, and ensure accountability for completion of strategies. Meeting discussions are documented through agendas and meeting notes, and the Plan of Care is reviewed at least every 30–45 days and updated as needed to reflect progress and adjust strategies to meet the youth and family’s evolving needs.
Direct Service Guidelines 5.2 CFT Facilitation, page 44
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Plan of Care
(b) WRAP and FSP – Staff receive training and ongoing coaching to implement the Plan of Care in alignment with High Fidelity Wraparound (HFW) principles. Training and practice processes emphasize strengths-based planning and include intentionally recognizing and celebrating successes as they occur throughout service delivery.
Direct Service Guidelines 3.1 Team Members, page 29
Direct Service Guidelines 12.7 WrapStat TOM 2.0 Team Observation Measure, page 73
Staff Development Guidelines 1.2 Agency Training Requirements – Module A (Clinical Direct Services), page 1
Staff Development Guidelines 7.5 High Fidelity Wraparound Training, page 8
5.2 Review and Update The Plan of Care
(a) WRAP and FSP – Teams reviews of strategies, progress, and action items occur during High CFT meetings, using the Plan of Care as the guiding document. The facilitator leads the team in reviewing assigned tasks, monitoring progress toward goals, and updating strategies and action items as needed to reflect the youth and family’s current needs and priorities.
Direct Service Guidelines 5.2 CFT Facilitation, page 44
(b) WRAP and FSP – The facilitator leads the CFT in adjusting the Plan of Care as successes are achieved, new needs are identified, or new strategies and action items are selected. Updates are made collaboratively with the team and documented in the youth’s record to ensure the plan remains current and responsive to the youth and family’s needs.
Direct Service Guidelines 5.2 CFT Facilitation, page 44
(c) WRAP and FSP – The facilitator documents and communicates completion of tasks, new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the Plan of Care. These updates are shared with all CFT members both in the CFT and also by receiving copies of the agreed upon plan.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Plan of Care
(d) WRAP and FSP – Forms are flexible and can be updated and individualized to reflect the changing needs of the youth, family, and Child and Family Team, ensuring the Plan of Care remains responsive and relevant over time. The Plan of Care document includes open text boxes throughout the document, to allow for individualization based on the client and family.
Direct Service Guidelines 12.7 WrapStat TOM 2.0 Team Observation Measure, page 73
Plan of Care
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
(a) WRAP and FSP – Team Agreements are developed collaboratively with the CFT within 30 days of intake and are included in the Plan of Care. They are utilized to guide values, communication, decision-making, and collaboration. Team Agreements are reviewed at the start of each CFT meeting and updated as needed to reflect changes in team membership, family/youth needs, or identified issues, ensuring ongoing alignment and effective team functioning.
Direct Service Guidelines 5.2 CFT Facilitation, page 44
Direct Service Guidelines 5.3 Team Agreements, page 45
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Plan of Care
(b) WRAP and FSP – Facilitators receive ongoing training and coaching focused on building, engaging, and maintaining effective CFTs. This includes strengthening facilitation skills, supporting effective team collaboration, and promoting consistent use of HFW principles throughout the planning process.
Staff Development Guide 1.2 Agency Training Requirements – Module A (Clinical Direct Services), page 1
Staff Development Guide 7.5 High Fidelity Wraparound Training, page 8
(c) WRAP and FSP – Use of natural supports is actively monitored over time through quarterly auditing of documents such as the Strengths, Needs, and Cultural Discovery document and the Plan of Care document. The Team Observation Measure (TOM) and fidelity coaching is also utilized. The HFW Coach and supervisors provide ongoing feedback and coaching to ensure natural supports are appropriately identified, engaged, and maintained within the CFT process.
Direct Service Guidelines 12.1 Data Management, page 62
Direct Service Guidelines 12.5 Tools to Support Documentation Compliance, page 67
Direct Service Guidelines 12.7 WrapStat TOM 2.0 Team Observation Measure, page 73
(d) WRAP and FSP – New CFT members, including formal and natural supports, are oriented by the FCNI facilitator prior to or during team meetings. Orientation includes an overview of the HFW process, review of the current Plan of Care, Team Mission, and team agreements, and clarification of each member’s role. The facilitator also incorporates engagement and team-building activities to support collaboration and documents all orientation activities in the case record.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Direct Service Guidelines 3.1 Team Members, page 29
Direct Service Guidelines 5.2 CFT Facilitation, page 44
Direct Service Guidelines 5.3 Team Agreements, page 45
Plan of Care
Transition
6.1 Develop a Transition Plan
(a) WRAP and FSP – During Child and Family Team (CFT) meetings. Through ongoing assessment and collaboration, the team evaluates strengths, progress, and stability, ensuring supports are adjusted as needed to meet evolving needs. When benchmarks are achieved and the team is in agreement, the facilitator supports the development of a formal, individualized transition plan to guide successful closure and continued stability.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
WRAP Guidelines 6.1 Case Reviews, page 25
WRAP Guidelines 6.3 Discharge and Transition Planning, page 27
FSP Guidelines 9.1 Internal Case Review, page 16
FSP Guidelines 9.2 Discharge Planning, page 17
Plan of Care
(b) WRAP and FSP – Once readiness for transition is determined, the plan is documented directly in the youth and family’s Plan of Care, ensuring it reflects supports that will continue beyond services. The finalized plan is shared with all team members to promote continuity of care and a coordinated transition process.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Plan of Care
(c) WRAP and FSP – During the CFT process, the youth, family, and all relevant supports actively participate in planning for transition. Facilitators guide this process by incorporating ongoing progress monitoring, strengths, and identified needs to ensure the plan reflects a shared understanding of readiness and next steps. Facilitators also receive training and coaching to support effective, consistent transition planning that aligns with policy expectations.
Direct Service Guidelines 5.1 Overview, page 42
Direct Service Guidelines 5.2 CFT Facilitation, page 44
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
Plan of Care
(d) WRAP and FSP – The transition plan identifies transitional needs, services, and supports that will persist past the formal program process and includes identifying community, natural, and professional supports that remain in place after services end.
WRAP Guidelines 5.3 High Fidelity Wraparound CFT Plan of Care, page 18
WRAP Guidelines 6.3 Discharge and Transition Planning, page 27
FSP Guidelines 9.2 Discharge Planning, page 17
Plan of Care
6.2 Develop a Post-Transition Safety Plan
(a) WRAP and FSP – Post-Transition Safety Plan is completed within 30 days of discharge through a facilitated review of the existing Safety Plan. This updated plan identifies potential post-transition crisis situations and includes proactive and reactive crisis response strategies selected by the youth and family. It incorporates culturally relevant supports and maximizes the use of natural and community supports, including key community crisis contacts.
WRAP Guidelines 5.2 Safety Plan 13
FSP Guidelines 8.1 Safety Planning, page 10
(b) WRAP and FSP – The Post-Transition Safety Plan is developed within the CFT in a collaborative, team-based environment facilitated by the social worker. During the CFT, the team works together to identify potential post-transition crisis situations and develop proactive and reactive strategies that reflect youth and family voice and maximize natural and community supports.
Direct Service Guidelines 5.1 Overview, page 42
Direct Service Guidelines 5.2 CFT Facilitation, page 44
WRAP Guidelines 5.2 Safety Plan 13
FSP Guidelines 8.1 Safety Planning, page 10
Staff Development Guide 1.2 Agency Training Requirements – Module A (Clinical Direct Services), page 1
Staff Development Guide 7.5 High Fidelity Wraparound Training, page 8
(c) WRAP and FSP – Audits of crisis and safety ensure they reflect individualized, culturally relevant strategies, and utilize natural supports. Monthly chart audits support continuous quality improvement by identifying trends, informing staff coaching, and ensuring timely updates to safety plans.
Direct Service Guidelines 12.1 Data Management, page 62
Direct Service Guidelines 12.5 Tools to Support Documentation Compliance, page 67
6.3 Create a Commencement and Celebrate Success
(a) WRAP and FSP – Transitions out of the Wraparound process are celebrated in alignment with the family’s culture, values, and preferences. Celebrations are client- and family-driven and may include acknowledgements such as a congratulatory meeting with the team, personalized messages or cards, or small tokens of recognition, based on client preference and consent. All celebrations are conducted respectfully, with cultural sensitivity, and may involve selected team members as determined by the client/family. Successes and transition milestones are documented in the Plan of Care.
Direct Service Guidelines 7.6 Client Celebrations, page 53
(b) WRAP and FSP – Policies support engagement in celebration by allowing access to flex funds, supporting time exploring resources, promoting community partnerships, and ensuring staff availability to participate in client celebrations. These structures help ensure celebrations are feasible and individualized.
Direct Service Guidelines 7.6 Client Celebrations, page 53
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
(a) WRAP and FSP – Youth and family input is actively sought and incorporated into program decisions. Data from fidelity measures is also shared to support informed, collaborative decision-making.
Direct Service Guidelines 1.3 Continuous Quality Improvement, page 4
Direct Service Guidelines 3.1 Team Members, page 29
Direct Service Guidelines 12.1 Data Management, page 62
(b) WRAP and FSP – Youth and family participate in decisions regarding local HFW implementation as standing members of community leadership meetings. FCNI shares data collected from the Wraparound Fidelity Index (WFI) and Fidelity Coaches to inform collaborative decision-making.
Direct Service Guidelines 1.5 System of Care Participation & Interagency Collaboration, page 11
7.2 Community Leadership Team
(a) WRAP and FSP – In San Luis Obispo County, Executive Leadership participates in the System of Care Interagency Team, supporting shared decision-making, cross-system collaboration, and removal of barriers to effective service delivery in alignment with HFW standards. Senior Leadership, including the Wraparound Program Manager, attends the weekly Interagency Placement Committee (IPC) to support coordinated service planning and placement decisions for youth.
Direct Service Guidelines 1.5 System of Care Participation & Interagency Collaboration, page 11
7.3 Eligibility and Equal Access
(a) – WRAP and FSP – Youth who meet established eligibility criteria are not excluded from receiving services based on the severity or nature of their needs. Referrals are accepted without regard to complexity and ensures services are individualized to meet each youth and family’s unique strengths and needs. Service delivery is tailored to provide appropriate intensity and supports necessary to achieve meaningful outcomes.
WRAP Guidelines 2.0 Eligibility, page 1
FSP Guidelines 2.1 Requirements & Process, page 1
(b) WRAP and FSP – Staffing is structured to maintain caseloads that align with the intensity and frequency of services required to meet the complex needs of children, youth, and families. Staffing patterns are designed to support consistent engagement, coordinated service delivery, and responsiveness to changing needs. Services include the capacity to provide 24/7 in-person support for families experiencing crisis situations.
Direct Service Guidelines 3.1 Team Members, page 29
Direct Service Guidelines 8.2 On-Call Services, page 57
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
(a) WRAP – The contract explicitly requires individualized, team-based, and family-driven services, including Child and Family Team (CFT) facilitation, individualized care planning, crisis intervention, and flexible service delivery aligned with youth and family needs.
26-27 FCNI WRAP Contract, Scope of Services, Section 2, Scope of Services
FSP – The contract explicitly requires individualized, team-based, and family-driven services, including Child and Family Team (CFT) facilitation, individualized care planning, crisis intervention, and flexible service delivery aligned with youth and family needs.
26-27 FSP Contract, Scope of Services Exhibit A-1 Scope of Services
(b) WRAP – The contracts establishes a multidisciplinary, team-based staffing structure that promotes shared responsibility for service delivery, program quality, and outcomes, consistent with High Fidelity Wraparound principles. The contracts support a flexible and creative work environment by allowing staffing structures and roles to be adapted to meet the individualized needs of youth and families, while maintaining required service functions.
26-27 FCNI WRAP Contract, Scope of Services, Section 2, Scope of Services
FSP – The contracts establishes a multidisciplinary, team-based staffing structure that promotes shared responsibility for service delivery, program quality, and outcomes, consistent with High Fidelity Wraparound principles. The contracts support a flexible and creative work environment by allowing staffing structures and roles to be adapted to meet the individualized needs of youth and families, while maintaining required service functions.
26-27 FSP Contract, Scope of Services Exhibit A-1 Scope of Services
(c) WRAP – The contract requires comprehensive data collection, documentation, and reporting practices to support program evaluation, accountability, and continuous quality improvement. The contract specifies the use of evaluative tools, maintenance of case records, and regular reporting of performance outcomes, ensuring alignment with High Fidelity Wraparound expectations for data-driven practice and system oversight.
26-27 FCNI WRAP Contract, Scope of Services, Section 2, Scope of Services
FSP – The contract requires robust use of data collection and management systems, including documentation in the County’s Electronic Health Record (EHR), administration of standardized assessment tools, and ongoing reporting to support Medi-Cal claiming, outcome tracking, and program evaluation. These requirements ensure consistent data-driven service delivery and compliance with regulatory and quality improvement standards.
26-27 FSP Contract, Scope of Services Exhibit A-1 Scope of Services
8.2 Equitable Funding Across System Partners
N/A
8.3 Cost Savings are Reinvested
N/A
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
(a) WRAP and FSP – Flex funds are available and incorporated into the funding structure for HFW services. These funds are utilized to support individualized needs identified through the CFT process, ensuring timely and flexible responses that align with youth and family voice and service goals.
WRAP Guidelines 4.3 Flexible Funding, page 9
FSP Guidelines 4.1 Flexible Funding, page 7
(b) WRAP and FSP – Processes to access and manage flexible funds are clearly defined and include timely access to meet urgent family needs, including the ability to address requests outside of the CFT meeting when necessary. A structured approval process is in place that applies defined evaluation criteria to all requests. When a request is denied, the WRAP Social Worker communicates the decision and rationale to the youth, family, and team, and facilitates an opportunity for review, clarification, and potential resubmission through a collaborative team process.
WRAP Guidelines 4.3 Flexible Funding, page 9
FSP Guidelines 4.1 Flexible Funding, page 7
8.5 Collaborative Oversight of Flex Funds
(a) WRAP and FSP – Flex Fund use is documented through our monthly contract reconciliation process, which tracks costs, rate alignment, and any contributions to or draws from the Wrap Reserve and/or contract allocations. These movements are transparently tied to actual service utilization and placement levels.
WRAP Guidelines 4.3 Flexible Funding, page 9
FSP Guidelines 4.1 Flexible Funding, page 7
(b) WRAP – Flex funds are maintained in a pooled Wrap Reserve that is used to support the overall Wraparound program, not individual families or set allocations. The reserve helps balance monthly fluctuations in placement and service costs to ensure all families served can be supported. Use of these funds is driven by aggregate program need and cost reconciliation.
WRAP Guidelines 4.3 Flexible Funding, page 9
FSP – FSP funds remain within currently contracted and approved funding parameters and will continue under these guidelines until further direction or formal guidance is issued regarding the structure or use of flexible funding accounts.
FSP Guidelines 4.1 Flexible Funding, page 7
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
(a) WRAP and FSP – FCNI utilizes braided funding by coordinating multiple funding sources, including Wraparound and FSP contract revenue, Medi-Cal billing revenue, and available donated funds, to support a single integrated system of care for youth and families. Each funding source is tracked and accounted for separately but is strategically aligned at the program level to ensure continuous availability of flexible funding and services. This structure allows FCNI to maximize resource availability while maintaining compliance with the requirements of each funding source.
WRAP Guidelines 4.3 Flexible Funding, page 9
FSP Guidelines 4.1 Flexible Funding, page 7
(b) WRAP and FSP – FCNI staff explore alternate funding options, including other contracted flexible funding streams and available donated funds, to meet identified family needs. Use of multiple funding sources is coordinated through established Wraparound approval processes to ensure appropriate and consistent support.
WRAP Guidelines 4.3 Flexible Funding, page 9
FSP Guidelines 4.1 Flexible Funding, page 7
(c) WRAP and FSP – FCNI staff have access to flexible funding through contract revenue, as well as donated funds available to the organization, to support the individualized needs of families. Access to these funding sources is guided by established Wraparound policies and does not restrict families from receiving support when needs are identified and approved through the appropriate authorization process.
WRAP Guidelines 4.3 Flexible Funding, page 9
FSP Guidelines 4.1 Flexible Funding, page 7
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
(a) Family Care Network, Inc. actively recruits individuals from diverse cultural, linguistic, and socioeconomic backgrounds to support service delivery that is reflective of the communities served. Recruitment practices are designed to promote equity and inclusiveness while ensuring candidates meet role qualifications and organizational standards.
Employee Handbook 2.3 Equal Opportunity Policy, page 1-2
Staff Demographic Charts
(b) Family Care Network, Inc. is committed to ensuring meaningful language access for families whose primary language is not English by providing clear communication and culturally responsive services from the initial point of contact through ongoing service delivery. When staff fluent in a family’s preferred language are available, services are provided directly in that language
Employee Handbook 2.2 Commitment to Diversity, page 1
Direct Service Guidelines 2.3.1 Serving Clients in Their Preferred Language, page 23
(c) Family Care Network, Inc. utilizes professional interpretation and translation resources to support effective communication across all service components and documentation. These practices ensure that families who speak languages other than English receive equitable access to services that support understanding, engagement, and positive outcomes.
Direct Service Guidelines 2.3.1 Serving Clients in Their Preferred Language, page 4-6
9.2 Tribally Responsive Workforce
(a) WRAP and FSP – Staff receive training on tribal sovereignty, ICWA, and the influence of culture on care, with an emphasis on honoring traditions, values, and spiritual practices in service delivery. This includes understanding generational trauma, supporting self-determination, and collaborating with tribal governments and community partners to ensure culturally aligned and equitable services. Staff are also trained in respectful communication, advocacy, and engaging families as partners to strengthen trust and engagement.
Direct Service Guidelines 2.3 Culturally Competent Care, page 20
Direct Service Guidelines 2.3.3 Serving Native American Youth, page 29
Staff Development Guide1.2 Agency Training Requirements – Module A (Clinical Direct Services), page 1
Staff Development Guide 7.5 High Fidelity Wraparound Training, page 8
(b) WRAP and FSP – When serving an Indian child, HFW teams are trained to collaborate with tribal governments and representatives to ensure culturally aligned, respectful care in accordance with ICWA principles. Services are tailored to honor traditions, values, and spiritual practices, and teams actively encourage participation in tribal ceremonies and cultural supports as part of the individualized plan. Staff also recognize and incorporate the value of tribal resources and services to strengthen engagement and promote stability.
Direct Service Guidelines 2.3 Culturally Competent Care, page 20
Direct Service Guidelines 2.3.3 Serving Native American Youth, page 29
Staff Development Guide1.2 Agency Training Requirements – Module A (Clinical Direct Services), page 1
Staff Development Guide 7.5 High Fidelity Wraparound Training, page 8
9.3 Flexible and Creative Work Environment
(a) WRAP and FSP – FCNI demonstrates a high degree of collective responsibility for program quality and improvement through its Continuous Quality Improvement framework, which engages all levels of the organization from staff to the Board of Directors in ongoing evaluation, problem-solving, and data-driven decision-making.
Direct Service Guidelines 1.1 Administration and Management Roles, page 1
Direct Service Guidelines 1.3 Continuous Quality Improvement, page 4
Direct Service Guidelines 12.1 Data Management, page 62
Direct Service Guidelines 12.5 Tools to Support Documentation Compliance, page 67
(b) WRAP and FSP – Shared responsibility across all levels of staff and leadership, structured communication, and regular collaborative processes such as CQI meetings, supervision feedback loops. These systems promote teamwork, shared accountability, and open communication, which are core components of cohesion and contribute to a positive, connected team environment.
Direct Service Guidelines 1.1 Administration and Management Roles, page 1
Direct Service Guidelines 1.3 Continuous Quality Improvement, page 4
(c) WRAP and FSP – FCNI’s Continuous Quality Improvement structure promotes cohesion and open communication by ensuring regular feedback loops, shared accountability, and transparent review of outcomes aligned with both agency mission and HFW principles.
Direct Service Guidelines 1.3 Continuous Quality Improvement, page 4
Direct Service Guidelines 12.1 Data Management, page 62
(d) WRAP and FSP – FCNI embeds its core principles such as family voice and choice, team-based planning, cultural responsiveness, and strengths-based practice into all services and decision-making processes.
Direct Service Guidelines 2.1 Core Philosophy & Evidence Based Practices, page 13
9.4 Hiring, Performance Evaluation, and Job Descriptions
(a) Family Care Network, Inc. ensures that all required HFW roles and functions are fulfilled through clearly defined staffing structures. Roles are assigned either to distinct positions or, when appropriate, combined within a single position with clearly outlined responsibilities to maintain clarity and accountability. Job descriptions specify each role’s purpose and functions to ensure all program requirements are met consistently and effectively. All other Job descriptions follow the similar structure.
Job Description: Peer Specialist
Job Description: Wraparound Fidelity Coach
(b) Job descriptions at Family Care Network, Inc. are reviewed and updated on a regular basis to accurately reflect the skills, competencies, and qualifications required for each position. This ongoing review process ensures role expectations remain aligned with program standards, service delivery needs, and evolving best practices within the High‑Fidelity Wraparound model.
Job Description: Peer Specialist
Job Description: Wraparound Fidelity Coach
(c) Family Care Network, Inc. ensures that all job descriptions for required High‑Fidelity Wraparound (HFW) positions are specifically tailored to reflect the unique roles and expectations of the HFW model. Each job description clearly outlines the attitudes, skills, knowledge, and experience necessary for success, including collaboration, cultural responsiveness, family‑centered practice, and strength‑based engagement. These role‑specific descriptions help attract and select individuals whose competencies and values align with HFW principles and support effective, high‑quality service delivery.
Job Description: Peer Specialist
Job Description: Wraparound Fidelity Coach
(d) Family Care Network, Inc. incorporates structured and intentional hiring practices that give candidates meaningful opportunities to demonstrate the attitudes, skills, and competencies essential to each role. The hiring process includes standardized interview questions, scenario‑based discussions, and targeted evaluation criteria designed to assess problem‑solving ability, cultural responsiveness, communication skills, and alignment with Wraparound values. These methods support informed hiring decisions and ensure selected candidates are well‑suited to meet the responsibilities and expectations of their positions.
Standardized Interview Questions: Peer Specialist
Leadership Training – Interviewing Skills
(e) Employees participate in regular, documented performance evaluations that provide clear expectations, constructive feedback, and opportunities for growth. Evaluations focus on performance outcomes, core competencies, and alignment with organizational values. Reviews are conducted after the initial 90 days from the hire date, 90 days following a move into a new position, and annually thereafter
Employee Handbook: 8.1 Performance Management Policy: Pages 10-12
Employee Evaluation Form DS
Field Observation Form
9.5 Workforce Stability
(a) Family Care Network, Inc. conducts periodic pay scale reviews to ensure compensation practices remain competitive, equitable, and aligned with market conditions and the organization’s geographic service area. Compensation is reviewed in consideration of workforce trends, cost‑of‑living factors, and organizational capacity to support retention and fairness.
Employee Handbook: 4.13 Pay Policy: Pages 5-10
(b) Workload management is supported through ongoing monitoring of caseloads, staffing levels, and service demands. Leadership regularly (weekly and as needed) provides supportive supervision to further contribute to manageable workloads and employee success.
Direct Service Guidelines 4.1 Staff Supervision & Professionalism, pages 37-38
(c) Family Care Network, Inc. maintains clearly defined advancement opportunities that are communicated through organizational policies and compensation structures. Advancement pathways are designed to be equitable and accessible, supporting employee growth while aligning individual performance with organizational goals.
Employee Handbook 4.10 Job Assignments/Training & Development Policy, pages 2-5
Employee Handbook 4.13 Pay Policy, pages 5-10
(d) Supports workforce stability by offering professional development, training opportunities, and structured supervision that allow employees to grow in skills, leadership capacity, and compensation without necessarily requiring a change in job title or role. These opportunities contribute to employee engagement, job satisfaction, and long‑term retention.
Employee Handbook 4.10 Job Assignments/Training & Development Policy, pages 2-5
Employee Handbook 4.13 Pay Policy, pages 5-10
9.6 High Fidelity Training Plan
(a) WRAP and FSP – Staff complete the Wraparound 101: Foundations of Fidelity training within 90 days of new hire or position change to comply with California’s High Fidelity Wraparound model (CA-HFW). The training will be taken through UC Davis as a series of virtual webinars (Wraparound 101: Foundations of Fidelity) or through in-house training with certified CA-HFW trainers.
Staff Development Guide 1.2 Agency Training Requirements – Module A (Clinical Direct Services), page 1
Staff Development Guide 7.5 High Fidelity Wraparound Training, page 8
(b) WRAP and FSP – All staff receive ongoing training in both general Wraparound principles and their specific roles through a combination of formal trainings, meetings, coaching, peer shadowing, and supervision. This includes participation in Wraparound Apprenticeship, annual refreshers, monthly training sessions, and role-specific instruction such as CFT facilitation, peer support certification, and evidence-based practice training. Ongoing coaching and field observations further reinforce skills and support fidelity to HFW implementation.
Staff Development Guide 7.5 High Fidelity Wraparound Training, page 8
Staff Development Guide 3.1 Field Training, page 4
Staff Development Guide 3.2 Field Observation, page 6
(c) WRAP and FSP – Staff receive ongoing annual booster trainings in general Wraparound and role-specific topics as part of training and development framework. In addition to initial apprenticeship and ongoing monthly training, staff participate in annual refreshers, coaching, and fidelity-based learning to reinforce HFW principles and skills. This ensures continued competency in Wraparound practice, including role-specific responsibilities and evolving best practices.
Staff Development Guide 7.5 High Fidelity Wraparound Training, page 8
(d) WRAP and FSP – All staff receive annual refresher training in general Wraparound and role-specific topics. Clinical and HFW Supervisors/Managers also receive training specific to their supervisory role, along with ongoing coaching to support needs-based planning and effective service delivery.
Staff Development Guide 7.5 High Fidelity Wraparound Training, page 8
(e) WRAP and FSP – All staff complete ICWA training as part of FCNI’s Core Curriculum and additional Wraparound training, which includes education on tribal sovereignty, cultural competency, and culturally responsive service delivery. Ongoing annual training requirements and specialized modules (such as cultural competency, LGBTQ+ affirming services, and trauma-informed care) ensure staff are prepared to meet the needs of diverse populations. FCNI also provides additional targeted training and coaching as needed to support populations with unique or specific needs.
Staff Development Guide 7.5 High Fidelity Wraparound Training, page 8
9.7 Community-based Training Program
(a) WRAP and FSP – Youth, families, and peer partners with lived Wraparound experience are meaningfully incorporated into training through direct engagement with staff. Family and Peer Specialists meet with new team members to share their experiences and provide insight into their roles, and 1–2 times per year youth and families are invited to share their Wraparound journeys and offer feedback to support continuous improvement. Additionally, Fidelity Coaches gather feedback during CFT observations to further inform training and practice enhancements.
Staff Development Guide 1.2 Agency Training Requirements – Module A (Clinical Direct Services), page 1
Staff Development Guide 7.5 High Fidelity Wraparound Training, page 8
(b) WRAP and FSP – Community partners are regularly invited to participate in Wraparound trainings, including both foundational HFW trainings and ongoing booster sessions offered during internal team meetings. This approach strengthens partner understanding of Wraparound principles and enhances their ability to actively participate on HFW teams. By extending these training opportunities, FCNI supports stronger collaboration and alignment across the System of Care.
Staff Development Guide 1.2 Agency Training Requirements – Module A (Clinical Direct Services), page 1
Staff Development Guide 7.5 High Fidelity Wraparound Training, page 8
9.8 Coaching and Supervision
(a) All HFW staff complete a Wraparound Apprenticeship within six months of hire or position change, which includes formal training such as Wraparound 101, ICWA and Tribal sovereignty content, field observations, CFT participation, and ongoing supervision. The apprenticeship is reinforced through weekly supervision, coaching, peer shadowing, and quarterly fidelity observations to ensure understanding of HFW principles, phases, and activities. Staff also receive ongoing training in needs-based planning and the effective use of flexible funding to support individualized family needs.
Staff Development Guide 1.2 Agency Training Requirements – Module A (Clinical Direct Services), page 1
Staff Development Guide 7.5 High Fidelity Wraparound Training, page 8
(b) Staff have access to 24/7 support through FCNI’s on-call system, which provides immediate consultation and guidance outside of regular business hours. On-call social workers are available to support staff with crisis situations, safety planning, and clinical decision-making, with additional escalation to the Manager on Duty and executive leadership as needed. This structure ensures staff have continuous access to supervision and coaching to effectively respond to client needs at any time.
Direct Service Guidelines 8.2 On-Call Services, page 57
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
N/A
10.2 Evaluation Metrics & Outcomes
(a) FCNI utilizes a comprehensive performance management system, including data dashboards, CANS outcomes, WrapStat, and CQI reporting, to monitor client progress and service effectiveness at both the individual and program levels. Trends identified through outcome measures, fidelity tools, incident reports, and client feedback are also used to inform staff training needs and continuous quality improvement efforts across programs.
Direct Service Guidelines 1.3 Continuous Quality Improvement, page 4
Direct Service Guidelines 12.1 Data Management, page 62
(b) FCNI uses its performance management system data to guide decisions related to program refinement, resource allocation, and policy adjustments to better meet the needs of youth and families. Findings are also shared through CQI reporting and the Annual Impact Report to support accountability and continuous program improvement.
Direct Service Guidelines 1.3 Continuous Quality Improvement, page 4
Direct Service Guidelines 12.1 Data Management, page 62
(c) FCNI uses its performance management system, data dashboards, CQI reporting, and tools such as WRAPSTAT and CANS outcomes to identify system-level trends and barriers that impact HFW. These findings are analyzed and communicated through established reporting structures, including quarterly reports and CQI processes, to inform the Community Leadership Teams.
Direct Service Guidelines 1.3 Continuous Quality Improvement, page 4
Direct Service Guidelines 12.1 Data Management, page 62
Fidelity Indicators
1.1 Timely Engagement and Planning
(a) First contact with families is made as soon as possible, but no later than 10 calendar days after referral (or self-referral in the case of AAP eligible child).
RCS does not initiate Wraparound services without documented referral approval and Inter-Agency Placement Committee (IPC) authorization. Initial contact with the family is initiated within one (1) business day of referral acceptance. A face-to-face orientation or “Meet and Greet” meeting is scheduled within seven (7) days, when feasible. If the team is unable to make contact with the family within this time period, the Care Coordinator will notify the program supervisor who will then notify the referring party.
Evidence:
Wraparound Screening and Assessment Procedures, pp. 1–2
RCS Wraparound Program Manual, pp. 5–6
Wraparound Roles and Expectations P&P, pp. 1–3
Wraparound Intake Packet, pp. 1–3
(b) Teams complete a Wraparound Plan of Care within 30 calendar days from start of services
The Care Coordinator initiates an individualized Plan of Care when the referral is received. For each family in Wraparound, the team develops an individualized Safety Plan and Crisis Response Plan within 30 days using a collaborative, team-based approach. The Crisis Response Plan developed at intake informs the safety planning process. It does not replace the ongoing Safety Plan.
Evidence:
RCS Wraparound Program Manual, pp. 6–8
Wraparound Services and After-Care, p. 1
Wraparound Roles and Expectations P&P, pp. 1–3
Wraparound Intake Packet, pp. 1–3
Plan of Care Form, pp. 1–5
Safety Plan Form, pp. 1–2
Crisis Resources (Lake and Humboldt Counties), p. 1
(c) Teams review the plan within the context of a HFW team meeting at least every 30–45 calendar days
The team formally reviews the Plan of Care at least monthly to evaluate progress toward the family’s goals. After the initial meeting, CFT meetings occur at least weekly (and more often as needed) during the Engagement phase.
Evidence:
RCS Wraparound Program Manual, pp. 8–9
Wraparound Services and After-Care, p. 1
Wraparound Roles and Expectations P&P, pp. 1–3
Wraparound Intake Packet, pp. 1–3
Plan of Care Form, pp. 1–5
CFT Notes Form, p. 1
(d) Teams update the plan of care, distribute to all team members, and document the updated plan in the child or youth’s file at least every 90 days and more often as needed
The team reviews and updates the Plan of Care continuously, at least monthly. The Care Coordinator updates the Plan of Care to reflect changes discussed by the team, at least monthly and more often as needed. The Care Coordinator facilitates each CFT meeting and ensures the meeting is documented in CFT meeting minutes. Copies are distributed to the family, team members, and referring parties.
Evidence:
RCS Wraparound Program Manual, pp. 9–10, 20
Wraparound Services and After-Care, p. 2
Plan of Care Form, pp. 1–5
CFT Notes Form, p. 1
(e) Staff and their supervisors are provided with feedback on their ability to meet timelines for CQI purposes
At least once annually, and more frequently as needed, the Performance Quality Improvement (PQI) Department conducts an internal audit of Wraparound program charts in collaboration with program leadership. At least quarterly, the Wraparound Program Supervisor joins a CFT meeting for each Care Coordinator and records observations on the CFT Observation Tool. Wraparound Program Supervisors utilize CREST in supervision with each Care Coordinator at least quarterly and more frequently during new staff onboarding or continued development as needed. Data collected from all tools is entered into the WrapStat database by the Wraparound Program Specialist in a timely manner and at least monthly. CQI data is reviewed on a routine basis, quarterly at a minimum, by Wraparound leadership and the PQI Department to inform coaching, supervision, and training priorities.
Evidence:
Wraparound Continuous Quality Improvement, pp. 1–3
RCS Wraparound Program Manual, pp. 23–24
CFT Notes Form, p. 1
CFT Observation Tool, pp. 1–10
CREST Tool, p. 1
(f) Staff are trained to timely engagement strategies that include encouraging alternate strategies when contact with the family is difficult
Initial contact with the family is initiated within one (1) business day of referral acceptance. A face-to-face orientation or “Meet and Greet” meeting is scheduled within seven (7) days, when feasible. If the team is unable to make contact with the family within this time period, the Care Coordinator will notify the program supervisor who will then notify the referring party.
Evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Screening and Assessment Procedures, pp. 1–2
Wraparound Roles and Expectations P&P, pp. 1–3
Wraparound Intake Packet, pp. 1–3
1.2 Led by Youth and Families
(a) Elicitation and use of families’ perspectives, including Tribes in the case of an Indian child (including development and documentation of the Family Vision and Team Mission statements):
During engagement and planning, the Wraparound team facilitates development of a written Family Vision and Team Mission statement with the youth and family, which are documented in the Plan of Care and reviewed during Child and Family Team meetings. For an Indian child, Tribal representatives are invited to participate in team meetings and planning activities, and Tribal perspectives are incorporated and documented in team records and plans.
Evidence:
RCS Wraparound Program Manual, pp. 4–6
Wraparound Services and After-Care, p. 1
CFT Scaling Form, p. 1
(b) Family values, culture, expertise, capabilities, interests and skills are elicited and clearly documented in the youth’s case file:
Care Coordinators elicit family values, culture, strengths, skills, and expertise through development of the family story, strengths identification, and needs based planning, and document this information in the Plan of Care, Child and Family Team meeting minutes, and associated case records. This information is carried forward and updated as part of ongoing team meetings and plan revisions.
Evidence:
RCS Wraparound Program Manual, pp. 5–8
Wraparound Screening and Assessment Procedures, pp. 1–2
(c) Supervisors/Coaches routinely observe HFW team meetings and review documentation to gather and provide feedback to staff to reinforce practice expectations, build skills, and increase confidence:
Program Supervisors and coaches conduct scheduled observations of Child and Family Team meetings and systematically review Plans of Care, CFT minutes, and related documentation using established CQI and observation tools. Feedback is provided to staff through supervision and coaching to reinforce fidelity expectations, improve facilitation skills, and support professional development.
Evidence:
Wraparound Continuous Quality Improvement, pp. 1–3
RCS Wraparound Program Manual, pp. 23–24
CFT Observation Tool, pp. 1–10
CREST Tool, p. 1
(d) Feedback from families is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) to share their experience of the Wraparound process:
Youth and families are routinely invited to provide feedback on their Wraparound experience through satisfaction surveys and other structured feedback tools. Feedback data is reviewed within the Continuous Quality Improvement process and used to inform program improvements and coaching priorities.
Evidence:
Wraparound Continuous Quality Improvement, pp. 1–2
RCS Wraparound Program Manual, pp. 21–22
Plan of Care Form, pp. 1–5
Crisis Resources (Lake and Humboldt Counties), p. 1
1.3 Strength-Based
(a) A strengths inventory is developed and updated for every member of the team, includes other resources in the family’s local community, and is posted at HFW team meetings:
During the Engagement and Planning phases, the Care Coordinator elicits and documents strengths for the youth, caregiver, formal providers, natural supports, and identified community resources as part of the family story and Plan of Care. Strengths are reviewed and updated during Child and Family Team meetings, which occur at least monthly, and are referenced in CFT agendas, minutes, and planning discussions to guide team decision making and action steps.
Evidence:
RCS Wraparound Program Manual, pp. 5–9, 20
Wraparound Screening and Assessment Procedures, pp. 1–2
Plan of Care form, pp. 1–5
Family Story form, pp. 1–3
(b) The identification of individualized strengths must include, but not be limited to, the strengths identified in the IP-CANS:
The assigned clinician completes the IP CANS at intake and at required reassessment intervals, and identified strengths are shared with the Care Coordinator and Child and Family Team. The Care Coordinator incorporates IP CANS strengths into the strengths inventory and Plan of Care, and supplements them with additional strengths identified through the family story and ongoing CFT discussions.
Evidence:
RCS Wraparound Program Manual, pp. 6–8, 21
Wraparound Continuous Quality Improvement, pp. 1–2
IP-CANS Form, pp 1-4
CFT Notes Form, p. 1
(c) Staff receive ongoing coaching and training in providing strengths-based, solution-focused services:
Care Coordinators, Parent Partners, and supervisors receive strengths based and solution focused training during onboarding and through annual booster trainings, with supervisors and fidelity coaches providing coaching at least quarterly and more frequently as needed. Coaching is informed by direct observation of Child and Family Team meetings, review of Plans of Care and CFT documentation, and feedback shared during supervision sessions.
Evidence:
RCS Wraparound Program Manual, pp. 15–17, 23–24
Wraparound Continuous Quality Improvement, pp. 1–3
Plan of Care form, pp. 1–5
CFT Notes Form, p. 1
CFT Observation Tool, pp. 1–10
(d) Feedback from families regarding their experience of strengths-based services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes:
Youth and caregivers are invited to participate in agency wide satisfaction surveys conducted annually, with data aggregated and reviewed by program leadership and the Performance Quality Improvement department. Results are shared with supervisors to identify strengths based practice trends, inform coaching priorities, and guide training and quality improvement activities.
Evidence:
Wraparound Continuous Quality Improvement, pp. 1–3
RCS Wraparound Program Manual, pp. 21–24
RCS Client Satisfaction Survey, pp 1-14
1.4 Needs Driven
(a) Underlying needs are identified and prioritized before goals and strategies are established for the youth and family:
During the Planning phase, the Care Coordinator facilitates Child and Family Team discussions to identify and prioritize underlying needs for the youth and caregiver before developing action steps and strategies. Needs statements are documented in the Plan of Care and guide the selection of outcomes, strategies, and action steps reviewed during team meetings.
Evidence:
RCS Wraparound Program Manual, pp. 6–8
Wraparound Services and After-Care, p. 1
Plan of Care Form, pp. 1–5
(b) Staff receive ongoing training and coaching in identifying needs, developing needs statements that are reflective of the underlying reasons why problematic situations or behaviors are occurring, and utilizing needs-focused planning over problematic behavior-focused planning:
Care Coordinators, Parent Partners, and supervisors receive onboarding and annual training focused on needs based, strengths driven planning, with supervisors/fidelity coaches providing at least quarterly coaching. Coaching sessions and supervision specifically reinforce development of needs statements that describe underlying reasons for challenges, rather than focusing solely on behaviors.
Evidence:
RCS Wraparound Program Manual, pp. 15–17, 23–24
Wraparound Continuous Quality Improvement, pp. 1–3
CFT Observation Tool, pp. 1–10
CREST Tool, p. 1
(c) The identification of individualized needs must include, but not be limited to, the needs identified in the IP-CANS:
The assigned clinician completes the IP CANS at intake and at required reassessment intervals, and identified needs are shared with the Child and Family Team. The Care Coordinator incorporates IP CANS needs into the Plan of Care and supplements them with additional needs identified through family story development and ongoing team discussions.
Evidence:
RCS Wraparound Program Manual, pp. 6–8, 21
Wraparound Continuous Quality Improvement, pp. 1–2
IP-CANS Form, pp 1-4
Plan of Care Form, pp. 1–5
(d) Transition is planned according to team and family agreement that needs are sufficiently met:
Transition planning is initiated early and revisited throughout service delivery, with the Care Coordinator facilitating Child and Family Team agreement that identified needs have been sufficiently met before transition. Transition decisions and step down plans are documented in team meeting records and final Plans of Care, and reviewed with the youth and family prior to discharge.
Evidence:
RCS Wraparound Program Manual, pp. 9–10
Wraparound Services and After-Care, pp. 1–2
Transition Plan Tool, pp. 1–8
Plan of Care Form, pp. 1–5
1.5 Individualized
(a) Forms/documentation allow for sufficient flexibility in creating individualized plans for each child/youth and family:
Wraparound forms and documentation are designed to support individualized planning by allowing Care Coordinators to document unique strengths, needs, outcomes, strategies, and natural supports specific to each youth and family. Plans of Care and CFT documentation are updated based on team discussion and family input rather than using pre set or checklist driven interventions.
Evidence:
RCS Wraparound Program Manual, pp. 6–8
Wraparound Services and After-Care, p. 1
Plan of Care Form, pp. 1–5
Family Story Form, pp. 1–3
Safety Plan Form, pp. 1–2
CFT Form, p 1
(b) Staff receive ongoing training and coaching in providing flexible, creative, and highly individualized services and strategies:
Staff receive training during onboarding and annual booster trainings that emphasize flexibility, creativity, and individualized problem solving within the Wraparound model. Supervisors/fidelity coaches provide ongoing coaching through supervision and review of practice to reinforce creative, family driven strategies that respond to individual needs.
Evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Continuous Quality Improvement, pp. 1–3
CREST Tool, p. 1
CFT Observation Tool, pp. 1–10
(c) Facilitators receive ongoing training and coaching in leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences:
Facilitators receive role specific training and coaching focused on leading Child and Family Team meetings and tailoring the Wraparound process and Plan of Care to the unique needs, strengths, culture, and preferences of each family. Coaching is provided through observation of team meetings and supervision to strengthen facilitation and customization skills.
Evidence:
RCS Wraparound Program Manual, pp. 13–17
Wraparound Continuous Quality Improvement, pp. 1–3
CFT Observation Tool, pp. 1–10
CREST Tool, p. 1
CFT Form, p 1
(d) HFW plans of care are routinely reviewed and assessed for use of individualized strengths, needs, outcomes, and strategies and for the presence of strategies that capitalize on the assets of the family’s community and informal networks:
Plans of Care are reviewed during Child and Family Team meetings that occur at least monthly, with supervisors and/or the Performance Quality Improvement department reviewing documentation as part of CQI activities to assess alignment with individualized strengths, needs, outcomes, and use of natural and community supports. Findings are used to guide feedback and coaching to staff.
Evidence:
RCS Wraparound Program Manual, pp. 8–9, 20, 23-24
Wraparound Continuous Quality Improvement, pp. 1–3
Plan of Care Form, pp. 1–5
CFT Form, p 1
CFT Observation Tool, pp. 1–10
RCS Client Satisfaction Survey, pp 1-14
(e) Family feedback regarding their experience of receiving customized services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes:
Youth and caregivers are invited to provide feedback on their experience receiving individualized and customized services through satisfaction surveys and other structured feedback tools, with data reviewed by program leadership and the Performance Quality Improvement department at least annually. Feedback is shared with supervisors and staff to inform training, coaching, and service improvements.
Evidence:
Wraparound Continuous Quality Improvement, pp. 1–3
RCS Wraparound Program Manual, pp. 21–24
CFT Observation Tool, pp. 1–10
RCS Client Satisfaction Survey, pp 1-14
1.6 Use of Natural and Community Based Supports
(a) A natural and community supports inventory is developed and updated for every family:
During the Engagement and Planning phases, the Care Coordinator works with the youth and family to identify and document natural supports and community resources (e.g., extended family, friends, cultural or faith based supports, community programs) as part of the family story and Plan of Care. The inventory is reviewed and updated during Child and Family Team meetings, which occur at least monthly, and is reflected in CFT minutes and planning discussions.
Evidence:
RCS Wraparound Program Manual, pp. 3, 5–8
Wraparound Services and After-Care, p. 1
Family Story Form, pp. 1–3
Plan of Care Form, pp. 1–5
Transition Plan Form, pp. 1–8
CFT Form, p 1
Safety Plan Form, pp. 1–2
(b) Staff receive ongoing training and coaching identification, engagement, and integration of natural supports in the HFW process and in decreasing reliance on formal supports:
Care Coordinators, Parent Partners, and supervisors receive onboarding and annual training focused on identifying, engaging, and integrating natural supports, with supervisors and fidelity coaches providing coaching at least quarterly and more frequently as needed. Coaching emphasizes increasing use of informal and community supports over time to reduce reliance on formal services.
Evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Continuous Quality Improvement, pp. 1–3
CFT Observation Tool, pp. 1–10
CREST Tool, p. 1
(c) HFW plans of care are routinely reviewed and assessed for the inclusion of natural supports in the plan and for use of community and natural supports in the assigning of strategies and action items:
Plans of Care are reviewed during Child and Family Team meetings held at least monthly, with the Care Coordinator documenting the role of natural and community supports in strategies and action items. Supervisors review Plans of Care and CFT documentation as part of CQI activities to assess the inclusion and use of natural supports and provide feedback as needed.
Evidence:
RCS Wraparound Program Manual, pp. 8–9, 20
Wraparound Continuous Quality Improvement, pp. 1–3
Plan of Care Form, pp. 1–5
CFT Form, p 1
CFT Observation Tool, pp. 1–10
(d) Family feedback regarding their experience of having natural supports engaged on their team is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes:
Youth and caregivers are invited to provide feedback through annual satisfaction surveys and other structured feedback tools regarding their experience with team composition and use of natural supports. Feedback is reviewed by program leadership and the Performance Quality Improvement department and used to inform supervision, training priorities, and coaching related to effective engagement of natural and community supports.
Evidence:
Wraparound Continuous Quality Improvement, pp. 1–3
RCS Wraparound Program Manual, pp. 21–24
1.7 Culturally Respectful and Relevant
(a) A strengths, needs, culture discovery is completed before the HFW plan of care is developed and is clearly documented in the child or youth’s case file:
During the Engagement phase and prior to development of the HFW Plan of Care, the Care Coordinator facilitates a strengths, needs, and culture discovery process through completion of the family story and initial Child and Family Team discussions. This information is documented in the youth’s case file through the Plan of Care and CFT meeting minutes and is reviewed as part of early planning activities.
Evidence:
RCS Wraparound Program Manual, pp. 5–8
Wraparound Screening and Assessment Procedures, pp. 1–2
Plan of Care Form, pp. 1–5
Family Story Form, pp. 1–3
CFT Form, p 1
(b) Staff receive ongoing coaching and training in the elicitation and use of family and culture in planning and service delivery and in providing culturally respectful and relevant strategies:
Wraparound staff receive onboarding training and annual booster trainings focused on eliciting and incorporating family culture, values, and preferences into planning and service delivery, with supervisors/fidelity coaches providing coaching at least quarterly and as needed. Coaching is informed by observation of Child and Family Team meetings and review of documentation for culturally relevant practice.
Evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Continuous Quality Improvement, pp. 1–3
CREST Tool, p. 1
CFT Observation Tool, pp. 1–10
Plan of Care Form, pp. 1–5
(c) Feedback from families regarding their experience of culturally relevant and respectful services and strategies is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes:
Youth and caregivers are invited to provide feedback on their experience of culturally respectful and relevant services through annual satisfaction surveys and other structured feedback tools, with results reviewed by program leadership and the Performance Quality Improvement department. Feedback findings are shared with supervisors to inform coaching, training priorities, and continuous quality improvement activities.
Evidence:
Wraparound Continuous Quality Improvement, pp. 1–3
RCS Wraparound Program Manual, pp. 21–24
RCS Client Satisfaction Survey, pp 1-14
1.8 High-Quality Team Planning and Problem Solving
(a) Team agreements are created for each HFW team and documented in the youth’s file:
The Care Coordinator facilitates the development of team agreements during early Child and Family Team meetings, outlining how the team will communicate, make decisions, and share responsibilities. These agreements are documented in CFT meeting minutes and reflected in the Plan of Care maintained in the youth’s case file, and are reviewed as team membership or needs change.
Evidence:
RCS Wraparound Program Manual, pp. 5–8, 20
CFT Form, p 1
Plan of Care Form, pp. 1–5
(b) Feedback from families and HFW team members regarding their experience of team engagement and collaboration is routinely elicited (e.g., through meeting observation, satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.):
Feedback regarding team engagement and collaboration is gathered through observation of Child and Family Team meetings, annual satisfaction surveys, and other structured fidelity and quality feedback tools. Input from families and team members is collected as part of routine CQI activities to understand their experience of collaboration and participation on the team.
Evidence:
Wraparound Continuous Quality Improvement, pp. 1–3
RCS Wraparound Program Manual, pp. 21–22
CFT Observation Tool, pp. 1–10
RCS Client Satisfaction Survey, pp 1-14
(c) This feedback is used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes:
Feedback data from team observations and family surveys is reviewed by program leadership and the Performance Quality Improvement department on at least an annual basis and as part of ongoing CQI review cycles. Findings are shared with supervisors to inform targeted coaching, supervision, and training priorities related to team engagement and collaboration.
Evidence:
Wraparound Continuous Quality Improvement, pp. 1–3
RCS Wraparound Program Manual, pp. 23–24
CFT Observation Tool, pp. 1–10
CREST Tool, p. 1
(d) HFW plans of care and meeting minutes are routinely reviewed and assessed for the shared ownership and follow through on strategies and action item:
Plans of Care and Child and Family Team meeting minutes are reviewed during at least monthly team meetings to confirm that strategies and action items are assigned across team members and that follow through is tracked. Supervisors review documentation as part of CQI activities to assess shared ownership and completion of action steps and provide feedback as needed.
Evidence:
RCS Wraparound Program Manual, pp. 8–9, 20
Wraparound Continuous Quality Improvement, pp. 1–3
Plan of Care Form, pp. 1–5
CFT Form, p 1
CREST Tool, p. 1
1.9 Outcomes Based Process
(a) The HFW plan of care includes specific, measurable strategies and action items with timeframes:
During the Planning phase, the Care Coordinator facilitates development of measurable outcomes aligned to prioritized needs and documents specific strategies and action items in the Plan of Care. Each strategy includes assigned responsibilities and timeframes, which guide follow through and ongoing review.
Evidence:
RCS Wraparound Program Manual, pp. 6–8
Plan of Care Form, pp. 1–5
Family Story Form, pp. 1–3
CFT Form, p 1
(b) Action item completion is tracked by facilitators and updated at HFW team meetings, or more often as needed:
The Care Coordinator tracks progress on action items through Child and Family Team meetings held at least monthly and documents updates in CFT meeting minutes. The Plan of Care is updated based on team discussion to reflect progress, completed tasks, and next steps.
Evidence:
RCS Wraparound Program Manual, pp. 8–9, 20
CFT Form, p 1
Plan of Care Form, pp. 1–5
(c) Forms and processes allow strategies and action items to be adjusted or changed as needed. These changes are communicated to all team members:
The Wraparound process allows strategies and action items to be revised based on team input, family feedback, and changing needs. The Care Coordinator communicates changes through updated Plans of Care and distribution of CFT meeting minutes to all team members and referring parties.
Evidence:
RCS Wraparound Program Manual, pp. 9, 20
Wraparound Screening & Assessment Procedures, pp. 1–2
Plan of Care Form, pp. 1–5
CFT Form, p 1
(d) There is a process in place for who will complete the IP-CANS and how the IP-CANS will be shared amongst all team members (please specify in your description who will be responsible for completion of the IP-CANS assessment):
The assigned clinician is responsible for completing the IP CANS at intake, at least every six months thereafter, and at discharge. IP CANS results are maintained in the electronic health record and used by the Care Coordinator and Child and Family Team to inform planning and decision making.
Evidence:
RCS Wraparound Program Manual, pp. 16, 22
IP-CANS Form, pp 1-4
CFT Form, p 1
(e) Data from the IP-CANS is used to support tracking and team decision-making, but does not replace using tracking of needs, goal completion, and action item completion to plan for transition:
IP CANS data is used to track changes in functioning over time, while progress toward needs, goals, and completion of action items is monitored through the Plan of Care and reviewed during team meetings. Transition planning is based on team and family agreement that needs have been sufficiently met, with final Plans of Care updated as part of graduation.
Evidence:
RCS Wraparound Program Manual, pp. 9–10, 22
Wraparound Services and After-Care, pp. 1–2
IP-CANS Form, pp 1-4
CFT Form, p 1
Plan of Care Form, pp. 1–5
Transition Plan Form, pp. 1–8
1.10 Persistence
(a) Teams are supported to keep working with a youth and family even when faced with setbacks or limited progress until the HFW team (with preference given to family voice and choice) agrees that services should end:
Wraparound teams continue working with the youth and family through challenges and limited progress, with services ending only after the Child and Family Team—giving preference to family voice and choice—reaches agreement that goals and needs have been sufficiently addressed. Persistence in service delivery is emphasized across all phases, and transition decisions are documented during team meetings and in the Plan of Care.
Evidence:
RCS Wraparound Program Manual, pp. 4, 9–10
Wraparound Services and After-Care P&P, pp. 1–2
Plan of Care Form, pp. 1–5
CFT Form, p 1
(b) There are clear processes for teams to access help when facing challenges including how to request additional coaching or supervision, how to access/request flexible funding, and how to access additional support:
Care Coordinators and team members may request additional support through supervision, on call supervisory consultation, and coaching when challenges arise, with supervisors providing guidance as needed. Clear procedures are in place for requesting flexible funding, including supervisor review and IPC approval thresholds, and for accessing additional supports through program leadership and system partners.
Evidence:
RCS Wraparound Program Manual, pp. 10–13, 15–17
Wraparound Flex Funds & Client Expenses P&P, pp. 1–2
Safety Plan Form, pp. 1–2
Flex Fund Request Form, pp. 1–2
Family Budget Form, pp. 1–2
(c) Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision:
Facilitators receive onboarding training and annual booster trainings covering post crisis safety planning, conflict resolution, and team facilitation skills, with supervisors and fidelity coaches providing at least quarterly coaching. Coaching is informed by observation of Child and Family Team meetings and review of Plans of Care to strengthen brainstorming and plan revision practices following crises or emerging needs.
Evidence:
RCS Wraparound Program Manual, pp. 15–17, 23–24
Wraparound Continuous Quality Improvement P&P, pp. 1–3
CFT Observation Tool, pp. 1–10
Safety Plan Tool
Transition Plan Tool, pp. 1–8
Plan of Care Form, pp. 1–5
1.11 Transitions as a part of the Fourth Phase of HFW
(a) HFW teams are able to provide adequate transitions and families do not experience sudden loss of services due to adverse events or due to administrative requirements:
Transition planning begins early and is revisited throughout service delivery, with the Care Coordinator ensuring continuity of supports until the Child and Family Team—including family voice—agrees that services should end. Plans of Care, Safety Plans, and Crisis Response Plans are updated prior to discharge, and families are supported to connect with ongoing natural and community resources to prevent sudden loss of services due to administrative changes or adverse events.
Evidence:
RCS Wraparound Program Manual, pp. 4, 9–10
Wraparound Services and After-Care P&P, pp. 1–2
Plan of Care Form, pp. 1–5
Safety Plan Form, pp. 1–2
Crisis Resources (Lake and Humboldt Counties), p. 1
Transition Plan Form, pp. 1–8
(b) Transitions out of HFW are celebrated according to the youth and family’s culture, values, and preferences and administrative structures are supportive of engaging in celebration including access to flex funds, accommodating staff time for community resourcing, developing community partnerships, and ensuring staff are available to attend celebrations:
Graduation and transition celebrations are planned by the Care Coordinator in collaboration with the youth and family to reflect family culture, values, and preferences, with the full Child and Family Team invited to participate. Administrative structures support these activities by allowing use of funds, including flex funds when appropriate, accommodating staff time for community engagement, and encouraging participation of staff and community partners in celebration activities.
Evidence:
RCS Wraparound Program Manual, pp. 9–10
Wraparound Flex Funds & Client Expenses P&P, pp. 1–2
Transition Plan Tool, pp. 1–8
Flex Fund Request Form, pp. 1–2
Family Budget Form, pp. 1–2
Expected Outcomes
2.1 Youth and Family Satisfaction
Youth and family satisfaction with the High Fidelity Wraparound experience is systematically collected and reviewed through established policies, procedures, and standardized tools. Satisfaction is gathered using a structured client satisfaction survey that includes items related to service benefit, flexibility, family voice in planning, and progress toward goals; results are reviewed as part of the Continuous Quality Improvement process to inform supervision, coaching, and program level improvements. In the case of an Indian child, Tribal representatives are engaged throughout assessment, planning, monitoring, transition, and aftercare, and Tribal perspectives are incorporated into documentation and considered as part of evaluating the overall Wraparound experience in accordance with ICWA collaboration requirements.
evidence:
Wraparound Continuous Quality Improvement P&P, pp. 1–3
RCS Wraparound Program Manual, pp. 21–24
Wraparound ICWA Collaboration P&P, pp. 1–2
CFT Scaling Form, p. 1
RCS Client Satisfaction Survey, pp 1-14
Wraparound Roles and Expectations P&P, pp. 1–3
Wraparound Intake Packet, pp. 1–3
CFT Observation Tool, pp. 1–10
CREST Tool, p. 1
Transition Plan Tool, pp. 1–8
Flex Fund Request Form, pp. 1–2
Family Budget Form, pp. 1–2
CFT Note Form, p. 1
2.2 Improved School Functioning
Youth educational and vocational functioning is monitored and supported as part of the High Fidelity Wraparound process through defined assessment, documentation, and review practices. School attendance, educational participation, and progress are tracked using identified outcome measures, including school records and standardized assessment data, and are documented in the Plan of Care and related records to inform team planning and monitor change over time. Policies and procedures require that this information be reviewed as part of ongoing service delivery and used to assess youth progress toward educational and vocational goals.
evidence:
RCS Wraparound Program Manual, pp. 21–22
Wraparound Continuous Quality Improvement P&P, pp. 1–3
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
Plan of Care Form, pp. 1–5
Family Story Form, pp. 1–3
CFT Scaling Form, p. 1
CFT Note Form, p. 1
2.3 Improved Functioning in the Community
Youth community functioning is monitored and supported through the High Fidelity Wraparound process, with changes in justice involvement and engagement in community activities documented and reviewed over time. Policies and procedures require the Wraparound team to record information related to community functioning, including justice involvement and participation in community based activities, and to use this information within the Plan of Care and ongoing team reviews to assess youth progress and inform service planning.
evidence:
RCS Wraparound Program Manual, pp. 21–22
Wraparound Continuous Quality Improvement, pp. 1–3
Plan of Care Form, pp. 1–5
Family Story Form, pp. 1–3
CFT Scaling Form, p. 1
CFT Note Form, p. 1
2.4 Improved Interpersonal Functioning
Youth and family interpersonal functioning is monitored and evaluated throughout participation in High Fidelity Wraparound using defined assessment, documentation, and review practices. Interpersonal functioning, family stress, and relationship quality are assessed through ongoing Wraparound screening and assessment, discussed during Child and Family Team meetings, and documented in the Plan of Care and CFT meeting records. Progress is routinely evaluated using structured tools, including the monthly CFT Scaling Form, and reviewed through Continuous Quality Improvement processes to inform team planning and service adjustments.
evidence:
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
RCS Wraparound Program Manual, pp. 21–22
CFT Scaling Form, p. 1
Wraparound Continuous Quality Improvement P&P, pp. 1–3
CFT Note Form, p. 1
2.5 Increased Caregiver Confidence
Families have access to needed services and supports through the High Fidelity Wraparound process, and caregiver confidence is monitored as part of ongoing service delivery. Caregiver confidence in managing future challenges, accessing services, and responding to crises is assessed during screening and planning, discussed in Child and Family Team meetings, and documented in the Plan of Care and CFT records. Changes in confidence and connectedness to community resources are reviewed over time and incorporated into team planning and Continuous Quality Improvement activities.
evidence:
RCS Wraparound Program Manual, pp. 21–22
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
CFT Scaling Form, p. 1
Plan of Care Form, pp. 1–5
Wraparound Continuous Quality Improvement P&P, pp. 1–3
CFT Note Form, p. 1
2.6 Stable and Least Restrictive Living Environment
Youth permanency and stability in community based living situations is monitored and evaluated throughout participation in High Fidelity Wraparound. Placement stability, including the occurrence, frequency, and type of placement changes, is tracked through assessment, documentation in the Plan of Care, and ongoing Child and Family Team reviews. This information is reviewed over time to assess whether youth are remaining in community settings safely and to inform service planning and Continuous Quality Improvement activities.
evidence:
RCS Wraparound Program Manual pp. 21–22
Wraparound Services and After-Care P&P pp. 1–2, pp. 1–2
Wraparound Continuous Quality Improvement P&P pp. 1–3
Plan of Care Form, pp. 1–5
CFT Note Form, p. 1
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Youth behavioral health stability is monitored throughout participation in HFW, with hospital and emergency behavioral health visits tracked and reviewed over time. Information related to behavioral health crises, use of emergency services, and stabilization is documented in the Plan of Care, Safety Plan, and Crisis Response Plan and reviewed during Child and Family Team meetings to assess progress and inform service planning and Continuous Quality Improvement activities.
evidence:
RCS Wraparound Program Manual, pp. 21–22
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
Safety Plan Form, pp. 1–2
Crisis Response Plan Form, pp. 1–2
Safety Plan Form, pp. 1–2
Wraparound Continuous Quality Improvement P&P, pp. 1–3
CFT Note Form, p. 1
2.8 Reduction in Crisis Visits
Youth and natural supports are supported to prevent and manage most crises through structured safety planning, crisis response planning, and routine Child and Family Team problem solving. Care Coordinators work with youth, caregivers, and natural supports to identify early warning signs, define specific proactive and reactive strategies, and clarify when professional support is needed, documenting this information in the Safety Plan and Crisis Response Plan. The frequency of crises and the level of professional involvement are reviewed during team meetings and documented over time to assess increasing youth and family capacity to manage crises independently and to adjust plans as needed.
evidence:
RCS Wraparound Program Manual, pp. 21–22
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
Safety Plan Form, pp. 1–2
Crisis Response Plan Form, pp. 1–2
Transition Plan Tool, pp. 1–8
Wraparound Continuous Quality Improvement P&P, pp. 1–3
CFT Note Form, p. 1
2.9 Positive Exit from HFW
Youth and families exit High Fidelity Wraparound based on stabilization and documented progress toward identified needs, rather than in response to adverse events. Decisions to transition or discharge are made through Child and Family Team agreement, with progress, remaining needs, and readiness for exit discussed during team meetings and documented in the Plan of Care and CFT records. Policies and procedures require that the timing and reasons for exit are recorded and reviewed to ensure discharges are planned, appropriate, and aligned with youth and family stability.
evidence:
RCS Wraparound Program Manual, pp. 9–10, 21–22
Wraparound Services and After Care P&P, pp. 1–2
Wraparound Continuous Quality Improvement P&P, pp. 1–3
CFT Notes Form, p. 1
Transition Plan Form, pp. 1–8
Plan of Care Form, pp. 1–5
Engagement
3.1 Orientation
(a) The HFW process is fully explained to every family including an overview of the principles and phases, legal and ethical considerations, and the role of each team member including the family, natural supports, and Tribes in the case of an Indian child:
The Care Coordinator serves as the central facilitator of the High-Fidelity Wraparound process and leads coordination of care across systems in partnership with the youth and family. The Care Coordinator facilitates Child and Family Team meetings, develops and updates the Plan of Care and safety/crisis plans collaboratively with the team, and maintains primary responsibility for documentation accuracy, timeliness, and compliance.
evidence:
RCS Wraparound Program Manual, pp. 4–6
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
Wraparound ICWA Collaboration P&P, pp. 1–2
Family Story Form, pp. 1–3
CFT Notes, p. 1
Plan of Care Form, pp. 1–5
Crisis Resources (Lake and Humboldt Counties), p. 1
(b) An overview of the principles and phases:
The Care Coordinator serves as the central facilitator of the High-Fidelity Wraparound process and leads coordination of care across systems in partnership with the youth and family. The Care Coordinator facilitates Child and Family Team meetings, develops and updates the Plan of Care and safety/crisis plans collaboratively with the team, and maintains primary responsibility for documentation accuracy, timeliness, and compliance.
evidence:
RCS Wraparound Program Manual, pp. 4–6
Plan of Care Form, pp. 1–5
Crisis Resources (Lake and Humboldt Counties), p. 1
CFT Note Form, p. 1
(c) Legal and ethical considerations:
The Care Coordinator serves as the central facilitator of the High-Fidelity Wraparound process and leads coordination of care across systems in partnership with the youth and family. The Care Coordinator facilitates Child and Family Team meetings, develops and updates the Plan of Care and safety/crisis plans collaboratively with the team, and maintains primary responsibility for documentation accuracy, timeliness, and compliance.
evidence:
RCS Wraparound Program Manual, pp. 19–20
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
Plan of Care Form, pp. 1–5
Crisis Resources (Lake and Humboldt Counties), p. 1
CFT Note Form, p. 1
(d) The role of each team member including the family and natural supports and Tribes in the case of an Indian child:
The Care Coordinator serves as the central facilitator of the High-Fidelity Wraparound process and leads coordination of care across systems in partnership with the youth and family. The Care Coordinator facilitates Child and Family Team meetings, develops and updates the Plan of Care and safety/crisis plans collaboratively with the team, and maintains primary responsibility for documentation accuracy, timeliness, and compliance.
evidence:
Wraparound Roles and Expectations P&P, pp. 1–3
RCS Wraparound Program Manual, pp. 5–6
Wraparound ICWA Collaboration P&P, pp. 1–2
Plan of Care Form, pp. 1–5
Crisis Resources (Lake and Humboldt Counties), p. 1
CFT Note Form, p. 1
3.2 Safety and Crisis stabilization
(a) Initial crisis and safety concerns are discussed during engagement. If pressing concerns are brought forward, the team develops an immediate crisis response plan which is provided to the family and is documented in the chart:
During the Engagement phase, the Care Coordinator discusses immediate safety and crisis concerns with the youth and family and screens for urgent needs. When pressing concerns are identified, the team develops a written Safety Plan that outlines early warning signs, specific response steps, and roles, which is provided to the family and maintained in the youth’s record along with Crisis Response Plan / Crisis Resources available to the youth and family.
evidence:
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
Wrap Safety Plan Form, pp. 1–2
RCS Wraparound Program Manual, pp. 5–6
Crisis Resources (Lake and Humboldt Counties), p. 1
(b) The crisis plan is used to inform, but not replace, the HFW Safety Plan developed during the Plan Development phase:
The Crisis Response Plan developed during engagement informs subsequent planning, while a comprehensive Safety Plan is developed during the Planning phase and updated collaboratively with the Child and Family Team. The Safety Plan expands on crisis information and remains the primary tool for ongoing safety monitoring and response.
evidence:
RCS Wraparound Program Manual, pp. 6–8
Wrap Safety Plan Form, pp. 1–2
Crisis Resources (Lake and Humboldt Counties), p. 1
(c) All families are provided with information regarding how to access 24/7 crisis response when needed:
Families are provided with information on how to access 24/7 crisis support during intake and early engagement, including review of emergency procedures and crisis contact information. This information is documented and reinforced through safety and crisis planning materials shared with the family.
evidence:
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
RCS Wraparound Program Manual, pp. 6–7
Wrap Safety Plan Form, pp. 1–2
Crisis Resources (Lake and Humboldt Counties), p. 1
3.3 Strengths, Needs, Culture and Vision Discovery
(a) A Family Vision is completed with every family and documented in the youth’s chart during the Engagement phase:
During the Engagement phase, the Care Coordinator facilitates conversations with the youth and family to identify their vision for a better future and documents the Family Vision as part of early Wraparound activities. The Family Vision is recorded in the youth’s chart and referenced in Child and Family Team meetings to orient team members and guide initial plan development.
evidence:
RCS Wraparound Program Manual, pp. 5–6
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
CFT Scaling Form, p. 1
Plan of Care Form, pp. 1–5
CFT Notes Form, p. 1
(b) A Strengths, Needs, Culture Discovery document is initiated with every youth and family, is included in the youth’s chart, is updated at least every 90 days, and the team adds new strengths, needs, and cultural preferences as they are discovered. The document is provided to new team members as they are identified:
The Care Coordinator leads a strengths, needs, and culture discovery process with the youth and family beginning in Engagement and continuing throughout service delivery. Information is documented in the youth’s chart, reviewed and updated during Child and Family Team meetings held at least monthly, and revised at a minimum every 90 days as new strengths, needs, and cultural preferences emerge. The documented summary is used to orient new team members and support ongoing plan development.
evidence:
RCS Wraparound Program Manual, pp. 5–9
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
CFT Notes Form, p. 1
CFT Scaling Form, p. 1
Plan of Care Form, pp. 1–5
3.4 Engage All Team Members
(a) A natural supports inventory is completed with all youth and families and is documented in the child or youth’s case file:
During engagement and ongoing service delivery, the Care Coordinator works with the youth and family to identify natural supports and community members who care about and can support the family. Identified natural supports are documented in the youth’s case file, referenced in Child and Family Team meetings, and incorporated into planning activities to support engagement and shared responsibility.
evidence:
RCS Wraparound Program Manual, pp. 5–8
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
Wraparound Intake Packet, pp. 1–3
CFT Notes Form, p. 1
Plan of Care Form, pp. 1–5
(b) Children’s System of Care partners who should be included on the HFW team are identified and engaged:
The Care Coordinator identifies Children’s System of Care partners involved with the youth and family, including child welfare, probation, behavioral health, education, and other relevant providers, and facilitates their participation on the Child and Family Team. Partner involvement is documented in team records and maintained throughout the Wraparound process.
evidence:
RCS Wraparound Program Manual, pp. 5–7
Wraparound Roles and Expectations P&P, pp. 1–3
Wraparound Intake Packet, pp. 1–3
Plan of Care Form, pp. 1–5
(c) The HFW team works with the youth and family to identify potential team members (including formal, natural supports and Tribes, in the case of an Indian child) and discusses their role on the team:
The youth and family actively participate in identifying formal and informal team members, including natural supports and Tribal representatives when applicable. Roles and expectations of team members are discussed during engagement and reinforced during Child and Family Team meetings to support shared understanding and collaboration.
evidence:
RCS Wraparound Program Manual, pp. 5–6
Wraparound Roles and Expectations P&P, pp. 1–3
Wraparound ICWA Collaboration P&P, pp. 1–2
CFT Notes Form, p. 1
Plan of Care Form, pp. 1–5
(d) Engagement and team building activities are documented in the youth’s file (for example, but not required, in meeting minutes or in case notes):
Engagement and team building activities, including discussions that promote collaboration, clarify roles, and support a positive team culture, are documented in Child and Family Team meeting minutes and case notes. Documentation is maintained in the youth’s file and reviewed to support continuity and effective team functioning.
evidence:
RCS Wraparound Program Manual, pp. 8–9
CFT Notes Form, p. 1
Wraparound Continuous Quality Improvement P&P, pp. 1–3
Plan of Care Form, pp. 1–5
3.5 Arrange Meeting Logistics
(a) Staff are flexible in working hours and scheduling meeting times and locations to accommodate family and Wraparound Team needs:
Care Coordinators schedule Child and Family Team meetings in collaboration with the youth and family, prioritizing family availability, preferences, and accessibility needs. Meetings are arranged at times and locations convenient for the family, including in the home, community settings, or remotely, and logistical needs such as transportation or interpretation are addressed and documented as part of engagement and ongoing service delivery.
evidence:
RCS Wraparound Program Manual, pp. 5–6
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
CFT Notes Form, p. 1
(b) Staff are trained to work collaboratively with families and the other members of the HFW team to schedule meetings that are in alignment with family needs and preferences as well as maximize participation:
Staff receive onboarding and ongoing training focused on family driven practice, collaboration, and trauma informed engagement, including strategies for scheduling and facilitating meetings that maximize participation. These expectations are reinforced through supervision, documentation review, and Continuous Quality Improvement activities.
evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Continuous Quality Improvement P&P, pp. 1–3
RCS Client Satisfaction Survey, pp. 1-14
CREST Tool, p. 1
CFT Observation Tool, pp. 1–10
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
(a) Before the HFW plan of care is developed, team agreements, a team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file:
During the engagement process and prior to development of the Wraparound Plan of Care, the Care Coordinator facilitates the establishment of team agreements that define how the team will work together and make decisions. The team also identifies and documents individual and collective strengths of the youth, family, team members, and community, and develops a written team mission statement aligned with the Family Vision. These materials are documented in the youth’s file and used to orient team members and guide initial plan development.
evidence:
RCS Wraparound Program Manual, pp. 5–8
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
CFT Notes Form, p. 1
Plan of Care Form, pp. 1–5
(b) The youth’s and family members’ strengths identified in engagement are updated to reflect any additionally discovered strengths as they are identified and are documented in the youth’s file:
Strengths identified during engagement are reviewed and expanded as new strengths of the youth, family, team members, and community are discovered through ongoing Child and Family Team discussions. Updated strengths are documented in the youth’s record and reflected in CFT notes and planning documents to ensure plans continue to build on evolving strengths.
evidence:
RCS Wraparound Program Manual, pp. 5–9
CFT Notes Form, p. 1
CFT Scaling Form, p. 1
Plan of Care Form, pp. 1–5
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
(a) Before the HFW plan of care is developed, underlying needs are identified and prioritized for each family and are documented in the youth’s file:
Before development of the Wraparound Plan of Care, the Care Coordinator facilitates Child and Family Team discussions to review needs identified during engagement, identify any additional underlying needs, and prioritize them based on urgency and impact. Identified and prioritized needs are documented in the youth’s file and form the foundation for subsequent planning activities.
evidence:
RCS Wraparound Program Manual, pp. 6–8
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
CFT Notes Form, p. 1
Plan of Care Form, pp. 1–5
(b) Measurable goals and outcomes are developed from these identified needs (as opposed to behavior or deficit-based goal development):
The team develops specific, measurable goals and outcomes directly linked to prioritized underlying needs rather than behaviors or deficits. Goals and outcomes are documented in planning materials and used to monitor progress and guide strategy selection.
evidence:
RCS Wraparound Program Manual, pp. 6–8
CFT Notes Form, p. 1
CFT Scaling Form, p. 1
Plan of Care Form, pp. 1–5
(c) These goals and outcomes are developed collaboratively with the youth, family, and the rest of the HFW team:
Goals and outcomes are developed collaboratively during Child and Family Team meetings with active participation from the youth, family, and team members. Team input and shared decision making are documented in meeting records and reflected in planning documents.
evidence:
RCS Wraparound Program Manual, pp. 6–8
CFT Notes Form, p. 1
Wraparound Roles and Expectations P&P, pp. 1–3
CFT Scaling Form, p. 1
Plan of Care Form, pp. 1–5
(d) Multiple individualized brainstormed strategies are documented in the youth’s file (e.g., in the HFW Plan of Care, in a form, in meeting minutes, or in progress notes) that can be referred to as needed:
The facilitator leads the team in brainstorming multiple individualized strategies to address prioritized needs and goals before selecting action steps. Brainstormed strategies and selected approaches are documented in meeting minutes and planning records to allow the team to revisit and adjust strategies as needed.
evidence:
RCS Wraparound Program Manual, pp. 7–9
CFT Notes Form, p. 1
(e) Facilitators are trained to lead teams in identifying, prioritizing, and selecting strategies and developing action items:
Facilitators receive onboarding and ongoing training focused on leading team based planning, needs prioritization, collaborative brainstorming, and development of action items. These skills are reinforced through supervision, observation, and Continuous Quality Improvement processes.
evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Continuous Quality Improvement P&P, pp. 1–3
CFT Observation Tool, pp. 1–10
(f) These steps are utilized to develop the individualized HFW Plan of Care in a team-based, collaborative environment:
Identified needs, collaboratively developed goals and outcomes, and selected strategies are used by the Child and Family Team to develop the individualized Wraparound Plan of Care. The Plan of Care reflects team consensus and is documented in the youth’s file to guide implementation and review.
evidence:
RCS Wraparound Program Manual, pp. 6–9
CFT Notes Form, p. 1
Plan of Care Form, pp. 1–5
4.3 Develop an Individualized Child or Youth and Family Plan
(a) Facilitators receive ongoing training and coaching to engage the team in a planning process that elicits multiple perspectives, builds trust and shared vision, and demonstrates the HFW principles:
Facilitators receive onboarding and ongoing training focused on leading high quality Wraparound planning processes that are team based, family driven, and aligned with the HFW principles. Training and coaching emphasize eliciting multiple perspectives, supporting shared decision making, and building trust and shared vision among team members during Plan of Care development.
evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Continuous Quality Improvement P&P, pp. 1–3
CFT Observation Tool, pp. 1–10
CREST Tool, p. 1
(b) The Plan of Care comprehensively integrates goals and objectives identified by all Children’s System of Care partners:
The Wraparound Plan of Care integrates goals, outcomes, and strategies identified by all Children’s System of Care partners, including behavioral health, child welfare, probation, education, and other involved providers. Information from all partners is reviewed during Child and Family Team meetings and incorporated into a single, coordinated plan.
evidence:
RCS Wraparound Program Manual, pp. 6–9
Wraparound Roles and Expectations P&P, pp. 1–3
CFT Notes Form, p. 1
Plan of Care Form, pp. 1–5
(c) The Plan of Care is documented in the child/youth’s file, is distributed to all team members, and meets all the criteria defined above (items 1–6):
The Plan of Care is documented in the youth’s file, updated based on team decisions, and distributed to all Child and Family Team members. The Plan reflects the Family Vision and Team Mission, addresses needs across life domains, documents strategies and action items with assigned responsibility and timelines, includes natural supports and community resources, and incorporates graduated transition planning.
evidence:
RCS Wraparound Program Manual, pp. 6–10
CFT Notes Form, p. 1
Plan of Care Form, pp. 1–5
(d) Procedures are in place to review Plans of Care for continuous quality improvement and to provide feedback to staff and supervisors/coaches for training and coaching purposes:
Plans of Care are reviewed through Continuous Quality Improvement processes to assess fidelity, quality, and effectiveness. Findings from documentation review are shared with staff and supervisors to guide supervision, coaching, and targeted training efforts.
evidence:
Wraparound Continuous Quality Improvement P&P, pp. 1–3
RCS Wraparound Program Manual, pp. 23–24
Plan of Care Form, pp. 1–5
CFT Observation Tool, pp. 1–10
CREST Tool, p. 1
4.4 Develop a Crisis and Safety Plan
(a) An individualized crisis and safety plan is documented in the youth’s file, which identifies potential safety, high risk and crisis situations with proactive and reactive crisis management strategies chosen by the family members and including who should be called for support 24/7:
The facilitator leads the youth, family, and team in developing a written Safety Plan and Crisis Response Plan that identifies specific safety concerns, high risk and crisis situations, early warning signs, and clearly defined proactive and reactive strategies. The plans document family selected strategies, natural supports, and professional contacts, including who should be contacted for support during and outside business hours, and are maintained in the youth’s file.
evidence:
Wraparound Screening and Assessment Procedures P&P, pp. 1–3
RCS Wraparound Program Manual, pp. 6–8
Safety Plan Form, pp. 1–2
Crisis Resources (Lake and Humboldt Counties), p. 1
(b) The development of the plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process:
Safety and crisis planning occurs within Child and Family Team meetings using a collaborative, family driven approach that elicits multiple perspectives and centers family voice and choice. Facilitators receive onboarding and ongoing training and coaching in leading team based safety planning, crisis response development, and collaborative decision making.
evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Roles and Expectations P&P, pp. 1–3
Wraparound Continuous Quality Improvement P&P, pp. 1–3
Safety Plan Form, pp. 1–2
Crisis Resources (Lake and Humboldt Counties), p. 1
(c) Crisis and safety plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes:
Safety and Crisis Response Plans are reviewed during ongoing Child and Family Team meetings and through documentation review to ensure strategies are individualized, culturally relevant, include natural supports, and reflect appropriate escalation from proactive to reactive responses. Review findings are used within Continuous Quality Improvement processes to support coaching, supervision, and training.
evidence:
Wraparound Continuous Quality Improvement P&P, pp. 1–3
RCS Wraparound Program Manual, pp. 23–24
Safety Plan Form, pp. 1–2
Crisis Resources (Lake and Humboldt Counties), p. 1
CFT Note Form, p. 1
Implementation
5.1 Implement The Plan of Care
(a) The facilitator leads the team to review strategies and action items at HFW team meetings (e.g., use of meeting agendas and meeting minutes that address action item completion and document progress), track individual assignments, check in to support meeting timelines and deliverables, and adjust strategies and action items as needed:
The facilitator leads Child and Family Team meetings to review progress on strategies and action items identified in the Plan of Care, including confirming completion, addressing barriers, and adjusting timelines or approaches as needed. Action items, assigned responsibilities, and progress updates are documented in meeting notes and used to monitor completion and effectiveness in meeting prioritized needs and outcomes.
evidence:
RCS Wraparound Program Manual, pp. 8–9
CFT Notes Form, p. 1
Wraparound Continuous Quality Improvement P&P, pp. 1–3
Plan of Care Form, pp. 1–5
(b) Staff receive training and coaching on implementing the plan of care in alignment with the HFW principles. Training and processes address celebrating successes as they occur:
Staff receive onboarding and ongoing training and coaching focused on implementing the Plan of Care in alignment with High Fidelity Wraparound principles, including reinforcing family voice, strengths based practice, and team based accountability. Training and team processes explicitly support recognizing and celebrating youth, family, and team successes as progress is made toward goals.
evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Continuous Quality Improvement P&P, pp. 1–3
5.2 Review and Update The Plan of Care
(a) Reviews of strategies, progress, and action items occurs in a HFW team meeting setting:
The facilitator leads Child and Family Team meetings to review the Plan of Care, including progress toward goals, completion of action items, and effectiveness of strategies. These reviews occur in the team meeting setting and are used to assess whether strategies are supporting progress toward identified needs and outcomes.
evidence:
RCS Wraparound Program Manual, pp. 8–9
CFT Notes Form, p. 1
Wraparound Continuous Quality Improvement P&P, pp. 1–3
Plan of Care Form, pp. 1–5
(b) The facilitator leads the team to adjust the plan accordingly as successes occur, as new needs are identified, or as new strategies and action items are selected, and the updated plan is documented in the youth’s file:
As progress is made, new needs are identified, or strategies require adjustment, the facilitator leads the team in revising goals, strategies, and action items during Child and Family Team meetings. Updates to the Plan of Care are documented in the youth’s file to reflect current needs, priorities, and agreed upon changes.
evidence:
RCS Wraparound Program Manual, pp. 8–10
CFT Notes Form, p. 1
Plan of Care Form, pp. 1–5
(c) The facilitator documents and communicates completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the plan. These updates are communicated to all team members, at a minimum, through the use of team meeting minutes:
The facilitator documents team discussions, task completion, new assignments, attendance, use of formal services, natural supports, flex funds, and plan updates in meeting minutes and related records. Team meeting minutes are used to communicate this information to all team members to support coordination, accountability, and follow through.
evidence:
RCS Wraparound Program Manual, pp. 8–9
CFT Notes Form, p. 1
Wraparound Services and After-Care P&P, pp. 1–2
Plan of Care Form, pp. 1–5
Transition Plan Tool, pp. 1-8
Wraparound Flex Funds P&P, pp. 1–2
Flex Fund Form Request, pp. 1-2
Family Budget Form, pp. 1-2
(d) Forms are able to be updated and individualized to meet the youth, family, and team’s changing needs:
Wraparound forms and documentation are designed to be updated and individualized over time to reflect changing needs, strategies, supports, and progress. Forms are revised as part of ongoing team meetings and planning activities to ensure documentation remains current and responsive to the youth and family.
evidence:
RCS Wraparound Program Manual, pp. 6–10
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
(a) Team agreements are utilized, reviewed regularly, and present at HFW team meetings:
The facilitator uses established team agreements during Child and Family Team meetings to guide how the team collaborates, communicates, and makes decisions. Team agreements are reviewed periodically and referenced during meetings to support cohesion, trust, and shared accountability.
evidence:
RCS Wraparound Program Manual, pp. 5–6
CFT Notes Form, p. 1
Plan of Care Form, pp. 1–5
(b) Facilitators receive ongoing training and coaching on building, engaging, and maintaining effective teams:
Facilitators receive onboarding and ongoing training and coaching focused on team engagement, collaborative facilitation, and maintaining effective team functioning. Coaching and supervision reinforce strategies for building trust, supporting participation, and addressing team dynamics consistent with High Fidelity Wraparound principles.
evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Continuous Quality Improvement P&P, pp. 1–3
(c) Use of natural supports are monitored over time and teams are provided feedback through coaching and supervision:
The facilitator and supervisors monitor the involvement of natural supports over time through Child and Family Team discussions and documentation review. Feedback regarding use of natural supports is provided through supervision and coaching to strengthen team engagement and increase reliance on informal supports.
evidence:
RCS Wraparound Program Manual, pp. 8–9
CFT Notes Form, p. 1
Wraparound Continuous Quality Improvement P&P, pp. 1–3
CREST Tool, p. 1
(d) There are processes for orienting new team members (including formal and natural supports) to the team which include explaining the HFW process, reviewing current plans and strategies, and engaging in team building exercises:
When new team members join, the facilitator orients them to the Wraparound process, reviews the Family Vision, Team Mission, and current Plan of Care, and clarifies roles and expectations. Orientation and engagement activities are supported through team meetings and documented to ensure continuity and effective collaboration.
evidence:
RCS Wraparound Program Manual, pp. 5–6
Wraparound Roles and Expectations P&P, pp. 1–3
CFT Notes Form, p. 1
Plan of Care Form, pp. 1–5
Transition
6.1 Develop a Transition Plan
(a) The facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process:
The facilitator leads Child and Family Team discussions to review progress toward the Team Mission, goals, and identified needs, using benchmarks and indicators monitored throughout service delivery. Transition readiness is determined through team agreement, including youth and family voice, and is based on demonstrated stabilization and progress documented over time.
evidence:
RCS Wraparound Program Manual, pp. 9–10
Wraparound Services and After-Care P&P, pp. 1–2
CFT Notes Form, p. 1
CFT Scaling Form, p. 1
(b) Once this determination has been made, the facilitator leads the team in creating an individualized transition plan that identifies needs, services, and supports, distributes the plan to all team members, and documents the plan in the youth’s file:
After transition readiness is agreed upon, the facilitator leads the team in developing a written, individualized transition plan that identifies ongoing needs, services, supports, and responsible parties. The transition plan is documented in the youth’s file and distributed to all team members to support continuity and accountability.
evidence:
RCS Wraparound Program Manual, pp. 9–10
Wraparound Services and After-Care P&P, pp. 1–2
CFT Notes Form, p. 1
Transition Plan Tool, pp. 1–8
Plan of Care Form, pp. 1–5
(c) The development of the individualized transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process:
Transition planning occurs within a team based, collaborative environment that actively involves the youth, family, and team members. Facilitators receive ongoing training and coaching on leading transition and step down planning consistent with High Fidelity Wraparound principles.
evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Continuous Quality Improvement P&P, pp. 1–3
Transition Plan Tool, pp. 1–8
(d) The team verifies that services and supports identified in the transition plan will persist past formal HFW and that the family is able to access them, including post adoption services if applicable:
The team verifies that identified services, natural supports, and community resources are established and accessible prior to discharge from Wraparound. For adoptive families utilizing Adoption Assistance Program funding, families are informed of and connected to available post adoptive services to support continued stability following transition.
evidence:
RCS Wraparound Program Manual, pp. 9–10
Wraparound Services and After-Care P&P, pp. 1–2
Plan of Care Form, pp. 1–5
6.2 Develop a Post-Transition Safety Plan
(a) The individualized crisis and safety plan is updated to reflect transition (or a new transition crisis and safety plan is completed) and documented in the youth’s file. The plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies that maximize use of natural support and that are chosen by the family:
As part of transition planning, the facilitator leads the youth, family, and team in reviewing and updating the existing Safety Plan and Crisis Response Plan, or developing a transition specific plan when needed. The updated plan identifies potential post transition crisis situations, outlines proactive and reactive strategies selected by the youth and family, incorporates natural and community supports who will remain after HFW ends, and is documented in the youth’s file.
evidence:
RCS Wraparound Program Manual, pp. 9–10
Wraparound Services and After-Care P&P, pp. 1–2
Safety Plan Form, pp. 1–2
Crisis Response Plan Form, pp. 1–2
Transition Plan Tool, pp. 1–8
(b) The development of the crisis and safety transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process:
Crisis and safety transition planning occurs within a Child and Family Team meeting, using a collaborative, family driven process that centers youth and family voice, culture, and preferences. Facilitators receive ongoing training and coaching in leading team based safety and crisis planning, including transition related risk assessment and step down planning.
evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Roles and Expectations P&P, pp. 1–3
Wraparound Continuous Quality Improvement P&P, pp. 1–3
CREST Tool, p. 1
(c) Processes are in place to review crisis and safety plans for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes:
Crisis and Safety Plans are reviewed during team meetings and through documentation review to assess whether strategies are individualized, culturally relevant, include appropriate proactive and reactive progression, and maximize the use of natural supports. Review findings are incorporated into Continuous Quality Improvement activities and used to inform supervision, coaching, and targeted training.
evidence:
Wraparound Continuous Quality Improvement P&P, pp. 1–3
RCS Wraparound Program Manual, pp. 23–24
Safety Plan Form, pp. 1–2
Crisis Response Plan Form, pp. 1–2
CREST Tool, p. 1
6.3 Create a Commencement and Celebrate Success
(a) Transitions out of the Wraparound process are celebrated according to the family’s culture, values, and preferences:
As part of the transition and graduation phase, the facilitator works with the youth and family to identify how they would like to mark the conclusion of formal Wraparound services in a way that is meaningful, culturally relevant, and affirming. Celebrations are planned collaboratively with the Child and Family Team and reflect the family’s values, preferences, and accomplishments.
evidence:
RCS Wraparound Program Manual, pp. 9–10
Wraparound Services and After-Care P&P, pp. 1–2
CFT Notes Form, p. 1
Transition Plan Tool, pp. 1–8
(b) Administrative structures are supportive of engaging in celebration (e.g., access to flex funds, time for community resourcing, community partnerships, ensuring staff are available to attend celebrations, etc.):
Administrative structures support transition celebrations by allowing flexibility in staff time, supporting participation in community based graduation activities, and permitting use of flex funds when appropriate. These supports enable staff to attend celebrations, assist families with community connections, and reinforce positive transitions from formal HFW services.
evidence:
RCS Wraparound Program Manual, pp. 9–10
Wraparound Services and After-Care P&P, pp. 1–2
Wraparound Flex Funds P&P, pp. 1–2
Flex Fund Form Request, pp. 1-2
Family Budget Form, pp. 1-2
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
(a) There are mechanisms in place for families to participate in decisions regarding local HFW implementation:
Families are provided with structured opportunities to share feedback on their Wraparound experience through formal feedback mechanisms and participation in Child and Family Team processes. Family input is solicited regarding service delivery, supports, and the overall Wraparound process, and this feedback is considered when reviewing and refining local High Fidelity Wraparound implementation.
evidence:
RCS Wraparound Program Manual, pp. 21–22
Wraparound Continuous Quality Improvement P&P, pp. 1–3
RCS Client Satisfaction Survey, pp. 1-14
CFT Note Form, p. 1
(b) Family feedback is used in the decision making regarding service planning and implementation, policy and procedure development, workforce development and quality improvement:
Family feedback is reviewed as part of Continuous Quality Improvement activities and used to inform adjustments to service planning and implementation, identify workforce development needs, and guide updates to policies and procedures. Feedback trends and findings are shared with leadership, supervisors, and staff to support quality improvement of Wraparound practice.
evidence:
Wraparound Continuous Quality Improvement P&P, pp. 1–3
RCS Wraparound Program Manual, pp. 21–24
RCS Client Satisfaction Survey, pp. 1-14
7.2 Community Leadership Team
(a) There is an identified representative who actively participates on the Community Leadership Team:
RCS designates program leadership to participate in interagency and community level collaboration structures to support alignment with California Wraparound Standards and system level decision making. Wraparound leadership participates in coordinated interagency processes, contributes program level information, and engages in shared decision making regarding system collaboration, referral pathways, and service oversight consistent with provider responsibilities.
evidence:
RCS Wraparound Program Manual, pp. 21–23
Wraparound Services and After-Care P&P, pp. 1–2
7.3 Eligibility and Equal Access
(a) Youth that meet established eligibility criteria are able to receive services and are not excluded based on the severity or nature of their needs:
Youth who meet established eligibility criteria are accepted into High Fidelity Wraparound regardless of the severity or complexity of their needs. Referral and screening processes focus on risk of placement, need for intensive coordination, and benefit from Wraparound supports, rather than excluding families based on diagnosis, behavior, or system involvement.
evidence:
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
RCS Wraparound Program Manual, pp. 5–6
(b) Staffing is planned to ensure appropriate caseload assignments that support the intensity and frequency of services necessary to meet families’ complex needs and enable staff to provide 24/7 support to families in crisis:
Staffing structures and caseload expectations are defined to support the intensity of High Fidelity Wraparound services, including frequent team meetings, coordination activities, and crisis response. Program roles, supervision, and on call procedures support availability and access to 24/7 crisis response when families experience urgent needs.
evidence:
Wraparound Roles and Expectations P&P, pp. 1–3
RCS Wraparound Program Manual, pp. 15–17
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
Wrap Referral Form, pp. 1-6
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
(a) High fidelity direct services and supports to meet the immediate individualized needs of youth and families:
Fiscal practices support the delivery of high fidelity Wraparound services by funding direct care coordination, facilitation, and individualized supports identified through the Child and Family Team process. Resources are allocated to allow flexible, family driven strategies that respond to immediate and individualized youth and family needs in alignment with Wraparound principles.
evidence:
RCS Wraparound Program Manual, pp. 6–9
Wraparound Services and After-Care P&P, pp. 1–2
Wraparound Flex Funds P&P, pp. 1–2
Flex Fund Form Request, pp. 1-2
Family Budget Form, pp. 1-2
(b) Required workforce development and staffing including required roles or functions from Workforce Development standard 9.3:
Budgets and contracts support required staffing roles and workforce development activities necessary to deliver High Fidelity Wraparound, including care coordination, supervision, and training. Workforce development is supported through onboarding, ongoing training, coaching, and supervision to ensure staff maintain competencies aligned with Wraparound standards.
evidence:
Wraparound Roles and Expectations P&P, pp. 1–3
RCS Wraparound Program Manual, pp. 15–17
Wraparound Continuous Quality Improvement P&P, pp. 1–3
CREST Tool, p. 1
(c) Required data collection and/or data management systems:
Fiscal practices support ongoing data collection, documentation, and review processes required to monitor fidelity, outcomes, and quality of Wraparound services. Data systems and documentation practices are used to support Continuous Quality Improvement, supervision, and program oversight.
evidence:
RCS Wraparound Program Manual, pp. 21–24
Wraparound Continuous Quality Improvement P&P, pp. 1–3
8.2 Equitable Funding Across System Partners
(a) A system is in place for identifying federal, state, local, or private resources that are potentially available across the Children’s System of Care:
The HFW team identifies available resources across child serving systems through ongoing coordination with Child Welfare, Behavioral Health, Probation, education, and community partners during referral, engagement, and Child and Family Team meetings. Available funding sources and supports are explored as part of planning to meet individualized youth and family needs.
evidence:
RCS Wraparound Program Manual, pp. 5–7
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
Wraparound Flex Funds P&P, pp. 1–2
Flex Fund Form Request, pp. 1-2
Family Budget Form, pp. 1-2
(b) These resources and funding streams are analyzed, and a plan/budget is created to leverage them to the maximum extent:
Available services and supports from multiple systems are reviewed and incorporated into the Plan of Care through team based planning to maximize use of existing resources. The Plan of Care reflects coordination of services and supports across systems rather than reliance on a single funding stream.
evidence:
RCS Wraparound Program Manual, pp. 6–9
CFT Notes Form, p. 1
Wraparound Flex Funds P&P, pp. 1–2
Flex Fund Form Request, pp. 1-2
Family Budget Form, pp. 1-2
Plan of Care, pp. 1-5
(c) Cost sharing agreements between Child Welfare, Probation, and Behavioral Health are in place:
As a contracted provider, RCS participates in coordinated service delivery across systems through referrals and interagency collaboration, with cost sharing and funding decisions managed at the county and system level. Provider documentation reflects alignment with county referral and authorization processes rather than direct cost sharing agreements.
evidence:
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
RCS Wraparound Program Manual, pp. 5–6
Wrap Referral Form, p. 1-6
(d) Multiple funding sources are explored and leveraged as much as possible to expand access to HFW services:
The HFW team coordinates services and supports funded through multiple systems, including behavioral health and community resources, and utilizes flex funds when appropriate to address individualized needs. Planning emphasizes braided supports and sustainable resources to expand access and continuity of services.
evidence:
RCS Wraparound Program Manual, pp. 6–9
Wraparound Flex Funds P&P, pp. 1–2
Flex Fund Form Request, pp. 1-2
Family Budget Form, pp. 1-2
Plan of Care, pp. 1-5
8.3 Cost Savings are Reinvested
(a) The process for identification and reinvestment of HFW savings is documented, followed, and transparently communicated to the community and stakeholders:
As a contracted provider, RCS participates in fiscal oversight and program planning processes that support reinvestment of resources to enhance service delivery, workforce capacity, and supports for youth and families. Program leadership uses outcome and utilization data to inform decisions about service enhancements and resource allocation within the scope of the provider contract, and participates in communication with county partners regarding service improvements and program sustainability.
evidence:
RCS Wraparound Program Manual, pp. 21–24
Wraparound Continuous Quality Improvement P&P, pp. 1–3
Wraparound Flex Funds P&P, pp. 1–2
Flex Fund Form Request, pp. 1-2
Family Budget Form, pp. 1-2
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
(a) Flexible funds are available and included as a part of the funding plan for HFW:
Flexible funds are available to support High Fidelity Wraparound service delivery when urgent or individualized needs cannot be met through other funding sources. The HFW team considers use of flexible funds as part of care planning to support the Team Mission, address prioritized needs, build on family strengths, and stabilize youth and families.
evidence:
RCS Wraparound Program Manual, pp. 6–9
Wraparound Flex Funds P&P, pp. 1–2
Flex Fund Form Request, pp. 1-2
Family Budget Form, pp. 1-2
Plan of Care, pp. 1-5
(b) Processes to access and manage flexible funds are articulated and at a minimum include:
The Care Coordinator serves as the central facilitator of the High-Fidelity Wraparound process and leads coordination of care across systems in partnership with the youth and family. The Care Coordinator facilitates Child and Family Team meetings, develops and updates the Plan of Care and safety/crisis plans collaboratively with the team, and maintains primary responsibility for documentation accuracy, timeliness, and compliance.
1)Processes are in place to allow timely access to flexible funds when urgent needs are identified by the team, including needs related to safety, stability, or engagement. Requests are brought forward through the Child and Family Team process and reviewed promptly to support responsiveness.
evidence:
CFT Notes Form, p. 1
Wraparound Flex Funds P&P, pp. 1–2
Flex Fund Form Request, pp. 1-2
Family Budget Form, pp. 1-2
Plan of Care, pp. 1-5
2) A defined approval process that includes the evaluation criteria defined above
Flexible fund requests are evaluated through a defined approval process that considers alignment with the Team Mission and Plan of Care, cultural relevance, use of natural and community supports, sustainability, and overall value of the investment. Team recommendations inform approval decisions consistent with provider and county requirements.
evidence:
CFT Notes Form, p. 1
Wraparound Flex Funds P&P, pp. 1–2
Flex Fund Form Request, pp. 1-2
Family Budget Form, pp. 1-2
Plan of Care, pp. 1-5
3) A process to appeal denied requests which include communication with teams, youth, and families regarding why the funds were denied
When flexible fund requests are denied, the decision and rationale are communicated to the team and the family. Processes allow for discussion, clarification, and reconsideration as appropriate to support transparency and collaborative problem-solving.
evidence:
Wraparound Flex Funds P&P, pp. 1–2
Flex Fund Form Request, pp. 1-2
Family Budget Form, pp. 1-2
CFT Notes Form, p. 1
8.5 Collaborative Oversight of Flex Funds
(a) Flex fund use and availability is documented and transparently communicated to funders and providers, including information regarding the amount, purpose and HFW team recommendation of the request:
The HFW team documents flexible fund requests, including the amount requested, intended purpose, and the HFW team’s recommendation, through Child and Family Team documentation and required approval processes. Information regarding the use, approval, or denial of flexible funds is maintained in the youth’s file and available for review as part of fiscal oversight, coordination with county partners, and Continuous Quality Improvement activities.
evidence:
Wraparound Flex Funds P&P, pp. 1–2
Flex Fund Form Request, pp. 1-2
Family Budget Form, pp. 1-2
CFT Notes Form, p. 1
RCS Wraparound Program Manual, pp. 6–9
(b) Flex funds are pooled and held to meet the needs of all families served:
Flexible funds are maintained at the program level and managed to support the needs of all families served by High Fidelity Wraparound. Use of flexible funds is guided by established procedures to ensure equitable access, responsiveness to urgent needs, and alignment with Wraparound principles across the program.
evidence:
Wraparound Flex Funds P&P, pp. 1–2
Flex Fund Form Request, pp. 1-2
Family Budget Form, pp. 1-2
RCS Wraparound Program Manual, pp. 6–9
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
(a) Flex funds and program resources are funded by braiding of available System of Care funding to ensure their availability:
The HFW program utilizes braided funding across available Children’s System of Care resources to support flexible funds and individualized services. Planning and service coordination emphasize use of multiple funding sources and system resources to ensure flexible funds remain available to meet youth and family needs without reliance on a single funding stream.
evidence:
RCS Wraparound Program Manual, pp. 6–9
Wraparound Flex Funds P&P, pp. 1–2
Flex Fund Form Request, pp. 1-2
Family Budget Form, pp. 1-2
(b) When funding limitations exist in a single funding source, alternate funding options are explored or reliance on other funding sources is increased to fill gaps:
When limitations are identified within a specific funding source, the HFW team explores alternative supports and resources across partner systems and community based options. Planning focuses on identifying other available services, natural supports, and flex fund options to ensure continuity of care and support for the youth and family.
evidence:
RCS Wraparound Program Manual, pp. 6–9
CFT Notes Form, p. 1
Plan of Care, pp. 1-5
(c) Requirements of any single funding source do not prohibit families from accessing flexible funds to meet their needs:
Flexible funds are accessed based on team recommendation and alignment with the individualized Plan of Care, rather than restrictions of any single funding source. Established procedures ensure families are able to access flexible funds to address urgent or unmet needs when other funding sources are not available or sufficient.
evidence:
Wraparound Flex Funds P&P, pp. 1–2
Flex Fund Form Request, pp. 1-2
Family Budget Form, pp. 1-2
RCS Wraparound Program Manual, pp. 6–9
Plan of Care, pp. 1-5
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
(a) The demographic composition of the population served is monitored and processes are in place to recruit/hire staff according to population needs:
The HFW program monitors the demographic characteristics of the youth and families served and uses this information to inform recruitment and hiring practices. Staffing processes emphasize alignment with the cultural, racial, and linguistic needs of the communities served in order to support culturally responsive and equitable service delivery.
evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Roles and Expectations P&P, pp. 1–3
(b) When unable to recruit/hire according to cultural, racial, and linguistic needs, efforts are made to meet families’ needs for cultural representation through alternative means such as engaging natural or formal supports on the HFW team:
When staff demographics do not fully reflect a family’s cultural, racial, or linguistic needs, the HFW team collaborates with the family to identify natural supports, cultural brokers, or formal providers who can support culturally responsive planning and service delivery. These supports are incorporated into the Child and Family Team to strengthen cultural representation and relevance.
evidence:
RCS Wraparound Program Manual, pp. 5–7
Wraparound Roles and Expectations P&P, pp. 1–3
CFT Notes Form, p. 1
(c) When unable to provide a staff member who can provide services in the family’s language, a translator or natural support person is utilized:
When language needs cannot be met directly through assigned staff, the HFW team ensures access to translation or interpretation services, or identifies trusted natural supports to assist with communication. Language access arrangements are discussed with the family, documented, and incorporated into team meetings and planning activities.
evidence:
Wraparound Screening and Assessment Procedures P&P, pp. 1–2
RCS Wraparound Program Manual, pp. 5–6
CFT Notes Form, p. 1
9.2 Tribally Responsive Workforce
(a) Staff are trained on tribal sovereignty, traditions, and values, as well as how to ensure respectful communication, collaboration, and advocacy:
Staff receive onboarding and ongoing training related to Indian Child Welfare Act (ICWA) requirements, including tribal sovereignty, cultural humility, and respectful engagement with Tribes. Training emphasizes understanding tribal traditions and values, ensuring respectful communication, and advocating appropriately while collaborating with tribal representatives and ICWA partners.
evidence:
Wraparound ICWA Collaboration P&P, pp. 1–2
RCS Wraparound Program Manual, pp. 15–17
Wraparound Roles and Expectations P&P, pp. 1–3
(b) When serving an Indian child, HFW teams build partnerships with tribal representatives, encouraging participation in tribal traditions and ceremonies and understanding the value of services and supports that the Tribe can offer:
When an Indian child is served, the HFW team actively collaborates with Tribal representatives and ICWA partners throughout assessment, planning, implementation, transition, and aftercare. The team encourages participation in tribal traditions and ceremonies when desired by the family and incorporates Tribal services, cultural supports, and community resources into the Plan of Care to promote culturally grounded, positive outcomes.
evidence:
Wraparound ICWA Collaboration P&P, pp. 1–2
RCS Wraparound Program Manual, pp. 5–6, 9–10
CFT Notes Form, p. 1
Plan of Care, pp. 1-5
CFT Scaling Form, p. 1
9.3 Flexible and Creative Work Environment
(a) Program quality and improvement:
Leadership and supervisors actively engage staff in Continuous Quality Improvement activities that focus on fidelity, effectiveness, and outcomes of High Fidelity Wraparound practice. Structures are in place for regular review of practice, documentation, and data to identify strengths and areas for improvement and to guide targeted training, supervision, and program enhancements.
evidence:
RCS Wraparound Program Manual, pp. 21–24
Wraparound Continuous Quality Improvement P&P, pp. 1–3
(b) Cohesion (minimally including creating a positive team environment):
Program leadership fosters staff cohesion by promoting collaborative practices, shared responsibility, and accountability across the Wraparound team. Supervision, team meetings, and coaching structures support a positive team environment that values collaboration, trust, and mutual support.
evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Roles and Expectations P&P, pp. 1–3
CREST Tool, p. 1
CFT Observation Tool, pp. 1-8
(c) Open communication:
Open communication is supported through regular supervision, team meetings, and feedback loops that allow staff to share challenges, successes, and ideas for improvement. Leadership encourages transparent communication across roles to support effective problem solving and alignment with High Fidelity Wraparound practice.
evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Continuous Quality Improvement P&P, pp. 1–3
CREST Tool, p. 1
CFT Observation Tool, pp. 1-8
(d) Creating a clear sense of mission and compliance with HFW philosophy (principles, values, phases and activities):
Leadership reinforces a shared understanding of the High Fidelity Wraparound mission through training, supervision, and review of practice aligned with Wraparound principles, values, and phases. Staff are supported in maintaining fidelity to the model through ongoing coaching, documentation review, and quality assurance processes.
evidence:
RCS Wraparound Program Manual, pp. 4–6, 15–17
Wraparound Continuous Quality Improvement P&P, pp. 1–3
CREST Tool, p. 1
CFT Observation Tool, pp. 1-8
9.4 Hiring, Performance Evaluation, and Job Descriptions
(a) Each of the above roles or functions are met within the HFW program either through a unique position or through combining positions with clearly defined role descriptions and responsibilities:
The HFW program ensures that all required roles and functions are met through a combination of designated positions and clearly defined functional responsibilities. Roles may be fulfilled by individual staff or through combined roles, with expectations and responsibilities clearly articulated to ensure all High Fidelity Wraparound functions are consistently implemented.
evidence:
Wraparound Roles and Expectations P&P, pp. 1–3
RCS Wraparound Program Manual, pp. 13–17
Parent Partner Job Description.pdf, pp. 1–5
Care Coordinator Job Description.pdf, pp. 1–5
Program Specialist Job Description.pdf, pp. 1–4
Licensed (Waivered) Mental Health Clinician Job Description.pdf, pp. 1–6
Mental Health Rehabilitation Specialist IV_V Job Description.pdf, pp. 1–6
Peer Support Specialist Job Description.pdf, pp. 1–6
(b) The description and responsibilities of each role minimally includes the role purpose, functions and qualities (including skills, competencies and attributes) specific to each role or function:
Job descriptions outline the purpose, core functions, and required skills, competencies, and attributes necessary to effectively deliver High Fidelity Wraparound services. Expectations align with best practices for family driven, strengths based care coordination, facilitation, supervision, coaching, and support.
evidence:
Wraparound Roles and Expectations P&P, pp. 1–3
RCS Wraparound Program Manual, pp. 13–17
Parent Partner Job Description.pdf, pp. 1–5
Care Coordinator Job Description.pdf, pp. 1–5
Program Specialist Job Description.pdf, pp. 1–4
Licensed (Waivered) Mental Health Clinician Job Description.pdf, pp. 1–6
Mental Health Rehabilitation Specialist IV_V Job Description.pdf, pp. 1–6
Peer Support Specialist Job Description.pdf, pp. 1–6
(c) Job descriptions for all required positions are specific to HFW and reflect the attitudes, skills, knowledge, and experience most likely to identify individuals who will be successful in the position:
Job descriptions emphasize family voice and choice, cultural humility, collaboration, flexibility, accountability, and fidelity to the Wraparound principles, phases, and activities. Required qualifications and experience align with the competencies necessary to support youth and families with complex needs.
evidence:
RCS Wraparound Program Manual, pp. 15–17
Parent Partner Job Description.pdf, pp. 1–5
Care Coordinator Job Description.pdf, pp. 1–5
Program Specialist Job Description.pdf, pp. 1–4
Licensed (Waivered) Mental Health Clinician Job Description.pdf, pp. 1–6
Mental Health Rehabilitation Specialist IV_V Job Description.pdf, pp. 1–6
Peer Support Specialist Job Description.pdf, pp. 1–6
(d) The hiring process includes opportunities that allow candidates to demonstrate specific attitudes and skills essential to the position:
Hiring practices include structured interviews and selection processes that assess alignment with Wraparound values, problem solving, engagement, teamwork, and effectiveness in working with youth and families using a family driven, strengths based approach.
evidence:
RCS Wraparound Program Manual, pp. 15–17
Parent Partner Job Description.pdf, pp. 1–5
Care Coordinator Job Description.pdf, pp. 1–5
Program Specialist Job Description.pdf, pp. 1–4
Licensed (Waivered) Mental Health Clinician Job Description.pdf, pp. 1–6
Mental Health Rehabilitation Specialist IV_V Job Description.pdf, pp. 1–6
Peer Support Specialist Job Description.pdf, pp. 1–6
(e) Employees are provided clear expectations for their performance and receive frequent feedback and coaching to support their success:
Staff are provided clear performance expectations through defined role responsibilities, supervision, and training requirements. Ongoing feedback and coaching are provided through supervision and Continuous Quality Improvement processes to support professional growth, fidelity, and consistent implementation of High Fidelity Wraparound.
evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Continuous Quality Improvement P&P, pp. 1–3
CFT Observation Tool, pp. 1–10
CREST Tool, p. 1
9.5 Workforce Stability
(a) Matching wages to cost of living in the location of the organization/service implementation area:
Program leadership reviews staffing needs and workforce stability as part of ongoing program oversight. Compensation decisions are made with consideration of local labor market conditions and the intensity and scope of services being delivered in the community. These reviews occur when positions are filled, when programs expand or shift, and when workforce sustainability concerns are identified.
evidence:
Wraparound Roles and Expectations P&P, pp. 1–3
RCS Wraparound Program Manual, pp. 13–17
(b) Maintaining manageable workloads for staff:
Workloads are structured through defined role functions and caseload expectations. Supervisors regularly review caseload size, acuity, and service demands during supervision and program oversight activities. When workload concerns arise, supervisors adjust assignments, redistribute tasks, or modify expectations to maintain staff capacity and service quality.
evidence:
Wraparound Roles and Expectations P&P, pp. 1–3
RCS Wraparound Program Manual, pp. 13–17
(c) Having clearly communicated and accessible promotion/advancement structures that are not prohibitive for those with lived experience:
Advancement occurs through demonstrated skill development, reliability, and increased responsibility rather than requiring staff to leave their role. Supervisors discuss professional growth during supervision and evaluations, support staff in expanding competencies, and assign leadership functions such as mentoring, coordination support, or participation in quality improvement activities. These pathways are accessible to staff with lived experience and do not rely on unnecessary credential barriers beyond what is required for the function being performed.
evidence:
Wraparound Roles and Expectations P&P, pp. 1–3
RCS Wraparound Program Manual, pp. 13–17
(d) Providing wage increases or leadership opportunities that do not require a position change to achieve:
Staff are provided opportunities to take on leadership and advanced responsibilities within their current role, including supporting onboarding of new staff, participating in practice improvement activities, and contributing to program oversight. These opportunities allow staff to grow professionally and be recognized for advanced contributions while maintaining continuity in service delivery.
evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Continuous Quality Improvement P&P, pp. 1–3
9.6 High Fidelity Training Plan
(a) All staff receive an initial HFW training using the Statewide Standardized Foundational HFW curriculum:
All new Wraparound staff receive initial High Fidelity Wraparound training prior to or at the start of service delivery through the UC Davis RCFFP. This training ensures that staff receive standardized curriculum used to ensure consistency in understanding the principles, phases, activities, and fidelity expectations of Wraparound practice.
evidence:
RCS Wraparound Program Manual, pp. 13–17
(b) All staff receive ongoing training both in general Wraparound and in their specific role:
Ongoing training occurs throughout employment and is integrated into regular program operations. Staff receive continued learning through structured trainings, team meetings, coaching, supervision, peer support activities, and review of practice. Training addresses both general Wraparound practice and the specific skills and responsibilities of each role.
evidence:
RCS Wraparound Program Manual, pp. 13–17
Wraparound Continuous Quality Improvement P&P, pp. 1–3
(c) All staff receive booster trainings at least annually in general Wraparound and in their specific roles:
Annual booster trainings are provided to reinforce core Wraparound principles, address practice drift, and strengthen role specific competencies. Booster trainings occur as part of ongoing workforce development and are informed by program needs, quality improvement findings, and observed practice challenges.
evidence:
RCS Wraparound Program Manual, pp. 13–17
Wraparound Continuous Quality Improvement P&P, pp. 1–3
(d) Clinical Supervisors and HFW Supervisors/Managers attend general Wraparound training and receive training specific to their supervisory role:
Supervisory staff participate in both general Wraparound training and training specific to supervision, coaching, fidelity monitoring, and staff development. Supervisors are responsible for supporting implementation of the Wraparound model through supervision, case review, observation, and practice feedback, and receive training to fulfill these responsibilities effectively.
evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Continuous Quality Improvement P&P, pp. 1–3
CFT Observation Tool, pp. 1–10
CREST Tool, p. 1
(e) All staff receive ICWA and Tribal sovereignty training and training to support populations with specific and unique needs:
All Wraparound staff receive training related to ICWA requirements, Tribal sovereignty, and culturally responsive practice. Training ensures staff understand when ICWA applies, how to engage Tribes respectfully, and how to support families in ways that honor culture, identity, and community context. Additional training is provided when staff are serving populations with specific or emerging needs.
evidence:
Wraparound ICWA Collaboration P&P, pp. 1–2
RCS Wraparound Program Manual, pp. 4–6
9.7 Community-based Training Program
(a) Youth, families, and peer partners with current or prior Wraparound experience are meaningfully incorporated into the delivery of required Wraparound trainings:
Youth, family members, and peer partners contribute to training by sharing lived experience, modeling family driven practice, and grounding training content in real Wraparound implementation. Their participation occurs during orientation, skill building activities, and discussions focused on family voice, youth engagement, cultural humility, and strengths based planning. Staff are exposed to these perspectives early and consistently to reinforce the role of families and youth as central decision makers in the Wraparound process.
evidence:
RCS Wraparound Program Manual, pp. 4–6
Wraparound Roles and Expectations P&P, pp. 1–3
(b) Community partners are invited to attend Wraparound trainings or are offered trainings on Wraparound:
Community and system partners are engaged through invitations to participate in Wraparound related trainings or through targeted training opportunities designed to support their role on Child and Family Teams. These efforts help partners understand the purpose, structure, and expectations of High Fidelity Wraparound, support alignment across systems, and strengthen collaboration within the Children’s System of Care. Training participation reinforces shared language, coordinated planning, and respectful collaboration across agencies.
evidence:
RCS Wraparound Program Manual, pp. 4–6
Wraparound ICWA Collaboration P&P, pp. 1–2
9.8 Coaching and Supervision
(a) All staff are provided with an initial apprenticeship that covers values, skills, and knowledge related to HFW principles, phases, and activities, and the effective use of flexible funds:
New staff participate in an initial apprenticeship period prior to carrying an independent caseload. During this period, staff shadow experienced team members, observe Child and Family Team meetings, and engage in guided practice focused on Wraparound values, phases, and activities. Supervisors and experienced staff provide structured coaching to support skill development, including when and how to propose and responsibly use flexible funds to address individualized family needs. Apprenticeship activities emphasize strengths based planning, family voice and choice, and practical application of the Wraparound process.
evidence:
RCS Wraparound Program Manual, pp. 13–17
Wraparound Services and After Care P&P, pp. 1–2
(b) Staff have access to supervision or coaching 24/7 as needed:
Supervisory and leadership staff ensure availability for consultation and coaching at all times to support staff responding to crisis situations, family needs outside traditional business hours, or urgent decision making related to safety, flexible resources, or system coordination. On call support and flexible supervision practices align with the non traditional schedules required for effective Wraparound implementation and crisis response.
evidence:
RCS Wraparound Program Manual, pp. 15–17
Wraparound Continuous Quality Improvement P&P, pp. 1–3
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
N/A
10.2 Evaluation Metrics & Outcomes
(a) Data is utilized to improve practice with youth and families, including giving staff timely feedback from data or reports relevant to their service provision and using data to identify staff training needs:
Supervisors and program leadership review practice and outcome data alongside documentation (including plans, safety/crisis materials, and team records) to identify strengths and gaps in service delivery. Feedback is provided to staff through coaching and supervision using findings from documentation review and fidelity/quality tools, and training priorities are updated based on patterns identified in the data.
evidence:
RCS Wraparound Program Manual, pp. 19, 23–24
Wraparound Continuous Quality Improvement P&P, pp. 1–3
Safety Plan Form, pp. 1–2
Crisis Resources (Lake and Humboldt Counties), p. 1
CREST Tool, p. 1
CFT Scaling Form, p. 1
(b) Data is utilized to identify and address program needs to better serve families and improve overall program effectiveness:
Program leadership and quality staff use aggregated outcome and fidelity information to identify program level needs, monitor trends, and select improvement actions. Data findings are used to guide updates to workflows, supervision focus areas, and program processes to strengthen effectiveness and responsiveness to families.
evidence:
RCS Wraparound Program Manual, p. 19
Wraparound Continuous Quality Improvement P&P, pp. 1–3
RCS Client Satisfaction Survey, pp. 1-14
(c) Data is utilized to identify and communicate system barriers to the Community Leadership Team which impacts the HFW implementation:
Program leadership identifies barriers that interfere with effective interagency collaboration and Wraparound implementation by reviewing patterns in service delivery data, documentation, and fidelity/quality findings. These barriers are communicated through established system level collaboration structures to support shared problem solving and system improvement.
evidence:
RCS Wraparound Program Manual , p. 19
Wraparound Continuous Quality Improvement P&P, pp. 1–3
Fidelity Indicators
1.1 Timely Engagement and Planning
a) EA’s Intake team contacts the family upon receiving (or self-referral in the case of AAP-eligible children) within 2 days, no later than 10 days, and begins the engagement phase, completing the assigned documents. All referrals and subsequent follow-up will be documented on the Intake Form and in EA’s electronic healthcare record, Kidnet. See Policy 1050.01: Timely Engagement & Plan Development, page 1, bullet (b) and EA Family Services Intake Form.
b) The EA Wraparound team, led by the Facilitator, will complete a Plan of Care within 30 calendar days of the referral from the County or the approval of the AAP contract by the designated county/state funding authority, and record it in Kidnet See Policy 1050.01: Timely Engagement & Plan Development, page 1, bullet (g).
c) The Child and Family Team (CFT) will meet regularly, typically every 30-45 days or at least every 90 days, to review and modify the Plan of Care. The team can meet more frequently if necessary. See Policy 1050.01: Timely Engagement & Plan Development, page 1, bullet (h) and EA’s Child and Family Team Meeting Template.
d) The CFT will update the Plan of care as per the information gathered at the CFT, typically every 30-45 days or at least every 90 days, and distribute the Plan to all the team members. See Policy 1050.01: Timely Engagement & Plan Development, page 1, bullet (h), and Plan of Care Update Template.
e) Supervision and coaching will be provided to all staff and supervisors with feedback on their ability to meet timeliness for CQI purposes. See Wraparound Program Statement: Supervision Plan on pages 24-25 and Wraparound Coaching Log Template “Documentation” on page 2.
f) Supervisors and managers will be responsible for providing staff with ongoing training, focusing on general and case-specific training, such as engagement strategies when contact with families is difficult. See the Wraparound Program Statement: Training Plan on pages 25-26, and the Wraparound Training Requirements Template, page 1.
1.2 Led by Youth and Families
a) The Faciliator will guide the team in elicitation of the family’s perspective, including the Tribe in the case of an Indian child. See Policy 1050.02: Plan Development and Implementation, page 1, bullet (a) and (b).
b) The Faciliator will ensure the family values, culture, expertise, capabilities, interests, and skills are elicited and clearly documented. See Policy 1050.02: Plan Development and Implementation, page 1, bullet (a) and the Strengths, Needs & Cultural Discovery template.
c) The Fidelity Coach and management will routinely observe HFW teams’ meetings and review records through the use of TOMS 2.0 and DART, and provide feedback to staff to reinforce practice expectations, build skills, and boost confidence. See Wraparound Program Statement: Supervision Plan, pages 24-25.
d) The Fidelity Coach and Manager will elicit feedback from the families through WFI-EZ, annual satisfaction surveys, and quarterly through quality assurance phone calls.
See Wraparound Program Statement: Program Evaluations and Outcomes, pages 13 & 14, and the Quality Assurance Phone Call Template.
1.3 Strength-Based
a) The Facilitator will guide the team in developing and updating a strengths inventory for the youth, family, and every team member. which will be posted at the HFW team meetings. See Policy 1050.04 Individualized Strength & Needs -Based Approach, page 1, bullet (b), and the Weekly Wraparound Team Meeting Minutes Template, page 2.
b) The Faciliator will identify the individualized strengths through the use of IP-CANS and the Wraparound Needs & Strengths Summary. See Policy 1050.04 Individualized Strength & Needs -Based Approach, page 1, bullet (c), and the Wraparound Needs & Strengths Summary template.
c) EA Staff will receive ongoing coaching and training in providing strengths-based, solution-focused services through monthly training and coaching sessions from their supervisor. See Policy 1050.04 Individualized Strength & Needs -Based Approach, page 1, bullet (d) and the Wraparound Program Statement; Training Plan pages 25- 26 and Wraparound Training Requirement Template.
d) The Fidelity Coach will elicit feedback from the families through WFI-EZ, annual satisfaction surveys, and quarterly through quality assurance phone calls. See Wraparound Program Statement: Program Evaluations and Outcomes, pages 13 & 14, and the Quality Assurance Phone Call Template.
1.4 Needs Driven
a) The Facilitator and HFW team members will help identify and prioritize underlying needs before establishing goals and strategies for the child, youth, and family in the Plan of Care. See Policy 1050.04 Individualized Strength & Needs -Based Approach, page 1, bullet (e), and the Needs Egg template.
b) Supervisors will provide staff with ongoing training and coaching to better recognize needs, craft needs statements that reveal the root causes of issues or behaviors, and adopt needs-focused planning instead of behavior-focused approaches, utilizing the “Needs Guide” curriculum by Patricia Miles. See the Wraparound Program Statement, Training Plan, page 26.
c) The Faciliator will identify the individualized needs through the use of IP-CANS and the Wraparound Needs & Strengths Summary. See Policy 1050.04 Individualized Strength & Needs -Based Approach, page 1, bullet (f), and the Wraparound Needs & Strengths Summary template.
d) Transition is planned based on meeting needs, and wraparound services may continue until the team and family agree that needs are sufficiently met. See Policy 1050.04 Individualized Strength & Needs -Based Approach, page 2, bullet (i), and the Wraparound Program Statement, Transition Planning on page 8.
1.5 Individualized
a) The Agency’s forms and documentation will also provide flexibility to create personalized care plans for each child, youth, and family. These will include open-ended questions, a choice of interventions, strategies, and goals, as well as sections for family input to share their priorities. See Policy 1050.04 Individualized Strength & Needs -Based Approach, page 2, under Individualized Strategies, bullet (b).
b) HFW staff will receive ongoing training and coaching in providing flexible, creative, and highly individualized services and strategies through the curriculum provided by UC Davis Curriculum and Wraparound Training Initiative either directly through those agencies or by their supervisor. See the Wraparound Program Statement and Training Plan, pages 25- 26, and Wraparound Training Requirement Template.
c) Facilitators receive ongoing training and coaching to lead the Wraparound team in customizing the Wraparound process and the Wraparound plan of care for each youth and family’s individual needs, strengths, values, culture, and preferences. See Policy 1050.04 Individualized Strength & Needs -Based Approach, page 2, Individualized Strategies, bullet (d), and the Wraparound Program Statement, Supervision Plan on pages 24-25.
d) On at least a quarterly basis, through the use of DART, the Supervisor will review and assess the HFW Plan of Care for the use of individualized strengths, needs, outcomes, and strategies, and for the presence of strategies that capitalize on the family’s community and informal networks. See Policy 1050.04 Individualized Strength & Needs -Based Approach, page 2, Individualized Strategies, bullet (a), and Wrapround Program Statement Page 13 and 14, Program Evaluation and Outcomes.
e) The Fidelity Coach will elicit feedback from families regarding their experience with receiving customized services through WFI-EZ, annual satisfaction surveys, and quarterly through quality assurance phone calls. See Wraparound Program Statement: Program Evaluations and Outcomes, pages 13 & 14, and the Quality Assurance Phone Call Template.
1.6 Use of Natural and Community Based Supports
a) The Facilitator will complete a natural and community support inventory to help the family identify available supports and to keep it updated for every family. This document will be reviewed regularly at team meetings. See Policy 1050.05 Engagement of Formal, Natural, and Community Supports, page 1, bullet (a), and the Natural and Community Supports Inventory.
b) EA staff receive ongoing training and coaching to identify, engage, and integrate natural supports into the Wraparound process and to reduce reliance on formal supports. See Policy 1050.05 Engagement of Formal, Natural, and Community Supports, page 1, bullet (f), and the Wraparound Program Statement, Training Plan, pages 25- 26, and Wraparound Training Requirement Template.
c)The Supervisor will routinely review the Plan of Care and assess it to ensure the inclusion of natural supports and the use of community and natural supports when assigning strategies and action items. See Policy 1050.05 Engagement of Formal, Natural, and Community Supports, page 1, bullet (c), and the Wraparound Coaching Log Template on page 2.
d) The Fidelity Coach will elicit feedback from families regarding their experience with natural supports engaged on their team, through WFI-EZ, annual satisfaction surveys, and quarterly, through quality assurance phone calls. See Wraparound Program Statement: Program Evaluations and Outcomes, pages 13 & 14, and the Quality Assurance Phone Call Template.
1.7 Culturally Respectful and Relevant
a) The Facilitator will complete a Strengths, Needs, and Culture discovery before the Wraparound plan of care is developed and will clearly document it in the child or youth’s case file in Kidnet. See Policy 1050.06 Culturally Respectful and Relevant Practices, page 1, bullet (b), and the Strengths, Needs and Cultural Discovery Template.
b) Staff will continue to receive coaching and training on incorporating family and cultural considerations into planning and service delivery, ensuring they use culturally respectful and relevant strategies through monthly training sessions and bi-weekly coaching. See Policy 1050.06 Culturally Respectful and Relevant Practices, page 1, bullet (e), and Wraparound Coaching Log “Coaching Session Details” on page 2.
c) The Fidelity Coach will elicit feedback from the families regarding their experience with culturally relevant and respectful services and strategies through WFI-EZ, annual satisfaction surveys, and quarterly, through quality assurance phone calls. See Wraparound Program Statement: Program Evaluations and Outcomes, pages 13 & 14, and the Quality Assurance Phone Call Template.
1.8 High-Quality Team Planning and Problem Solving
a) Before the development of the Plan of Care, the Facilitator will lead the team in formalizing “team agreements” on how it will function during meetings and in decision-making, which will be documented in the youth’s file in Kidnet. See Policy 1050.07 Team-Based Approach, page 1, bullet (a), and the Wraparound Team Agreement Template.
b) The Fidelity Coach will elicit feedback from the families regarding their experience with team engagement and collaboration through WFI-EZ, annual satisfaction surveys, and quarterly, through quality assurance phone calls. See Wraparound Program Statement: Program Evaluations and Outcomes, pages 13 & 14, and the Quality Assurance Phone Call Template.
c) The feedback will be used for continuous quality improvement, including providing feedback to staff and their supervisors for training and coaching. See Wraparound Program Statement: Program Evaluations and Outcomes, pages 13 and 14.
d) The Supervisor will regularly review and evaluate wraparound care plans and team meeting minutes to promote shared ownership and monitor progress on strategies and action items during supervision and quarterly using the DART tool. See Policy 1050.07 Team-Based Approach, page 1, bullet (f), and Wraparound Program Statement: Program Evaluations and Outcomes, pages 13 and 14.
1.9 Outcomes Based Process
a) EA’s HFW Plan of Care will set specific measurable goals that utilize the SMART (Specific, Measurable, Achievable, Relevant, and Timebound) method, along with action items, timeframes, and benchmarks. See Policy 1050.08 Outcomes-Based Approach, page 1, bullet (a), and SMART Goals & Benchmarks Template.
b) The Facilitator will be responsible for tracking and updating “action item” completion at weekly team meetings or more often as needed. See Policy 1050.08 Outcomes-Based Approach, page 1, bullet (b), and Wraparound Team Meeting Minutes template.
c) Agency forms and processes enable strategies and action items to be flexible and adjusted as needed. This will be achieved through regular weekly team meetings dedicated to reviewing current strategies and discussing potential adjustments. Additionally, the Agency has a clear communication protocol—such as sending updated documents via email— to ensure all team members receive timely notifications about changes. See Policy 1050.08 Outcomes-Based Approach, page 1, bullet (c).
d) The Facilitator, trained through Praed Foundation to administer the IP-CANS, will be responsible for completing the assessment, which will be documented in the youth’s case plan, updated in the Plan of Care, and shared at the CFT. See Policy 1050.08 Outcomes-Based Approach, page 1, bullet (d).
e) The HFW team will use the data from the IP-CANS to support team discussions, track progress, and inform decision-making, but that data alone will not replace tracking needs, goal completion, and action-item completion for the transition. See Policy 1050.08 Outcomes-Based Approach, page 1, bullet (e).
1.10 Persistence
a) The Agency expects the teams to continue working with youth and families, even during setbacks or limited progress, until the wraparound team, prioritizing the family’s voice and choice, agrees that services can conclude. The team will collaborate with the family to identify alternative solutions when traditional supports and services are unavailable, leveraging community resources and seeking informal supports. See Policy 1050.09 Program Persistence, page 1, bullet (a) and Wraparound Program Statement, page 13, paragraph 2.
b)The Supervisor serves as the primary contact for the HFW team to receive support or extra coaching when encountering challenges or setbacks, or when needing help with flex fund requests or additional assistance for their families. The Fidelity Coach and Wraparound Manager will also provide regular check-ins and feedback to HFW staff to ensure teams feel supported and that any challenges and barriers are promptly addressed. See Policy 1050.09 Program Persistence, page 1, bullet (c).
c) Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and leading teams in effective brainstorming and ongoing plan revision. See Policy 1050.09 Program Persistence, page 1, bullet (d), and Wraparound Program Statement, Training Plan on pages 25- 26, and Wraparound Training Requirement Template.
1.11 Transitions as a part of the Fourth Phase of HFW
a) To ensure smooth transitions from HFW services, the team will begin planning early, engaging youth, families, and team members in regular discussions about long-term goals, natural supports, and community resources that will remain after formal HFW services end, to avoid sudden loss. Transition will occur only when the youth’s and the family’s needs are met, not because of an adverse event or an administrative requirement. See Policy 1050.10 Transition Planning and Graduation, page 1 under Transition Plan, bullet (a).
b) Transitions out of the Wraparound process will be celebrated in accordance with the child or youth and family’s culture, values, and preferences. The Agency will provide administrative support for engaging in celebration, including access to flex funds, accommodating staff time for community resourcing, developing community partnerships, and ensuring staff are available to attend celebrations. See Policy 1050.10 Transition Planning and Graduation, page 1 under Transition Plan, bullet (e), and page 2 under Commencement, bullets (a) and (b).
Expected Outcomes
2.1 Youth and Family Satisfaction
The Agency utilizes the WFI-EZ, a self-report survey given twice a year, to gauge satisfaction among caregivers, youth, and, for Indian children, the Tribe’s approval. Additionally, the Agency conducts annual surveys at the start of each year to evaluate program satisfaction. The Fidelity Coach will also make quarterly assurance calls to review experiences with EA Family Services. In assessing effectiveness, EA’s HFW program will maintain ongoing monitoring of its outcome performance indicators, documented on the Performance Improvement Plan. See Policy 1050.08, Outcomes-Based Approach on page 1, bullet (g), and EA Family Services Performance Improvement Plan Template.
2.2 Improved School Functioning
The Agency will use the IP CANS data to track academic performance, school attendance, and behavioral indicators within the educational setting. Progress in school functioning will be monitored by regular scoring and reassessment. In assessing effectiveness, EA’s HFW program will maintain ongoing monitoring of its outcome performance indicators, documented on the Performance Improvement Plan. See Policy 1050.08, Outcomes-Based Approach page 1, bullet (g), and EA Family Services Performance Improvement Plan Template.
2.3 Improved Functioning in the Community
The Agency will use the IP CANS, which includes domains addressing community involvement, participation in positive activities, and behavior in community settings. In assessing effectiveness, EA’s HFW program will maintain ongoing monitoring of its outcome performance indicators, documented on the Performance Improvement Plan. See Policy 1050.08, Outcomes-Based Approach page 1, bullet (g), and EA Family Services Performance Improvement Plan Template.
2.4 Improved Interpersonal Functioning
The Agency will utilize the IP CANS and WFI-EZ to assess social relationships, communication skills, and peer interactions. EA’s HFW program will maintain ongoing monitoring of its outcome performance indicators, documented on the Performance Improvement Plan. See Policy 1050.08, Outcomes-Based Approach page 1, bullet (g), and EA Family Services Performance Improvement Plan Template.
2.5 Increased Caregiver Confidence
The Agency will collect data from IP CANS “Caregiver Resources & Needs” SurveyMonkey’s annual surveys to gather both qualitative and quantitative feedback from caregivers. This feedback will focus on their confidence in managing their child’s needs, accessing resources, and engaging in treatment planning. EA’s HFW program will maintain ongoing monitoring of its outcome performance indicators, documented on the Performance Improvement Plan. See Policy 1050.08, Outcomes-Based Approach page 1, bullet (g), and EA Family Services Performance Improvement Plan Template.
2.6 Stable and Least Restrictive Living Environment
The Agency will use data from the IP CANS tracks to monitor living arrangements and transitions, identifying stability or movement toward less restrictive placements. Quarterly Quality Assurance calls can offer extra context and verify progress. EA’s HFW program will maintain ongoing monitoring of its outcome performance indicators, documented on the Performance Improvement Plan. See Policy 1050.08, Outcomes-Based Approach page 1, bullet (g), and EA Family Services Performance Improvement Plan Template.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
DART (Data Analysis Reporting Tool) and incident reports will be used to monitor and analyze service utilization data, including admissions and emergency department visits. Trends and reductions can be reported quarterly. See Policy 1050.08, Outcomes-Based Approach page 1, bullet (g), and EA Family Services Performance Improvement Plan Template.
2.8 Reduction in Crisis Visits
DART and incident reports will also capture the frequency of crisis interventions and visits, providing measurable evidence of program impact over time. See Policy 1050.08, page 1, bullet (g), and the Incident Report Template.
2.9 Positive Exit from HFW
The Agency will utilize the TOM 2.0 to team functioning and adherence to wraparound principles, helping to ensure that youth exiting the program do so after achieving desired outcomes. IP CANS and WFI-EZ will corroborate sustained improvements in needs and strengths upon exit. EA’s HFW program will maintain ongoing monitoring of its outcome performance indicators, documented on the Performance Improvement Plan. See Policy 1050.08, Outcomes-Based Approach page 1, bullet (g), and Incident Report Template.
Engagement
3.1 Orientation
a) The HFW intake team will provide an overview of the HFW process during the intake, and either email or mail the family a copy of the “Wraparound Process User’s Guide” developed by the National Wraparound Initiative, which explains the Wraparound program to the family.
The Facilitator will review the HFW process at the first meeting with the family, ensuring the family understands the following:
a) the overview of principles and phases,
b) legal and ethical considerations,
c) the role of each team member.
See Policy 1050.01 Timely Engagement and Plan Development, page 1, bullet (c).
3.2 Safety and Crisis stabilization
a) The facilitator, with the support of the EA Clinician, will address initial crisis and safety concerns during engagement and develop an immediate crisis plan for intervention and stabilization to provide to the family, and document it in the youth’s chart. See Policy 1050.13 Crisis Intervention, bullet (a) and Initial Crisis Safety Plan Template.
b) The crisis plan will then be used to inform the HFW Safety Plan during the Plan development phase.
See Policy 1050.13 Crisis Intervention, bullet (a).
c) The Facilitator will provide the family with information on how to access EA’s 24/7 on-call system for emergencies. See Policy 1050.13 Crisis Intervention, bullet (a).
3.3 Strengths, Needs, Culture and Vision Discovery
a) The Faciliator will guide the family in developing the family vision during the engagement phase, and documented in the youth’s chart.
b) The Facilitator will complete the Strengths, Needs, and Cultural Discovery, which will be updated every 90 days, adding new strengths, needs, and cultural preferences as they are discovered. The document will be provided to new team members.
See Policy 1050.01 Timely Engagement & Plan Development, page 1, bullet d.
3.4 Engage All Team Members
a) a) The Facilitator will complete a natural and community support inventory to help the family identify available supports and to keep it updated for every family. See Policy 1050.05 Engagement of Formal, Natural, and Community supports, bullet (a), and the Natural and Community Supports Inventory Template.
b)The Facilitator will help the team understand and help connect with the Children’s System of Care partners to be included in the Plan of care. See Policy 1050.05 Engagement of Formal, Natural, and Community supports, bullet (b).
c) The HFW team will work with the youth and family to identify potential team members, including formal, informal, and natural supports (and Tribes in the case of an Indian child) and discuss their roles. See Wraparound Program Statement, Program Standards, and Principles on page 10.
d) The facilitator will document engagement activities and team-building activities in the meeting minutes. See Policy 1050.05 Engagement of Formal, Natural, and Community supports, bullet (d), and Wraparound Meeting Minutes Template.
3.5 Arrange Meeting Logistics
a) The HFW team will ensure meetings are held at times and locations that are convenient and accessible to all team members, and staff will have flexibility in working hours and scheduling to maximize participation. See Policy 1050.01 Timely Engagement and Plan Development, page 1, bullet (i).
b) The team is trained to collaborate with families and HFW team members to schedule meetings that meet family needs and preferences, ensuring maximum participation. They will also handle meeting logistics, including transportation, interpretation, and telehealth arrangements. See Wraparound Program Statement, Program Standards and Principles on page 10 and Wraparound Team Agreements Template.
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
a) The facilitator will lead the team in developing team agreements, a team’s strengths inventory, and a mission statement, which will be documented in the youth’s file in EA’s EHR system, Kidnet. See Policy 1050.02 Plan Development and Implementation, page 1, bullet (c), and the following two templates: Wraparound Team Agreements and Team Mission Statement.
b) The youth’s and family members’ strengths will be highlighted at each HFW meeting and updated to reflect any additional strengths on the meeting’s minutes page and in the youth’s file. See Policy 1050.02 Plan Development, page 1 (c), and the Wraparound Team Minutes template.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
a) The Facilitator will guide the team in identifying and prioritizing underlying needs before establishing goals and strategies for the child, youth, and family in the Plan of Care. The Facilitator can use the “Needs Egg,” based on information gathered during the engagement phase, to generate ideas about underlying needs to present to the CFT. These will be documented in the youth’s file. See Policy 1050.04 Individualized Strengths and Needs Approach, page 1, bullet (e).
b & c ) The Facilitator will use the SMART (specific, measurable, achievable, relevant, and time-bound) template to develop measurable goals and outcomes collaboratively within the CFT from these identified needs (rather than behavior- or deficit-based goal development). See Policy 1050.04 Individualized Strengths and Needs-Based Approach, page 2, bullet (g), and the SMART Goals and Benchmarks Template.
d) h) The HFW team, led by the facilitator, will document multiple brainstormed strategies in the Plan of Care (and meeting minutes as they arise during team meetings) and the youth’s file in Kidnet, for reference as needed. See Policy 2050.04 Individualized Strengths & Needs Based Approach, page 2, bullet (h), and the Plan of Care Template.
e) The supervisor will ensure the facilitator receives ongoing training and coaching to lead the HFW team to identify and prioritize strategies and select action items. See Wraparound Program Statement, Supervision Plan on page 24, and Training Plan on pages 25- 26.
f) In a collaborative environment, the facilitator will guide the prioritization of the needs that youth and families identify as most important, and select strategies to address them and achieve outcomes. See Wraparound Program Statement, last paragraph on page 10.
4.3 Develop an Individualized Child or Youth and Family Plan
a) The supervisor will ensure the facilitator continually receives training and coaching … eliciting diverse perspectives, and fostering trust and a shared vision. See Wraparound Program Statement, Supervision Plan, page 24-25, and Wraparound Coaching Log, page 2.
b) A comprehensive Plan of Care will be developed to prioritize needs, goals, objectives, and strategies for the youth and family. The facilitator will ensure the Plan includes highly individualized strategies tailored to each youth and family’s needs, strengths, values, and culture; reduces harm over time; aligns with the family’s vision and mission statement; addresses needs across multiple life domains; and is coordinated with the Children’s system of care partners. See Policy 1050.02 Plan Development and Implementation, page 1, bullet (f), and Plan of Care Template.
c) The HFW team, led by the facilitator, will ensure the Plan of Care is documented in the youth’s file. and meets all the criteria as defined in items 1-6. See Policy 1050.02 Plan Development and Implementation under Plan Development, bullets (a), (f), (g), (h), and (i), and the Plan of Care and Plan of Care update templates.
d) Facilitators will have dedicated time set aside by the supervisor to plan meetings, review plans, receive feedback on leading the HFW team in customizing the Plan of Care to each youth and family’s individual needs and preferences, and address any obstacles to plan implementation. The Supervisor will use coaching sessions and the DART tool to review the Plan of Care for CQI purposes and provide feedback. See Wraparound Program Statement under Supervision Plan on page 24, and Program Evaluation and Outcomes pages 13-14.
4.4 Develop a Crisis and Safety Plan
a & b) The Facilitator will guide the youth and team in developing a crisis and safety plan, including how to access EA’s 24/7 on-call system for emergencies, to be documented in the youth’s file. The development of the safety plan will occur in a team-based, collaborative environment that identifies potential safety risks, high-risk situations, and crises, and includes proactive and reactive crisis management strategies chosen by family members. See Policy Crisis Intervention, bullets (a) and (b), and Safety Plan template.
b) Supervisors will review safety plans, personalized strategies, and the ongoing development of strategies—both proactive and reactive—focusing on cultural relevance and natural supports. This review will occur during coaching sessions and quarterly via the DART review, aimed at continuous quality improvement, training, and coaching. See Policy 1050.13, Crisis Intervention bullet (c).
Implementation
5.1 Implement The Plan of Care
a) During weekly team meetings, the Facilitator will guide Wraparound team meetings to discuss strategies and action items. Agenda and meeting minutes will be used to track completed tasks, new assignments, and progress. Facilitators will also oversee individual assignments, check in to ensure meeting timelines and deliverables are on track, and modify strategies and action items as needed. See Policy 1050.02 Plan Development and Implementation, page 2 under Plan Implementation, bullet (a), and the Weekly Wraparound Team Meeting Template.
b) Supervisors will provide staff with training and coaching on implementing the Plan of Care in alignment with the HFW principles, and will address celebrating success as needs are met. See Policy 1050.02, page 2 under Plan Implementation, bullet (e), and Wraparound Team Meeting Template, page 1 “Accomplishments and Success Since Last Meeting” box.
5.2 Review and Update The Plan of Care
a) The facilitator guides the team in reviewing the strategies, action items, and progress in weekly HFW team meetings. See Policy 1050.02, Plan Implementation on page 2, bullet (c), and the Wraparound Team Meeting Template.
b) The facilitator will lead the team to adjust the plan as successes occur, new needs are identified, or new strategies or action items are selected, every 30-45 days or at least 90 days during CFTs. See Policy 1050.02 Plan Development and Implementation, Plan Implementation page 2, bullet (c), and Plan of Care Update template.
c) During weekly team meetings, the facilitator will document completion of tasks and new assignments, team attendance, the use of formal and informal support, the use of flex funds, and updates to the Plan, and those minutes will be provided to all members of the team. See Policy 1050.02, Plan Development and Implementation, Plan Implementation on page 2, bullet (d), and Wraparound Team Meeting Minutes template.
d) b) The Agency’s forms and documentation will also provide flexibility to create personalized care plans for each child, youth, and family. This flexibility enables the wraparound team to customize interventions, supports, and goals based on each participant’s individual needs and circumstances, as well as the team’s changing needs. See Policy 1050.04 Individualized Strengths and Needs-Based Approach, page 2, Individualized Needs, bullet (b).
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
a) Team agreements will be documented on the Weekly Wraparound Team Minutes and reviewed regularly. See Policy 1050.07 Team-Based Approach, bullet (a) and Wraparound Team Meeting template.
b) The supervisor will ensure the facilitator receives ongoing training and coaching, building, engaging, and maintaining effective teams. See Wraparound Program Statement, Supervision Plan on pages 24-25, and the Training Requirements template, page 1.
c) The Supervisor will routinely review the Plan of Care and assess it to ensure the inclusion of natural supports and the use of community and natural supports when assigning strategies and action items. See Policy 1050.05 Engagement of Formal, Natural, and Community Supports, page 1, bullet (c), and the Wraparound Coaching Log Template on page 2.
d) When new team members join the HFW team, including formal and natural supports, the facilitator and/or supervisor will orient them to the HFW model, including its phases and principles. See Wraparound Program Statement, page 26, Orienting New Team Members
Transition
6.1 Develop a Transition Plan
a) As the family’s situation changes and the family reaches predetermined benchmarks indicating sufficient progress toward completing the team’s mission and goals, and with the family’s agreement, the facilitator leads the team to create and execute transition plans to maintain continuity of care and progress. See Wraparound Program Statement, page 7, Transition Planning.
b) Once the team has made the determination for transition, the facilitator will lead the team in creating an individualized transition plan that identifies needs, services, and supports; distribute the plan to all team members; and document the plan in the youth’s file, no later than 60 days from the planned transition. See Policy 1050.10 Transition Planning and Graduation, Transition Plan, page 1, bullet (b), and Transition Plan Template.
c) Facilitators will coordinate the development of the transition plan by conducting regular team meetings that involve the youth, family, and support members, including formal and natural supports. In these meetings, the team collaboratively identifies strengths, challenges, and goals, ensuring everyone’s voice is heard and included in the plan. Facilitators will train to become CFT facilitators and participate in Transition Planning training from the UC Davis Center for Excellence. Supervisors will provide ongoing training and coaching in collaborative planning and engagement strategies. See Policy 1050.10 Transition Planning, page 1, bullet (c).
d) d) The team will verify that services in the transition plan will continue beyond Wraparound and that the family can access them, including post-adoption support. The team will review the plan with the family and providers to confirm each service has a contact and clear access instructions, including completed referrals, confirmed eligibility, and scheduled appointments or authorizations. See Policy 1050.10 Transition Planning and Graduation, page 1, bullet (d).
6.2 Develop a Post-Transition Safety Plan
a) The facilitator will lead the team in developing a post-transition crisis and safety plan that reflects the transition and identifies potential crises that may occur after transitioning from formal services. See Policy 1050.10, page 2, Post Transition Safety Planning, bullet (a) and Post-Transition Safety Plan Template.
b) The development of the crisis and safety transition plan will be a structured, team-based process that prioritizes collaboration and family voice. During this meeting, participants will identify potential crisis triggers, warning signs, and specific strategies for de-escalation and safety. The team will work together to outline clear roles and responses, ensuring everyone understands their responsibilities in a crisis. Facilitators and their supervisors will undergo formal training provided by UC Davis, Center for Excellence. Additionally, supervisors will offer training in collaborative planning, trauma-informed care, and strengths-based approaches. See Policy Transition Planning and Graduation 1050.10, page 2, Post Transition Safety Planning, bullets (b) and (c).
c) d) The CQI process for reviewing safety plans, including individualized strategies, proactive and reactive strategy progression, cultural relevance, and the use of natural supports for ongoing quality improvement, training, and coaching, will incorporate TOM 2.0 and DART. Coaching sessions will provide staff with feedback. See Policy Transition Planning and Graduation 1050.10, page 2, Post Transition Safety Planning, bullet (d).
6.3 Create a Commencement and Celebrate Success
a) To celebrate transitions out of the Wraparound process in a way that honors the family’s culture, values, and preferences, the facilitator will engage the family in meaningful conversations about what a celebration means to them, and traditions, favorite activities, and any cultural or spiritual practices that are important to the family. See Policy Transition Planning & Graduation, page 2, Commencement, bullet (a).
b) The Agency aims to foster a supportive environment where youth feel valued and acknowledged by actively promoting participation in celebrations. Management will ensure staff are available to attend and support these events, provide access to flex funds for celebrations like milestone events and graduation parties, and establish community partnerships to assist with hosting or sponsoring celebrations. See Policy Transition Planning & Graduation, page 2, Commencement, bullet (b).
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
a) The Agency values feedback from families and will obtain ongoing feedback on the quality and effectiveness of the HFW program through annual surveys, Quality Assurance phone calls, and WFI-EZ. The Agency will encourage families to attend quarterly parent coaching and education sessions, held at local EA offices, offering opportunities to provide feedback on program policies, share their experiences, and influence improvements in service delivery. See Policy 1050.11 Quality Supports and Services, bullet (a).
b) EA will ensure that youth and family feedback will inform all levels of HFW programs, including service planning and implementation, policy and procedure development, workforce development, and quality improvement, through program satisfaction surveys with questions focused on program improvement, quality assurance phone calls, and quarterly parent coaching and education sessions. HFW teams will receive timely feedback from data or reports relevant to their position, and training and coaching will be provided to improve practices. See Policy 1050.11 Quality Supports and Services, bullets (b) and (c)
7.2 Community Leadership Team
EA will designate a representative from each county where the Agency provides HFW to participate in Community Leadership Teams. This representative will be familiar with the Agency’s wraparound services, current initiatives, and community partnerships to effectively contribute to discussions and decision-making. See Policy 1050.11 Quality Supports and Services, bullet (e).
7.3 Eligibility and Equal Access
a) Youth who meet the established eligibility criteria will receive services and will not be excluded based on the severity or nature of their needs. The HFW process will adapt services to each youth’s unique situation, leveraging a flexible range of supports from clinical interventions to community resource navigation and crisis planning. See Policy 1050.01 Timely Engagement & Plan Development, page 1, bullet (a).
b) The facilitator-to-family ratio will be 1:10 and may increase to 1:12 during transitions out. However, case load assignments will be tailored to ensure the intensity and frequency of services meet the families’ needs and will be adjusted as necessary. The agency will establish a staffing schedule that includes on-call rotations to ensure support is available 24/7, while considering caseload assignments to maintain balance, prevent burnout, and ensure families consistently receive the level of care required. See Policy 1050.15 Workforce Development and Supervision, Workforce Stability on page 2, bullets (k) and (l).
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
a, b, & c:
EA does not hold any county contracts due to being a new wraparound provider. The Agency currently provides AAP wraparound services, and those services are built into the contract. EA is dedicated to developing and maintaining comprehensive HFW services that support the County’s vision in helping youth and families meet their needs. EA is open to negotiations and collaborations with counties with whom the Agency does not currently have a contract for HFW services, and will actively engage with county partners and behavioral health departments to build relationships.
Once a contract is secured, EA will follow the terms specified in each County agreement, including rates for direct HFW services and support to address the immediate needs of youth and families. These contracts should also include provisions for workforce development and staffing, ensuring that rates support ongoing training, supervision, and professional development, as well as each county’s data collection and communication requirements. The Agency uses DART, WFI-EZ, and TOM 2.0 for data collection, and will share all required data in the specified time frames.
See Wraparound Program Statement, Facilitative Organization Supports and Systems Standards on page 16.
8.2 Equitable Funding Across System Partners
8.3 Cost Savings are Reinvested
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
a) Flexible funding will be incorporated into the funding plan for HFW by the Agency to ensure that when a need arises, the funding is available. Funds will be reserved for individualized, non-clinical needs that foster stability and positive outcomes for youth and families, supplementing clinical services. See the Wraparound Program Statement and Flex funds on page 20.
b) The Agency will ensure families have timely access to the flex funds to meet urgent needs. The CFT will be the first step in requesting, and a no-cost or low-cost option will be explored first. If those are not suitable for the family’s individualized needs, the facilitator will submit a funding request to their immediate supervisor using the Flexible Funding Request form, which includes evaluation criteria. The facilitator may submit appeals on the family’s behalf to the Program Director for review if the family or the team disagrees with a denial. All appeals will be examined within 14 days of submission, and the family will receive a written response. See Wraparound Program Statement, Flex funds, paragraph 3 on page 20, and Flexible Funding Request form.
8.5 Collaborative Oversight of Flex Funds
a) Through regular email correspondence and meetings, EA will ensure full transparency of the funds and their usage. Flex fund requests are submitted via a standardized documentation process, tracked in internal spreadsheets, and reviewed in accordance with a defined approval procedure that considers factors such as the request’s purpose, eligibility, and alignment with the care plan. See Wraparound Program Statement, page 21, paragraphs 2 and 3.
b) To pool flex funds, the Agency will develop a formal agreement with funders that outlines how funds from various sources will be combined and managed to serve all eligible families equitably. This agreement will specify how requests are submitted, reviewed, and approved to meet the needs of all families served. See Policy 1050.14 Fiscal Management, bullet (b).
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
a) EA Management will examine all current grants, contracts, and funding streams related to Systems of Care, and funds will be pooled from multiple sources, including child welfare, Medi-Cal, private donations, and grants.
b) b. When funding limitations exist within a single funding source, alternative funding options can be explored, or reliance on other sources can be increased to fill gaps, including seeking grants, donations, or state and local funds that offer greater flexibility or can be used for expenses not covered by the original funding stream.
c) The Agency will ensure that families have access to flexible funds to meet their needs. The Agency will shift to another funding source to fill any gaps that may prevent timely and adequate support if any single funding source’s requirements prohibit funding. Management teams will familiarize themselves with the specific restrictions and eligibility requirements for each funding stream to avoid gaps in timely service.
See Wraparound Program Statement, page 21, for all three procedure requirements.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
a) The Agency recruits and retains staff according to the population served to ensure staff meet the cultural, racial, and linguistic needs of families served.
b) In the case the Agency cannot find a staff member who can meet the cultural, racial, or linguistic needs, the Agency will utilize natural supports or formal supports from the community to ensure the family receives services that respect their cultural preferences.
c) In the case the Agency is unable to find staff to provide services in the family’s language, translation services or natural/formal supports will be utilized. The Facilitator will ask the family for their preference.
See Wraparound Program Statement, page 22 under Workforce Development, both paragraph 1 and bullet 1 for all three procedures.
9.2 Tribally Responsive Workforce
a) The Agency will work to recruit, train, and support staff who demonstrate cultural humility and understand tribal communities. Training will be provided through collaboration with Tribes, or online via UC Davis Northern Academy, NICWA, or other sources that offer training opportunities. See Policy 1050.15 Workforce Development and Supervision, page 1, Culturally Responsive Workforce, bullet (c).
b) The Agency will ensure contact with the Tribe when serving an Indian child, and prioritize respect for tribal sovereignty, traditions, and values, and ensure respectful communication, collaboration, and advocacy. See Wraparound Program Statement Workforce Development & Training Plan on page 22, bullet 2: Tribally Responsive Workforce.
9.3 Flexible and Creative Work Environment
a) The Agency’s leadership (including managers and supervisors) is committed to engaging staff in program quality and improvement through feedback, training, and coaching of staff. This will be a part of EA’s ongoing CQI efforts, as discussed in previous sections.
b & c) The Agency’s leadership (including managers and supervisors) is committed to open communication and a cohesive and positive team environment through collaboration and team building.
d) The Agency’s leadership (including managers and supervisors) is committed to ensuring a clear sense of mission and alignment with the Wraparound philosophy as outlined in the standards through regular meetings, coaching, and training.
See Policy 1050.15 Workforce Development & Supervision, Flexible and Creative Work Environment on page 1, bullet (d) for all four procedures.
9.4 Hiring, Performance Evaluation, and Job Descriptions
a) The Agency will ensure that each of the roles in HFW is met through an individualized position or by combining positions, and ensuring that if positions are combined, each role is defined with clear responsibilities outlined in the job descriptions. See Policy 1050.15 Workforce Development and Supervision, page 1, Hiring, Performance Evaluation, and Job Descriptions, bullet (e) and EA’s Org Chart.
b) To ensure the Agency is recruiting adequate staff for the HFW program, EA will use the role descriptions provided in the Wraparound Standards Toolkit, as they provide
the requirements, necessary skills, functions, experience, and expectations. See Policy 1050.15 Workforce Development and Supervision, page 1, Hiring, Performance Evaluation, and Job Descriptions, bullet (f).
c) EA will use the job/role descriptions provided in the Wraparound Standards Toolkit, as they provide the requirements, necessary skills, functions, experience, and expectations. See Policy 1050.15 Workforce Development and Supervision, page 1, Hiring, Performance Evaluation, and Job Descriptions, bullet (f).
d) g) The hiring process will include opportunities for candidates to demonstrate the specific attitudes and skills essential to the position, as described in the job descriptions. The Agency will ask scenario-based questions to assess their knowledge and abilities. See Policy 1050.15 Workforce Development and Supervision, page 2, Hiring, Performance Evaluation, and Job Descriptions, bullet (g).
e) EA Staff will receive clear expectations for their performance, with a 90-day performance review and biweekly coaching sessions. Annual performance reviews will not contain any surprises and will focus on future professional development opportunities. See Policy 1050.15 Workforce Development and Supervision, page 2, Hiring, Performance Evaluation, and Job Descriptions, bullet (h) and Wraparound Evaluation Template.
9.5 Workforce Stability
a) As the Agency serves most of California, it aligns wages with the community where the program operates to maintain a stable workforce and reduce turnover. See Policy 1050.15 Workforce Development and Supervision, page 2, Workforce Stability, bullet (i).
b) EA offers a flexible work environment, ensuring individuals have a work-life balance, which reduces stress, boosts morale, and increases productivity. The workload is structured to ensure staff members can fulfill their responsibilities effectively without feeling overwhelmed. The facilitator-to-family ratio will be 1:10 and may increase to 1:12 during transitions out. See Policy 1050.15 Workforce Development and Supervision, page 2, Workforce Stability, bullets (j), (k), and (l).
c) EA provides a structured pathway for advancement within the Agency through a leadership development program, including opportunities to mentor, train, or coach new staff and movement into different roles. See Wraparound Program Statement, page 22, paragraph three (right before the Supervision Plan).
d) The Agency recognizes that not all wage increases and leadership opportunities require a position change, and provides merit-based wage increases and opportunities to develop leadership skills through the leadership training program. See Policy 1050.15 Workforce Development and Supervision, page 2, Workforce Stability, bullet (o).
9.6 High Fidelity Training Plan
b) EA’s High Fidelity Wraparound Program will remain compliant with all training requirements outlined by Medi-Cal High Fidelity Wraparound Center of Excellence and UC Davis Foundational Wraparound Curriculum. The Agency will require all initial, role-specific, and annual training to be completed through UC Davis.
c) The Agency will conduct regular refresher training during staff meetings or individual supervision sessions to improve staff knowledge and skills in providing strengths-based, solution-focused services using material from the National Wraparound Initiative, and the UC Davis Training Foundational Wraparound Curriculum.
d)The training plan encompasses both general wraparound training and role-specific training for all staff, including dedicated training for Facilitators, Clinical Supervisors, and Wraparound Supervisors/Managers
e) The training plan also includes ICWA and Tribal sovereignty training, as well as programs designed to support populations with specific needs.
For all bullets, see Wraparound Program Statement, pages 25-26 for Training Plan, and EA’s Wraparound Training Template.
9.7 Community-based Training Program
a) EA will also ensure that youth, families, and peer partners with current or prior Wraparound experience are actively involved in any training the Agency offers. This inclusion will help them stay up to date with new methodologies and receive ongoing refresher training. See Policy 1050.16 High Fidelity Training Plan, bullet (h).
b) The Agency will extend invitations to Community partners to attend Wraparound trainings or to offer Wraparound trainings to strengthen their participation on HFW teams or their role in supporting HFW within the System of Care. For example, the Agency currently offers Therapeutic Crisis Intervention to community partners and invites them to specialized training or guest speakers to strengthen the relationship. See Policy 1050.16 High Fidelity Training Plan, bullet (i).
9.8 Coaching and Supervision
a) Prior to starting any new role, regardless of their level of experience, all staff will have the opportunity to job shadow and learn the program and role requirements, including skills and knowledge related to HFW principal phases and directives, and the effective use of flex funds to meet the families’ needs. See Policy 1050.15 Workforce Development & Supervision, page 2 under Coaching and Supervision, bullet (p).
b) EA’s Leadership team is available by direct phone line and email during regular business hours, and available after hours for emergencies, either by direct phone line, email, or via the answering service. EA Staff have access to supervision and coaching 24/7 as needed. See Policy 1050.15 Workforce Development & Supervision, page 2, under Coaching and Supervision, bullets (r) and (s).
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
a) EA’s Continuous Quality Improvement (CQI) committee will regularly review and refine its performance goals, data collection methods, and analysis techniques, and share performance reports with stakeholders, including program staff, participants, families, and funding sources. See Policy 1050.12 Performance Outcome Management and Measurement, page 2, Reporting and Feedback, and the Continuous Improvement sections.
b) The CQI committee will use data to improve program practices, identify and address program needs, and enhance overall program effectiveness, including gaps in service delivery, resource shortages, training requirements, and program updates. See Policy 1050.12 Performance Outcome Management and Measurement, page 2, Continuous Improvement section.
c) The CQI committee will identify and communicate system barriers to the Community Leadership team, which impacts the Agency’s HFW program. EA will maintain transparency and report all system barriers objectively, ensuring ongoing collaboration and clear communication with the Community Leadership team.
See Policy 1050.12 Performance Outcome Management and Measurement, page 2, Continuous Improvement section.
Fidelity Indicators
1.1 Timely Engagement and Planning
a) Special Service for Groups (SSG) first contact with families to occur as soon as possible. The initial contact occurs within 24 hours of the referral date. (LACDMH-CWD Wraparound P&P, p7; PSE Children & Youth FSP-HFW, p6-7).
b) SSG teams conduct a Plan of Care with the child or youth and family, as well as with formal and informal supports, within 30 days subsequent to the first initial contact. Plan of Care will also include a Safety Plan to anticipate crisis. (LACDMH-CWD Wraparound P&P, p21, 25; Wraparound SOW, p3; General Programs & Clinical Operations P&P, p21-22; Plan of Care; Safety Plan).
c) SSG teams to review the plan within the context of a High Fidelity wrap team at least every 30-45 calendar days. (LACDMH-CWD Wraparound P&P, p21; Wraparound Program SOW, p3).
d) SSG teams will update the plan of care every 90 days and distribute it to all team members, the child, and the family, with documentation maintained in the client’s chart. (LACDMH-CWD Wraparound P&P, p21; Wraparound Program SOW, p3).
e) SSG team and their supervisors are provided with feedback to meet timelines for CQI purposes. HFW Fidelity Coach/Clinical supervisor partners with HFW program manager in fidelity monitoring, providing feedback to the team and ensuring that the team adheres to required timelines from engagement to care planning and throughout the program. (LACDMH-CWD Wraparound P&P, p15; PSE Children and Youth FSP-HFW, p21, 24).
f) SSG team to be trained in timely engagement strategies that include encouraging alternative strategies when contact with families is difficult. During HFW staff orientation and ongoing supervision, staff are instructed, trained and coached to use a variety of methods, multiple times per week, to outreach and engage youth and families. These include meeting the youth/family in their homes, field or other accessible locations, enlisting assistance from trusted providers, community partners, informal supports, and being responsive to the youth’s gender, ethnicity and/or language preferences (PSE Children and Youth FSP-HFW, p6-7; Wraparound Program SOW, p11)
1.2 Led by Youth and Families
SSG HFW team prioritizes the perspectives of voices of the youth and family when developing and modifying strategies. It is important that it coincides with and aligns with the preferences of the youth and family. The youth and family’s values, culture, expertise, capabilities, interests, and skills are elicited, fully understood, and celebrated. They are viewed as critical to a successful process and are the basis for decision-making and problem-solving.
SSG team will ensure that Family Voice and Choice guide all aspects of service planning, from eliciting the family’s vision and team mission to care planning and service delivery. The youth and family’s perspectives, culture, preferences, and goals drive decision-making (Wraparound Program SOW, p3, Sec. 2.2.2; PSE Children and Youth FSP-HFW, p1; SSG General Programs & Clinical Operations P&P, p124-125).
SSG team will actively engage children, youth, and families in a planning process that promotes their voice and choice. SSG team will facilitate the Child and Family Team (CFT) process to ensure youth and families play a central role in creating a plan of care that reflects their needs and preferences. SSG team will continuously monitor and adapt care plans through the CFT process, refining strategies based on evolving youth and family needs. These individualized and dynamic care plans will be documented in the youth’s file (LACDMH-CWD–Wraparound Program P&P, p4, 18, 21-22; General Programs & Clinical Operations P&P, p21-22).
SSG team will participate in program monitoring activities, including administrative and clinical chart reviews, interviews, and feedback processes, to assess service delivery and reinforce practice expectations. SSG team will maintain fidelity to Wraparound standards through ongoing supervision and oversight provided by Clinical Supervisors/Fidelity Coaches. SSG team will engage in ongoing coaching and training to build staff skills, competence, and confidence in delivering high-fidelity Wraparound services (Wraparound Program P&P, p13, 17; General Programs & Clinical Operations P&P, p90-94).
d) SSG team will collect and review satisfaction data through fidelity tools such as the Wraparound Fidelity Index (WFI‑EZ), which evaluates youth and caregiver satisfaction and supports continuous quality improvement in service delivery. (PSE Children and Youth FSP-HFW, p11).
1.3 Strength-Based
(A) SSG HFW team will develop a strengths inventory with the youth and family as part of the CFT process. The CANS is one of the tools to identify the youth and family’s strengths. Strengths of the youth and family, as well as resources in the family’s community, are documented on flipchart paper or poster boards for visibility to all team members. Strengths will be referenced in the youth’s plan of care to address needs and for goal-setting (LACDMH-CWD Wraparound P&P, p24; PSE Children and Youth FSP-HFW, p13; Strengths-Needs-Culture Inventory)
b) SSG team will use the Child and Adolescent Needs and Strengths (CANS) assessment as part of the referral and ongoing service process. Team will gather and update individualized strengths and needs, and incorporate functional strengths into care planning (LACDMH-CWD Wraparound P&P, p7, 15-18; CANS).
c) SSG team will receive ongoing coaching and training in providing strength-based, solution-focused services through regular clinical supervision, observation and coaching by Fidelity Coach, ongoing trainings through UC Davis and LAC DMH training portals. Training topics include “Underlying Needs: A Strengths/Needs-Based Service Crafting Approach.” (LACDMH-CWD Wraparound P&P, p13, 16-17; humanservices.ucdavis.edu; https://eventshub.dmh.lacounty.gov).
d) The SSG team will routinely elicit feedback from families regarding their experience of strengths‑based services, including but not limited to satisfaction surveys such as the Wraparound Fidelity Index (WFI‑EZ) or Team Observation Measure (TOM 2.0), quality assurance phone calls, and informal check‑ins during Child and Family Team (CFT) meetings. The SSG team will use this feedback for continuous quality improvement activities, including sharing themes and findings with staff, incorporating feedback into clinical supervision, identifying training needs, and guiding individual and team‑based coaching efforts. (LACDMH-CWD Wraparound P&P, p42; PSE Children and Youth FSP-HFW, p11–12).
1.4 Needs Driven
a)SSG team will identify and prioritize underlying needs of the youth and family prior to establishing goals and strategies by using structured assessments, including the IP-CANS, in combination with active youth and family engagement. Identified needs are validated with the family and prioritized through the Child and Family Team (CFT) process. Goals are then developed to directly address the prioritized needs, and strategies are selected based on their effectiveness in meeting those needs. The CFT regularly reviews and updates needs, goals, and strategies to ensure continued alignment with the youth and family’s evolving circumstances (LACDMH-CWD Wraparound P&P, p. 4, 21-23)
b) SSG team will ensure staff receive ongoing training, coaching, and supervision focused on needs-based, rather than behavior-focused, planning. Staff are trained to identify underlying needs, develop clear and meaningful needs statements that reflect the root causes of behaviors, and apply needs-focused service approaches in practice. Ongoing coaching occurs through in-house supervision and team meeting case reviews, and staff participate in continuing education through UC Center of Excellence and the DMH Events Hub to strengthen skills in needs-focused assessment and planning with youth and families. (humanservices.ucdavis.edu; https://eventshub.dmh.lacounty.gov; LACDMH-CWD Wraparound P&P, p13, 17).
c) SSG team will utilize the IP-CANS as a foundational tool to identify individualized needs and will supplement this information through ongoing assessment, family input, and multidisciplinary team collaboration. Identified needs are discussed and validated with the youth and family, translated into individualized needs statements, and prioritized through the CFT process. These needs directly guide goal development and service planning and are continuously reviewed and updated through reassessment and team discussion to ensure a comprehensive and accurate understanding of underlying needs. (LACDMH-CWD Wraparound P&P, p15-16,18; PSE Children & Youth FSP-HFW, p13; CANS; CANS PSC Bulletin).
d) SSG team will implement transition planning through the ongoing assessment of progress toward identified needs within the Child and Family Team process. Transition is initiated when the team, including the youth and family, mutually agrees that priority needs have been sufficiently addressed or stabilized. A transition plan is developed that identifies ongoing supports, promotes continuity of care, and includes a gradual step-down of services to support independence and successful discharge. (LACDMH-CWD Wraparound P&P, p21-22; PSE Children & Youth FSP-HFW,p10, section 2.1.6; General Programs & Clinical Operations P&P, 62-63, 66).
1.5 Individualized
(a) SSG team will utilize forms and documentation as flexible tools that support the creation of individualized plans for each child/youth and family. Documentation is used as a guide to capture information generated through the Child and Family Team (CFT) process and is written in family-centered and culturally responsive language that reflects the youth and family’s strengths, needs, values, preferences, and identified natural and community supports. Plans are updated regularly based on team discussions to ensure they remain relevant, individualized, and responsive to changes in the family’s circumstances. (LACDMH–CWD Wraparound P&P, p18, 24; General Programs & Clinical Operations P&P, p21-22; Plan of Care).
(b) SSG team will ensure staff receive ongoing training, coaching, and supervision focused on providing flexible, creative, and highly individualized services and strategies. These practices are reinforced through in-house supervision and team meeting case review process. Staff participate in ongoing professional development through UC Davis COE and the DMH Events Hub, with a focus on individualized service planning and implementation with youth and families during Child and Family Team meetings. (humanservices.ucdavis.edu; https://eventshub.dmh.lacounty.gov; LACDMH-CWD Wraparound P&P, p13-14, 17; General Programs & Clinical Operations P&P, p45-46).
(c) SSG team will provide facilitators with ongoing training and coaching to effectively lead the High Fidelity Wraparound (HFW) team in customizing both the HFW process and the plan of care. Facilitators are supported in adapting the wraparound process to reflect each youth and family’s individual needs, strengths, culture, values, and preferences, ensuring that services remain family-driven, strengths-based, and culturally responsive. (PSE Children & Youth FSP-HFW, p26; LACDMH–CWD Wraparound P&P, p. 13, 21–22).
(d) SSG team will routinely review and assess HFW plans of care during Child and Family Team meetings to ensure that individualized strengths, needs, outcomes, and strategies remain relevant and effective. Staff evaluate whether strategies directly address identified needs and intentionally capitalize on the assets of the family, including community resources and informal support networks. Plans are updated based on family input, reassessment data such as the IP‑CANS, and observed progress to maintain individualized and effective service delivery. (PSE Children & Youth FSP‑HFW, p11–13; LACDMH–CWD Wraparound P&P, p. 21–22; Plan of Care)
(e) SSG team will routinely elicit family feedback regarding their experience of receiving customized and individualized services through satisfaction surveys, the Wraparound Fidelity Index (WFI‑EZ), and other quality assurance activities. Family feedback is reviewed and incorporated into continuous quality improvement efforts, including providing feedback to staff and supervisors to inform training, coaching, and service improvements. (PSE Children and Youth FSP‑HFW, p11–12; LACDMH-CWD Wraparound P&P, p42).
1.6 Use of Natural and Community Based Supports
(a) SSG team will develop, document, and maintain a natural and community supports inventory for every family, beginning at intake and continuing throughout service delivery. Natural and informal supports are identified in collaboration with the youth and family during intake and Child and Family Team (CFT) meetings and are documented in the Plan of Care. The inventory is routinely reviewed and updated during CFT meetings to ensure supports are current, active, and reflective of available community resources, promoting consistent use of natural and informal supports to meet identified needs. (PSE Children and Youth FSP‑HFW, p11–12; LACDMH–CWD Wraparound P&P, p18-19, 21-22).
(b) SSG team will ensure staff receive ongoing training, coaching, and supervision focused on the identification, engagement, and integration of natural and community supports within the High Fidelity Wraparound process, including strategies to decrease reliance on formal supports when appropriate. These practices are reinforced through in‑house supervision and team meeting case reviews. Staff also participate in ongoing professional development through UC Davis COE and the DMH Events Hub that emphasizes engaging natural supports in partnership with youth and families during CFT meetings. (PSE Children and Youth FSP‑HFW, p11–12; LACDMH-CWD Wraparound P&P, p13-14, 17; SSG General Programs & Clinical Operations P&P, p45-46).
(c) SSG team will routinely review and assess HFW Plans of Care during Child and Family Team meetings to ensure that natural and community supports are included and actively incorporated into strategies and action steps. Staff evaluate the effectiveness of identified supports, update the supports inventory, and assign clear roles and responsibilities to natural and community supports in addressing prioritized needs. Plans are revised as needed to expand the use of informal and community resources and to promote sustainable, family-centered outcomes. (PSE Children & Youth FSP‑HFW, p11–13; LACDMH–CWD Wraparound P&P, p. 21–22, 24; Plan of Care)
(d) SSG team will routinely elicit family feedback regarding their experience with the engagement of natural supports on their team through satisfaction surveys, the Wraparound Fidelity Index (WFI), and other quality assurance activities. Feedback and WFI results are reviewed over time to identify strengths and areas for improvement and are shared with staff and supervisors through supervision and team meetings. This information is used to guide continuous quality improvement efforts, including targeted training and coaching to strengthen the effective use of natural and community supports. (PSE Children and Youth FSP‑HFW, p11–12; LACDMH-CWD Wraparound P&P, p42).
1.7 Culturally Respectful and Relevant
(a) SSG team will complete and document a comprehensive strengths, needs, and cultural discovery process prior to development of the HFW Plan of Care. The team will recognize family traditions, values, heritage, and cultural identity as strengths and intentionally incorporate them into individualized planning and service delivery. Strategies will be culturally relevant and respectful of the youth and family’s background, including engagement with Tribes for Indian children when applicable. The team will actively connect families to culturally relevant individuals and community-based organizations and ensure these supports are sustained following transition from formal HFW services, with all information clearly reflected in the case file and guiding all planning and interventions (PSE Children and Youth FSP-HFW, p1, 12; LACDMH-CWD Wraparound P&P, p4, 21-22; Strengths-Needs-Culture Inventory).
(b) SSG team will ensure staff receive ongoing coaching and training in culturally responsive and respectful practices, including elicitation and integration of family culture, values, and traditions into Plans of Care and service delivery. Supervisors will reinforce these practices through regular supervision, team meeting case reviews, and review of Plans of Care to ensure alignment with family preferences. Staff will participate in ongoing in-house supervision, UC Davis COE trainings, and DMH Events Hub offerings focused on cultural sensitivity, and will be supported in connecting families to culturally appropriate resources as part of continuous quality improvement efforts (PSE Children and Youth FSP-HFW p.11-12; LACDMH-CWD Wraparound P&P, p13-14, 17; General Programs & Clinical Operations P&P, p45-46)
(c) SSG team will routinely solicit and use family feedback regarding the cultural relevance and respectfulness of services through tools such as satisfaction surveys, quality assurance phone calls, the Wraparound Fidelity Index (WFI), and TOMS. Feedback and WFI results will be reviewed to identify strengths, gaps, and patterns related to cultural responsiveness, shared with staff and supervisors during supervision and team meetings, and used to inform targeted coaching, training, and service adjustments. Cultural strategies and supports will be refined based on this input and monitored over time as part of continuous quality improvement processes (PSE Children and Youth FSP-HFW, p11–12; LACDMH-CWD Wraparound P&P, p42).
1.8 High-Quality Team Planning and Problem Solving
(a) SSG team will collaboratively develop team agreements with the youth, family, and Child and Family Team (CFT) during initial and ongoing HFW meetings to establish shared expectations for communication, participation, engagement, and collaboration. These family-driven agreements will be documented in the youth’s case file, including CFT meeting notes, and reviewed and updated as needed to reflect evolving team needs. Team agreements will be consistently used to guide interactions and promote respectful, effective team functioning throughout service delivery (PSE Children and Youth FSP-HFW p.1, p.12; LACDMH-CWD Wraparound P&P p.21–22, p.24; Plan of Care).
(b) SSG team will routinely elicit feedback from families and HFW/CFT members regarding their experience of team engagement, collaboration, and shared decision-making through methods such as team meeting observation, satisfaction surveys, quality assurance phone calls, and fidelity and outcome measures including the Wraparound Fidelity Index (WFI) and TOM 2.0. Feedback will be gathered consistently to capture multiple perspectives on team functioning and engagement quality (PSE Children and Youth FSP-HFW, p11–12; LACDMH-CWD Wraparound P&P, p42).
(c) SSG team will analyze and use feedback from families and team members as part of continuous quality improvement processes. Feedback results will be reviewed with staff and supervisors through supervision, debriefings, and team meetings, and will inform targeted coaching, training, and practice adjustments to strengthen facilitation, collaboration, follow-through, and engagement. Ongoing monitoring and reassessment will ensure that feedback leads to measurable and sustained improvements in service delivery and team performance (PSE Children and Youth FSP-HFW, p11–12; LACDMH-CWD Wraparound P&P, p17, 42; General Programs & Clinical Operations P&P, p45-46)
(d) SSG team will routinely review HFW Plans of Care and CFT meeting minutes during supervision, team meetings, debriefings, case consultations, and team preparation activities to assess shared ownership, accountability, and follow-through on strategies and action items. Reviews will focus on clarity of roles, timeliness of implementation, and alignment with team agreements, and will be used to support effective coordination and implementation of services (LACDMH-CWD Wraparound P&P, p17; CFT Facilitator Guidebook p.49–50).
1.9 Outcomes Based Process
(a) SSG team will develop HFW Plans of Care that translate identified needs into specific, measurable goals, strategies, and action items with clearly defined responsibilities and timeframes. Strategies and action steps will be actionable and outcome-oriented, reviewed regularly during Child and Family Team (CFT) meetings, and adjusted based on progress, data, and youth and family feedback to ensure responsiveness to evolving needs (CFT Facilitator Guidebook, p19, 24, 35–40; PSE Children and Youth FSP-HFW, p12-13; LACDMH-CWD Wraparound P&P, p18, 21–22; General Programs & Clinical Operations P&P, p21-22; Plan of Care).
(b) SSG team will track completion of action items through documentation in the Plan of Care, with facilitators monitoring progress between meetings and reviewing status at each CFT meeting or more frequently as needed. The team will discuss progress, identify barriers, update timelines, and revise action steps in real time to support accountability and continued movement toward goals (CFT Facilitator Guidebook, p19, 34, 44; PSE Children and Youth FSP-HFW, p12-13, 18, 21-22; General Programs & Clinical Operations P&P, p21-22; Plan of Care).
(c) SSG team will utilize forms and planning processes that allow strategies and action items to be adjusted or changed as needed based on team input and progress. Revisions will be documented clearly, communicated to all team members through follow-up communication, and reviewed at subsequent CFT meetings to ensure shared understanding, alignment, and consistency in implementation (CFT Facilitator Guidebook p.19, p.34; PSE Children and Youth FSP-HFW, p12-13; LACDMH-CWD Wraparound P&P, p18, 24; Plan of Care).
(d) SSG team will ensure that the IP-CANS is completed by SSG staff certified in CANS assessment (can be facilitator, clinician, and/or therapist) in collaboration with the youth, family, and Child and Family Team (CFT) within required timelines and updated regularly to reflect current strengths and needs. IP-CANS results will be shared with all team members during CFT meetings and through appropriate communication methods (e.g., secure email to CFT members who could not attend the CFT meeting), documented as reviewed with the team, and used to inform development and revision of the Plan of Care (PSE Children and Youth FSP-HFW, p13; LACDMH-CWD Wraparound P&P, p21–22; Facilitator Guidebook p19, 34; CANS PSC Bulletin; CANS-IP).
(e) SSG team will use IP-CANS data to support tracking, team decision-making, and planning in conjunction with ongoing monitoring of identified needs, goal attainment, and action item completion. During CFT meetings, both IP-CANS results and real-time progress data will be reviewed to guide decisions and inform transition planning, with the IP-CANS serving as a complementary tool rather than a replacement for demonstrated progress toward goals and completion of action steps (PSE Children and Youth FSP-HFW, p12–13; Facilitator Guidebook, p44).
1.10 Persistence
(a) SSG team will continue working with youth and families through the Child and Family Team (CFT) process despite setbacks, crises, or limited progress, using challenges as opportunities to reassess needs and revise strategies. The team will apply a “whatever it takes” approach that prioritizes family voice and choice in all decision-making and will not move toward transition or discharge until the youth, family, and team mutually agree that services should end. Ongoing needs, barriers, and plan adjustments will be documented to support sustained engagement and progress (PSE Children and Youth FSP-HFW, p9, 12; LACDMH-CWD Wraparound P&P p.18, p.21; SSG General Programs & Clinical Operations P&P, p124-125; CFT Facilitator Guidebook p34-40).
(b) SSG team will utilize clearly defined processes to access support when challenges arise, including consultation with supervisors and program leadership for coaching, guidance, and problem-solving. Team members may request additional coaching through supervision and team consultation structures, access flexible funding through established approval processes to address identified youth and family needs, and obtain additional services and supports through the CFT process. All requests, decisions, and follow-up actions will be discussed, documented, and monitored to ensure challenges are effectively addressed and resolved (LACDMH-CWD Wraparound P&P, p17, 52-56; Wraparound Guidebook, p49–50; PSE Children and Youth FSP-HFW p.12, 26).
(c) SSG team will ensure facilitators receive ongoing training and coaching to strengthen persistence, engagement, leadership, and problem-solving skills, including training in post-crisis safety planning, conflict resolution, effective brainstorming, and ongoing plan revision. Facilitators will participate in ongoing professional development through UC Davis COE and DMH Events Hub trainings, as well as receive regular supervision guidance to enhance facilitation and team leadership capabilities (LACDMH-CWD Wraparound P&P, p13-14,17; Facilitator Guidebook, p34, 49–50; PSE Children and Youth FSP-HFW, p26).
1.11 Transitions as a part of the Fourth Phase of HFW
(a) SSG team will ensure youth and families experience planned, supported transitions from High Fidelity Wraparound (HFW) services without sudden loss of services due to adverse events or administrative requirements. Transition planning will begin early and occur through the Child and Family Team (CFT) process, with readiness assessed based on progress toward goals, stability, and availability of natural, community, and formal supports. Family voice and choice will guide all transition decisions, and services will not end without team agreement. The team will maintain continuity of care during disruptions, implement gradual step-down strategies, and document transition supports and follow-up plans to prevent abrupt service interruptions (PSE Children and Youth FSP-HFW, p11–12; LACDMH-CWD Wraparound P&P, p18, 21, 39-40; General Programs & Clinical Operations P&P, p61-63, 66, 125).
(b) SSG team will collaborate with youth and families to plan and implement transition celebrations that honor the child or youth’s culture, values, and preferences as part of the overall transition process. Celebrations may include participation of natural and community supports and are used to reinforce accomplishments, relationships, and continuity beyond formal services. Administrative structures will support these practices through access to flexible funding for culturally appropriate activities, accommodation of staff time for planning and community coordination, development of community partnerships, and ensuring staff availability to participate. Transition celebration planning and implementation will be discussed and supported through supervision and team meetings (LACDMH-CWD Wraparound P&P, p18, 52-56; CFT Facilitator Guidebook, p49–50).
Expected Outcomes
2.1 Youth and Family Satisfaction
SSG HFW team collects feedback from youth and families through annual consumer surveys and ongoing feedback from youth and families. Responses are compiled and reviewed bi-annually to assess satisfaction levels and to make program improvement. The Youth Services Survey (Youth and Families versions) are available in threshold languages to ensure that families have linguistical choice in their feedback.
The Wraparound Fidelity Index (WFI) is used to gather family feedback regarding the cultural relevance and respectfulness of services and strategies. Results are reviewed to identify strengths and areas for improvement, including patterns related to cultural responsiveness. Feedback is shared with staff and supervisors through supervision and team meetings, and is used to provide targeted coaching and training to improve culturally responsive practices. Staff adjust planning and service delivery based on feedback, including incorporation of culturally relevant strategies and supports. WFI results are monitored over time as part of continuous quality improvement efforts.
In cases involving an Indian child, the Tribe is also consulted and asked to provide feedback to ensure cultural and procedural appropriateness. Data from the survey is reviewed with SSG leadership to direct future program development and improvement.
(BHIN-25-004-MH-Consumer-Perception-Survey-Data-Collection-2025; Youth Services Survey-Youth; Youth Services Survey-Families; PSE CHILDREN AND YOUTH FSP-HFW, p11-13; LACDMH-CWD Wraparound P&P, p42; Wraparound Fidelity Index)
2.2 Improved School Functioning
To track educational and vocational functioning and the youth’s progress, SSG HFW team reviews specific needs and resources related to school and vocational functioning during the CFT meeting and documenting goals in the Plan of Care. Review of progress is ongoing throughout the course of involvement in HFW and documented in case notes and Plan of Care. Progress is documented in the Transition Plan at exit. SSG HFW team will utilize IP-CANS and the OMA (Outcome Measures Application) at baseline, every 3 months and at discharge to evaluate progress in school functioning. Data will be used in conjunction with ongoing tracking of needs, goal completion, and action item progress through the Plan of Care. During Child and Family Team (CFT) meetings, both IP-CANS data and real-time progress are reviewed to guide team decision making. (PSE Children & Youth FSP-HFW, p16-17; LACDMH-CWD Wraparound P&P, p43-44; Plan of Care; IP-CANS; OMA; Transition Plan)
2.3 Improved Functioning in the Community
Youth progress is evaluated and monitored through structured assessments and case notes that track both justice involvement (e.g., arrests, court appearances, probation compliance) and participation in community activities (e.g., volunteering, school involvement, recreational programs). Review of progress is ongoing throughout the course of involvement in HFW and documented in the IP-CANS, Plan of Care and case notes. Progress is also documented in the Transition Plan at exit. (PSE Children & Youth FSP-HFW, p16-17; LACDMH-CWD Wraparound P&P, p43-44; IP-CANS; Plan of Care; IP-CANS; OMA; Transition Plan)
2.4 Improved Interpersonal Functioning
SSG HFW team will monitor youth and family interpersonal functioning through structured assessments (IP-CANS), family interviews, and case notes. Indicators include reduced family conflict, improved communication skills, and stronger peer and family relationships. Case notes are reviewed regularly to adjust service and support plans and strengthen positive family dynamics. (Family and Interpersonal Functioning Procedures, p22–25; PSE Children & Youth FSP-HFW, p16-17; LACDMH-CWD Wraparound P&P, p43-44; IP-CANS; OMA; Plan of Care; Transition Plan)
2.5 Increased Caregiver Confidence
SSG HFW team provides caregivers with information, coaching, and resource navigation to strengthen their skills and confidence in managing family challenges. The team tracks caregiver confidence through the WFI surveys, family interview, Youth Services Survey-Families, and case notes, as well as how caregivers are connected to community resources. The IP-CANS data and caregiver feedback are reviewed in team consultation and at CFT meetings (and documented in the Plan of Care) to improve services and ensure caregivers can effectively address crises and future needs. (HFW Policy Manual: Caregiver Support and Resource Navigation, p18–21; PSE Children & Youth FSP-HFW, p10-11; Youth Services Survey-Families; Wraparound Fidelity Index; IP-CANS; Plan of Care)
2.6 Stable and Least Restrictive Living Environment
SSG HFW team will track youth placements to ensure stability in community-based settings and minimize moves to restrictive environments such as detention centers, psychiatric hospitals, treatment centers, or STRTPs. The Plan of Care is used to document placement, monitor changes, and evaluate the reasons for moves. Team will use this information to develop individualized support plans that promote permanency, reduce disruptions, and maintain youth in the least restrictive setting appropriate for their needs. SSG team will utilize IP-CANS and the Outcome Measure Application (OMA) to assess living situation and track placement at admission, 3 months interval or key event changes and at exit. Youth and family’s needs and strengths will be reviewed during CFT meetings to guide team decision-making. (HFW Policy Manual: Placement Stability Procedures, p12–16; PSE Children & Youth FSP-HFW, p16-17; LACDMH-CWD Wraparound P&P, p43-44; Plan of Care; IP-CANS; OMA; Transition Plan)
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
SSG HFW team will monitor youth behavioral health stability by tracking hospital admissions, including inpatient stays and emergency department visits. The OMA is used to track any ER, urgent care or hospital visits at admission, 3 months interval or key event changes and at exit. The Plan of Care and case notes also document crisis, utilization of behavioral health, formal and informal services to manage crisis.
Data is reviewed in supervision, weekly team consults to inform individualized interventions, ensure continuity of care, and address emerging behavioral health needs proactively. (HFW Policy Manual: Monitoring Hospital Admissions, p14–17; PSE Children & Youth FSP-HFW, p16-17; LACDMH-CWD Wraparound P&P, p43-44; Plan of Care; Crisis intervention case notes; OMA; Transition Plan)
2.8 Reduction in Crisis Visits
SSG HFW team will track youth crises and the involvement of professional support to monitor crisis prevention and management through monthly CFT meetings, weekly supervision and team consults. Clinicians will document each crisis event on the Crisis Intervention case note in SSG’s Electronic Health Record (EHR) system, where the frequency of crises can be tracked. Team members review each reported crisis event, the strategies used by youth and their natural supports to manage it, and the level of professional intervention required. Data is reviewed to evaluate trends, identify areas for skill-building, and strengthen the family’s ability to handle crises independently. (HFW Policy Manual: Crisis Management and Documentation, p12–15; Wraparound SOW, p7-8; SSG General Programs & Clinical Operations P&P, p74-78; Crisis Intervention case note)
2.9 Positive Exit from HFW
SSG HFW team will utilize the IP-CANS, Pediatric Symptom Checklist (PSC), OMA, Plan of Care data to review progress and to ensure that youth and families exit HFW based on demonstrated stabilization and progress toward their goals, rather than due to adverse events. The Plan of Care documents the timing and plan of program exit. SSG team reviews exit data with youth and family and other formal and informal supports to evaluate the effectiveness of interventions, identify patterns, and inform future service planning to promote positive, sustainable outcomes for families. ( Discharge and Positive Exit Procedures, p20–23; SSG General Programs & Clinical Operations P&P, p62-63, 66, 125; LACDMH-CWD Wraparound P&P, p39-40; Transition-Discharge Plan)
Engagement
3.1 Orientation
a) SSG HFW provides outreach and engagement and provides a structured orientation to youth and families that includes a clear overview of the High Fidelity Wraparound (HFW) principles and four phases: Engagement and Team Preparation, Plan Development, Plan Implementation, and Transition. The facilitator explains these components in a family-friendly and culturally responsive manner, emphasizing Family Voice and Choice, the role of the Child and Family Team (CFT), and inclusion of natural supports and Tribes when applicable. The team provides explanations in the preferred language of the youth and family. Orientation occurs during initial face-to-face engagement and is reinforced through ongoing contact. The facilitator checks for understanding and ensures the family is prepared to actively participate in the HFW process. (LACDMH-CWD Wraparound P&P, p18; Strengths-Needs-Culture Inventory, p1-2; Wraparound SOW, p1-4; SSG Welcome Packet).
b) SSG HFW team will orient youth and families to the HFW process, including providing an overview of the HFW principles and phases. The team will highlight the HFW principles of family voice and choice, team-based collaboration, natural supports, community-based services, cultural competence, individualized and strengths-based planning, persistence, outcome-based focus, and unconditional care, emphasizing that these principles are intended to promote youth well-being and support long-term family stability. The team will also review the four phases of Wraparound—Engagement, Planning, Implementation, and Transition—and emphasize that these phases are dynamic and may shift based on the evolving needs and circumstances of the family. (LACDMH-CWD Wraparound P&P, p18; PSE Children & Youth FSP-HFW, p12)
c) SSG HFW team will ensure that all youth and families are oriented to legal and ethical considerations at the beginning of services. This includes a clear explanation of confidentiality, informed consent, and the use and disclosure of Protected Health Information (PHI). The facilitator reviews the limits of confidentiality, including mandated reporting requirements, and ensures that families understand their rights related to participation in services and information sharing.
Families are informed of their rights, including the right to participate in decision-making, to consent to or decline services, and to understand how their information will be shared among team members. Written consent forms are reviewed, signed, and maintained in the youth’s clinical records prior to the exchange of protected health information. The SSG HFW team will ensure that information is shared in compliance with HIPAA and county requirements, and only the minimum necessary information is disclosed to support care coordination. All discussions are conducted in a culturally and linguistically appropriate manner to ensure comprehension and meaningful participation. (LACDMH-CWD-Wraparound P&P, p 6-7, 12; Limits of Confidentiality; SSG Consent for Services; SSG Welcome Packet, p. 7-11).
d) SSG HFW provides a comprehensive orientation to youth and families regarding the roles and responsibilities of each Child and Family Team (CFT) member. This includes clearly defining the role of the facilitator, clinician, parent partner, and other formal service providers, as well as emphasizing the central role of the youth and family in guiding all planning and decision-making.
The program prioritizes Family Voice and Choice, ensuring that youth and caregivers are recognized as equal partners and primary decision-makers within the team. Natural supports (e.g., extended family members, friends, community members, and faith-based supports) are actively identified, invited, and engaged as integral members of the team to promote sustainability and community integration.
In the case of an Indian child, the HFW team ensures that Tribes are engaged as appropriate and in accordance with applicable laws and cultural considerations. Tribal representatives are included as key partners in planning and service delivery to ensure culturally responsive care and compliance with federal and state requirements.
Roles and expectations of all team members are reviewed during orientation and reinforced throughout the HFW process to ensure collaboration, accountability, and shared ownership of the Plan of Care. (Wraparound Program SOW, p 3-4)
3.2 Safety and Crisis stabilization
The SSG HFW team will address initial safety and crisis concerns during the Engagement Phase through direct conversations with the youth and family. This is always facilitated in their preferred language to reinforce being culturally sensitive to our clients and families’ needs. If immediate or concerns are identified, the team develops an individualized crisis response plan that outlines specific interventions, roles, and steps to stabilize the situation. This plan is reviewed with the family, provided in written form, and maintained in the client record. The approach ensures that urgent needs are addressed promptly so the family can effectively engage in the HFW process. (Wraparound SOW, p7-8; LACDMH-CWD Wraparound P&P, p25, 28, 45-46; PSE Children & Youth FSP-HFW, p15; SSG General Programs & Clinical Operations P&P, p74-76; Safety & Crisis Plan).
The SSG HFW team will utilize the initial crisis response plan as a short-term stabilization tool that informs the development of the comprehensive Safety Plan during the Plan Development Phase. The Safety Plan is a more detailed and individualized document that incorporates identified triggers, prevention strategies, and coordinated team responses. The program ensures continuity between immediate crisis interventions and longer-term safety planning, while maintaining both documents in the client record as appropriate. All team members during a crisis has access to the Safety & Crisis Plan, SSG 24/7 crisis phone, and supervisor/management phone). (LACDMH-CWD Wraparound P&P, p25, 28, 45-46).
All families are provided with information on how to access 24/7 crisis response services at the time of engagement. The crisis phone numbers are included in the Safety & Crisis Plan, which is provided in English, Spanish, and other preferred languages for the clients and families. The SSG HFW team reviews available crisis resources, including emergency contacts and county crisis lines, and ensures that this information is included in the crisis and/or safety plan. The program maintains protocols to support timely response to crises and reinforces this information with families throughout service delivery. (LACDMH-CWD Wraparound P&P, p25, 28, 45-46; Wraparound Process Users Guide, p10).
3.3 Strengths, Needs, Culture and Vision Discovery
a) During the Engagement Phase, the SSG HFW team will conduct structured and informal conversations with the youth and family to elicit their Family Vision, ensuring alignment with Family Voice and Choice. The vision reflects the family’s desired future, priorities, and outcomes and is written in the family’s own words. This vision is reviewed with the family for accuracy and incorporated into the Plan of Care to guide all service planning and team activities. (Plan of Care; LACDMH-CWD Wraparound P&P, p4; Wraparound Process Users Guide, p. 15),
b) The SSG HFW team will facilitate ongoing, structured conversations with the youth and family to identify and document strengths, needs, and cultural preferences. This information is captured in a Strengths, Needs, and Culture Inventory document, which is initiated during the Engagement phase and maintained in the youth’s chart.
The document is treated as a living document and is formally reviewed and updated at a minimum of every 90 days, or more frequently as new information is identified through CFT meetings, family engagement, and service delivery. The team actively incorporates newly identified strengths, emerging needs, and cultural considerations to ensure the plan of care remains individualized and culturally responsive. The updated document is shared with all current and new team members to ensure continuity, shared understanding, and alignment in service planning. (Strengths-Needs-Culture Inventory; LACDMH-CWD Wraparound P&P, p4, 24; Wraparound Program SOW, p3)
3.4 Engage All Team Members
a) The SSG HFW team will collaborate with the youth and family during the Engagement phase to complete a natural supports inventory, identifying individuals who are meaningful and supportive within the family’s network. This includes extended family, friends, community members, and other informal supports. The facilitator gathers this information through conversations and assessment activities and documents it in the Strengths, Needs, Culture & Supports Inventory, which is maintained in the youth’s case file and updated as new supports are identified. (Wraparound SOW, p3-4; Strengths- Needs-Culture-Supports Inventory; Wraparound Process Users Guide, p. 7).
b) The SSG HFW team will identify and engage all relevant Children’s System of Care partners (e.g., DCFS, Probation, mental health providers, education, and other service providers) through ongoing outreach and collaboration. The facilitator ensures that both formal and informal supports are engaged in the Child and Family Team (CFT) process to support coordinated service planning and delivery. Engagement is guided by Family Voice and Choice to ensure appropriate and meaningful participation of all partners. (Wraparound Program SOW, p3-4; LACDMH-CWD Wraparound P&P, p21-23; PSE Children & Youth FSP-HFW, p13).
c) The SSG HFW team will collaborate with the youth and family to identify team members, including formal supports, natural supports, and Tribal representatives when applicable. The facilitator ensures that team members are selected based on Family Voice and Choice and that each member’s roles and responsibilities are clearly defined during Child and Family Team (CFT) Meetings. (Wraparound Program SOW, p 4; LACDMH-CWD Wraparound P&P, p21-23; Wraparound Process Users Guide, p6-7).
d) The SSG HFW team facilitates intentional engagement and team-building activities to promote a positive, strengths-based, and collaborative team culture. These activities occur during CFT meetings and through ongoing communication between meetings. The Wraparound process requires ongoing collaboration, shared responsibility, and regular meetings to review progress and update plans. All engagement and team-building activities are documented in the youth’s file through meeting minutes and case notes. (CFT Meeting Follow Up; Wraparound SOW, p3-4; Wraparound Process Users Guide, p. 6,8,16).
3.5 Arrange Meeting Logistics
a) The SSG HFW team will ensure that CFT meetings are scheduled at times and locations that are convenient and accessible to the youth, family, and team members, with priority given to family voice and choice. Staff demonstrate flexibility in scheduling, including evenings, weekends, and community-based or virtual locations, to accommodate family needs, work schedules, cultural considerations, and transportation barriers.
The SSG HFW team will conduct timely engagement and coordination with families, including face-to-face contact within 24 hours of referral and ongoing service delivery in settings where the youth and family are naturally located, supporting flexibility in meeting logistics and accessibility. (Wraparound SOW, p4-5; LACDMH-CWD Wraparound P&P, p6-7; Wraparound Process Guide, p14).
b) SSG HFW staff are trained to collaborate with youth, families, and team members to schedule meetings that align with family preferences and maximize participation. Scheduling decisions are guided by Family Voice and Choice, ensuring that families identify who participates, when and where meetings occur.
The Wraparound facilitator works with the family to coordinate meetings, invite team members, and ensure participation, while maintaining ongoing communication between meetings to support engagement. HFW team is also responsible for arranging logistics such as transportation, interpretation services, and telehealth access as needed to ensure equitable participation for all team members. (Wraparound SOW, p3-4; Wraparound Process Users Guide, p 5, 16).
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
Before the HFW Plan of Care is developed, the SSG HFW team will lead the completion of team agreements, a team strengths inventory, and a shared mission statement with the family. These will be documented in the youth’s file. Team agreements outline how meetings and decisions will occur (e.g., respectful communication and consensus-based decision-making), while the strengths inventory captures youth and family strengths and natural supports (e.g., family advocacy skills or presence of community mentors). Strengths identified during engagement are updated as new strengths emerge and are documented in the youth’s file on an ongoing basis. (LACDMH -CWD LACDMH-CWD Wraparound P&P, p24; Strengths-Needs-Culture Inventory; Plan of Care)
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
Before developing the HFW Plan of Care, the SSG HFW team works collaboratively with the youth and family to identify and prioritize the family’s underlying needs, ensuring they are clearly documented in the youth’s file. These needs focus on root causes rather than surface-level behaviors (e.g., a need for consistent adult support or family stability instead of “noncompliance”). From these identified needs, the team will develop measurable, strengths-based goals and outcomes that reflect meaningful change for the youth and family (e.g., increased school engagement through supportive routines or improved family communication).
The SSG HFW team will develop these goals and outcomes jointly with the youth, family, and all team members to ensure shared understanding, buy-in, and alignment with the family’s vision. The team then engages in structured brainstorming to identify multiple individualized strategies that may address the prioritized needs, which are documented in the youth’s file and referenced as needed (e.g., natural supports, community resources, family-led solutions).
Facilitators are trained to guide the team through identifying, prioritizing and selecting strategies and action steps. These coordinated efforts are used to develop an individualized HFW Plan of Care within a team-based, collaborative environment that remains flexible and responsive to the family’s evolving needs.
(LACDMH -CWD Wraparound P&P, p24; SSG General Programs & Clinical Operations P&P, p21-22; Plan of Care)
4.3 Develop an Individualized Child or Youth and Family Plan
The SSG HFW team will develop a comprehensive initial HFW Plan of Care that is grounded in the prioritized needs, goals, and strategies identified by the youth and family. This work is accomplished through a high-quality, collaborative team process across all Children’s System of Care partners that elicits multiple perspectives, builds trust and shared vision, and demonstrates core HFW principles. The facilitator leads the team to ensure the Plan of Care aligns with the family’s vision and the team mission statement and is based on the youth’s and family’s strengths, needs, culture, and lived experience.
The SSG HFW team ensures the Plan of Care addresses needs across multiple life domains and system partners as identified and prioritized by the team. Clearly documented strategies and action steps identify responsible parties, establish timelines, and promote shared accountability, with strategies that are culturally relevant and include a balance of formal services, natural supports, and community and family resources, with intentional movement toward increased reliance on natural supports over time. The Plan includes a coordinated array of services and supports tailored to the unique needs of the youth and family, delivered in the community in which they live, and guided by family voice and choice while taking into account family schedules, cultural considerations, and histories of trauma.
Natural supports and sustainable community resources are incorporated into the Plan of Care whenever possible, or the Plan includes clear strategies to identify and develop these supports prior to transition from the HFW Program. The SSG HFW team also ensures that transitions from formal services are gradual and intentional, with benchmarks that support movement toward less restrictive and less formal supports, allowing families to progress at a pace that aligns with their readiness and capacity.
(SSG General Programs & Clinical Operations P&P, p21-22; LACDMH -CWD Wraparound Program P&P, p 24; Plan of Care)
4.4 Develop a Crisis and Safety Plan
a) Ensure that an individualized crisis and safety plan is documented in the youth’s file. The plan identifies potential safety, high‑risk, and crisis situations; outlines proactive and reactive crisis management strategies selected by youth and family members; and specifies appropriate contacts for 24/7 support.
(b) Ensure that the development of the crisis and safety plan occurs in a team‑based, collaborative environment. HFW facilitators will receive training and coaching to effectively support this planning process.
SSG HFW supervisors will regularly review crisis and safety plans during clinical supervision and Quality Assurance reviews to ensure individualized strategies, appropriate progression of proactive and reactive interventions, cultural relevance, and effective use of natural supports. These review processes will be used to support continuous quality improvement, as well as to inform training and coaching efforts.
(General Program & Clinical Operations P&P, p 64-66; LAC-DMH/CWD Addressing High-Risk Behaviors and Safety Planning; LACDMH -CWD Wraparound Program P&P, p25-26; Safety Plan; LPS Hospitals-Urgent Care List)
Implementation
5.1 Implement The Plan of Care
(A) SSG HFW team will implement the Plan of Care through coordinated team action, with clearly assigned roles and timelines. Facilitators track completion of action items between meetings and lead structured reviews during Child and Family Team (CFT) meetings using agendas and meeting minutes to monitor progress. The team evaluates the effectiveness of strategies in meeting identified needs and adjusts strategies and action steps as needed. Progress and completion are documented, and successes are recognized and celebrated to reinforce engagement and progress. (SSG General Programs & Clinical Operations P&P, p21-22; Facilitator Guidebook, p19, 43–44; LACDMH-CWD Wraparound P&P, p8, 21; Plan of Care).
(B) SSG HFW team will receive ongoing training and coaching on carrying out the Plan of Care in alignment with High Fidelity Wraparound principles. Training includes guidance on monitoring action items, evaluating the effectiveness of strategies, and maintaining a strengths-based, family-driven approach. Supervisors and coaches provide ongoing support through case consultation and feedback. Staff are also trained to recognize and celebrate successes as they occur, incorporating acknowledgment of progress into Child and Family Team (CFT) meetings and documentation to reinforce engagement and positive outcomes. (LACDMH-CWD Wraparound P&P, p13-14, 17; Facilitator Guidebook, p44, 49–50; PSE Children & Youth FSP-HFW, p26; SSG General Programs & Clinical Operations P&P, p45-46; humanservices.ucdavis.edu).
5.2 Review and Update The Plan of Care
(A) SSG HFW team will facilitate regular Child and Family Team (CFT) meetings to review the Plan of Care, including progress toward goals, completion of action items, and effectiveness of strategies. The facilitator guides the team in assessing what is working and what needs adjustment, and updates goals, strategies, and action steps as needed. All updates are documented in meeting minutes and the Plan of Care, including assignments, timelines, team attendance, and use of formal and natural supports. The updated Plan of Care is distributed to all team members at least every 90 days, and more frequently as needed. (see supporting docs below)
(B) SSG HFW facilitator will facilitate ongoing Child and Family Team (CFT) meetings where progress, successes, and emerging needs are reviewed. The facilitator leads the team in adjusting goals, strategies, and action items based on this review, including adding new strategies or modifying existing ones as needed. All updates are documented in the Plan of Care and meeting minutes and maintained in the youth’s file, and the updated plan is shared with all team members to ensure alignment and continued progress.
(C) SSG HFW facilitator will document all Child and Family Team (CFT) meeting activities, including completion of tasks, new assignments, team attendance, use of formal and natural supports, use of flexible funds, and updates to the Plan of Care. Facilitators maintain structured meeting minutes that capture progress, assigned responsibilities, and timelines. These updates are communicated to all team members through distribution of meeting minutes and updated plans, ensuring shared understanding and accountability. All documentation is maintained in the youth’s file.
(D) SSG staff will utilize the Plan of Care and CFT Meeting Follow up forms and related documentation, as living documents that are regularly updated during Child and Family Team (CFT) meetings to reflect changing needs, priorities, and strategies. Forms are individualized to the youth and family by incorporating their language, culture, and preferences, and are revised as new needs are identified or strategies are adjusted. Updates are documented, shared with the team, and maintained in the youth’s file to ensure accuracy and alignment with current planning.
(Facilitator Guidebook, p19, 34, 43-44, 49-50; LACDMH-CWD Wraparound P&P, p18, 21-22, 24; SSG General Programs & Clinical Operations P&P, p21-22; Wraparound SOW, p3-4; Plan of Care; CFT Meeting Follow Up form)
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
(A) SSG HFW team will establish team agreements during early Child and Family Team (CFT) meetings and incorporate them into ongoing team processes. Facilitators ensure that team agreements are reviewed regularly during meetings and used to guide communication, participation, and accountability. Facilitators continually assess team cohesion, trust, and engagement, address conflicts and ensure all voices are heard. Natural supports are identified and integrated into the team, and new team members are oriented to the team’s goals and agreements. Team agreements and related discussions are documented in meeting minutes to support ongoing collaboration and team functioning. (supporting documents listed below)
(B) SSG HFW facilitators will receive ongoing training and coaching on building, engaging, and maintaining effective Child and Family Teams (CFTs). Trainings include facilitation skills, engagement strategies, conflict resolution, and application of High Fidelity Wraparound principles. Supervisors and coaches provide ongoing support through supervision, case consultation, and feedback, including review of team dynamics and facilitation practices. Additional coaching is provided as needed to address challenges and support continuous skill development.
(C) SSG HFW team will continue to assist the youth and families in identifying natural supports and monitoring their use over time through ongoing Child and Family Team (CFT) meetings and case documentation. Facilitators regularly review the effectiveness of natural supports with the team and adjust as needed to strengthen their role in supporting the youth and family. Supervisors and coaches review documentation and provide feedback during supervision and coaching sessions to support staff in effectively engaging and utilizing natural supports, consistent with High Fidelity Wraparound principles.
(D) SSG HFW team will utilize a structured process to orient new team members, including both formal and natural supports, to the Child and Family Team (CFT). Facilitators provide an overview of the High Fidelity Wraparound process, review the current Plan of Care including goals, strategies, and action items, and clarify the new member’s role on the team. New members are introduced during CFT meetings, team agreements are reviewed, and opportunities for team-building and engagement are provided. Orientation activities and role assignments are documented in meeting minutes to ensure consistency and team alignment.
(Facilitator Guidebook, p19, 34, 49–50; LACDMH-CWD Wraparound P&P, p13, 17, 21–23; Wraparound SOW, p3-4, 14, PSE CHILDREN AND YOUTH FSP-HFW, p12-13; humanservices.ucdavis.edu; https://eventshub.dmh.lacounty.gov;).
Transition
6.1 Develop a Transition Plan
As described in section 5.2 Review and Update the Plan of Care, the youth/family’s progress is reviewed and assessed throughout the HFW process via CFTs. Once it is determined by the team that the youth/family are ready to transition out of HFW, SSG HFW facilitator will:
– Organize team members for a CFT.
– Engage the child/youth, family, and team members in developing an individualized Transition Plan through a collaborative process.
– Lead the team in analyzing progress based on benchmarks (Plan of Care, CANS, PSC-35, OMAs, other rating scales).
-Engage the team to identify any needs, services and supports to include in the transition plan that will persist beyond formal HFW and ensure that the family is able to access them. SSG team will distribute the plan to all team members and document the plan in the youth’s file.
SSG team will make the necessary linkages to the most appropriate services and supports.
In addition, SSG HFW facilitators will receive training and ongoing coaching to this process of leading the CFT in developing and implementing the transition plan. (LACDMH-CWD Wrapround P&P, p13-14, 39-40; SSG General Program & Clinical Operations P&P, p 52-53; Transition-Discharge Plan Form)
6.2 Develop a Post-Transition Safety Plan
SSG HFW team will:
(a) Ensure that each youth’s individualized crisis and safety plan is reviewed and updated to reflect the transition process, or that a new transition-focused crisis and safety plan is developed when needed. The updated plan is documented in the youth’s file and identifies potential crisis triggers and situations that may arise following transition from HFW. The plan includes both proactive and reactive crisis management strategies, such as positive coping skills and the use of natural supports, as selected by the youth and family.
(b) Facilitate the development of the crisis and safety transition plan within a team-based, collaborative environment. Facilitators engaged in this process will receive appropriate training and ongoing coaching to effectively support collaborative planning and family-driven decision-making.
SSG HFW supervisors will regularly review crisis and safety plans during clinical supervision and Quality Assurance reviews to ensure individualized strategies, appropriate progression of proactive and reactive interventions, cultural relevance, and effective use of natural supports. These review processes will be used to support continuous quality improvement, as well as to inform training and coaching efforts.
(SSG General Program & Clinical Operations P&P, p 64-66; LACDMH-CWD Wraparound P&P, p13-14, 25-26; LACDMH-CWD Addressing High-Risk Behaviors and Safety Planning staff handout; Safety & Crisis Plan Form, List of LPS Hospitals & Urgent Care Centers)
6.3 Create a Commencement and Celebrate Success
The SSG HFW team will:
(a) Ensure that a youth/family’s transition out of HFW is celebrated in ways that reflect the family’s culture, values, and stated preferences.
(b) Ensure that administrative structures support engagement in these celebrations, including access to flexible funding (e.g., for refreshments, appropriate/meaningful graduation incentives, etc.), staff time for community resourcing and establishing community partnerships to connect youth/families to lasting natural supports, and staff availability to attend and participate in celebrations.
(Wraparound Process Users Guide, p17-18; Facilitator Guidebook, p54)
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
Los Angeles county DMH facilitates monthly meetings that include stakeholders, families and peer advocates, service providers to identify ongoing needs, resources, emerging issues within the larger communities to ensure service delivery is timely, appropriate, culturally relevant and empowering for youth and families. SSG HFW supervisor and manager participate in these meetings throughout LA county districts.
7.2 Community Leadership Team
SSG HFW supervisor and manager participate in the community leadership meetings throughout LA county districts.
7.3 Eligibility and Equal Access
SSG Behavioral health programs function based on the continuum of needs. Youth and families are enrolled in programs based on their eligibility criteria and when approved by the funder – LACDMH. Staffing in HFW is assigned based on the program requirement and level of needs of the participants, that may include varying caseload and/or after hour crisis support. The SSG HFW team may include individual therapist and family therapist based on family needs and voice and choice. (SSG Program & Operations Continuum of Care)
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
SSG HFW programs allocated funding comes from LACDMH. Staffing is planned and assigned based on specific roles and functions delineated in the LACDMH Wraparound model.
SSG leadership reviews billings and claims for HFW program monthly and track cost and revenue to ensure that funding allocation is sufficient to continue to meet the immediate needs of the families. SSG supervisor reviews team members case notes weekly and billing claims monthly to ensure appropriate clinical service and efficient productivity for the service. (DMH SSG Wraparound cost-revenue report)
8.2 Equitable Funding Across System Partners
SSG HFW utilizes funding from several sources to support the youth and families in different capactities:
– Utilization of private donations when there are needs that can not be funded through established funding sources.
– Utilization of flexible funds to support youth and families for life needs – housing, utilities, clothing. SSG HFW coordinates with the Department of Children & Families services to share these costs when possible.
– Referral and linkage to housing, regional center, foodbank and other resources in the youth/family communities to maximize resources and support the families for their respective needs.
(SSG Program & Operations, policy #3050)
8.3 Cost Savings are Reinvested
SSG HFW programs are funded through LACDMH cost reimbursement. The annual maximum cost allowance is provided to the legal entity and the programs submit claims monthly to be reimbursed directly by LACDMH.
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
SSG HFW uses the CFT meetings to identify youth/family’s needs for flexible funds. The discussion of needs and resources incorporate formal and informal resources, cultural relevance and sustainability. SSG HFW team members support the family to identify low cost options.
SSG HFW supervisor approves the flexible fund within 1 week. Each HFW team has an internal system to access the funds from SSG fiscal department. All approved expenses are submitted to SSG fiscal department within 5 days of the previous month for submission to the LA county DMH for reimbursement.
(SSG Program & Operations Policy 3050 ; LACDMH-CWD Wraparound P&P, p52-57)
8.5 Collaborative Oversight of Flex Funds
SSG HFW programs share the cool of flex funds within SSG. SSG fiscal department provides fiscal oversight. SSG fiscal department submits documents to the LA county DMH for reimbursement monthly.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
SSG team collaborates with other formal sources to identify the best resources for the youth and family needs. SSG team also utilizes internal SSG resources such as housing, vocational services. Resource funds is a braiding of available system of care funding that may include but not exclusive sources such as Calworks, foundation, BHSA, respite care. SSG programs share flex funds to ensure resources can be available to families based on needs. (SSG Programs&Operations, policy#3050)
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
SSG ensures a culturally responsive workforce for High-Fidelity Wraparound (HFW) programs by implementing hiring, training, and service delivery standards that reflect the diversity of the youth and families served. This commitment is operationalized through the following strategies:
Hiring and Workforce Diversity
Reflecting the Community: HFW programs prioritize hiring staff who can meet the cultural, racial, and linguistic needs of families. The goal is for the workforce to reflect the diversity of the surrounding communities and the lived experiences of the population served.
Inclusive Recruiting: The organization promotes the inclusion of individuals from all backgrounds and lived experiences to ensure service delivery is informed by a wide range of perspectives.
Linguistic Competence and Capacity
Monolingual Client Support: Programs are required to ensure that every monolingual client is assigned at least one staff member who is culturally and linguistically competent in the client’s primary language. SSG has several divisions with bilingual staff with linguistic capability in threshold AAPI languages and Spanish.
Appropriate Matching: During the intake and screening process, assignments are specifically made to match staff language and cultural capabilities with the needs of the client.
Service Delivery: All services must be provided in a language that is culturally and linguistically appropriate for all participants.
Culturally Sensitive Engagement
Diverse Engagement Teams: Outreach and engagement efforts respond to the gender, ethnicity, and language preferences of individuals by utilizing a diverse engagement team based on the family’s preferences.
Cultural Discovery: Facilitators work with families to gather information regarding their cultural identity and past traumatic experiences, highlighting these assets to empower the family throughout the treatment process.
(SSG General Programs & Clinical Operations policy #2000. #3010 #3030; PSE Children & Youth FSP-HFW, p1 ; Wraparound Program SOW, p3, Sec. 2.2.2; LACDMH-CWD Wraparound P&P, p13, 16-17 )
9.2 Tribally Responsive Workforce
In the case of Indian child/ family, the SSG Team will identify available SSG staff who has capacity to serve the family with the most cultural training. If the team does not have capacity, SSG will offer the family choice for referral to an appropriate service provider. If the family prefers to continue working with the SSG team. The SSG team will collaborate with tribal representative consultants to help in the engagement and treatment phases to ensure that services respect tribal sovereignty, traditions and values. The tribal representative consultant can also to identify appropriate resources to support the youth and family within the formal and informal tribal networks.
9.3 Flexible and Creative Work Environment
SSG Leadership ensures staff engagement through the following procedures and initiatives:
(a) Program Quality and Improvement
SSG team leadership maintains a high degree of collective responsibility for program quality by implementing local Continuous Quality Improvement (CQI) evaluation plans to routinely monitor the HFW initiative. Supervisors and managers utilize collected data at all levels to improve overall program effectiveness and practice with families. Managers are required to attend quarterly learning community sessions to analyze outcome data and track progress toward specific performance metrics. (LACDMH-CWD Wraparound P&P ) Additionally, leadership incorporates feedback from youth and families to inform quality improvement of the HFW model. (Youth Service Survey). Clinical concerns discovered during quarterly chart reviews are reported to Program Managers and Directors to facilitate ongoing improvements in documentation and service delivery. (SSG General Program & Clinical Operations )
(b) Cohesion and Positive Team Environment
SSG team leader is responsible for creating structures that promote staff creativity, flexibility, and cohesion. To foster a positive team environment, facilitators intentionally engage the HFW team in activities designed to build a collaborative culture. Supervisors utilize team meetings and case conferences to involve teams from varying disciplines, ensuring all staff understand how their unique roles contribute to program impact. Furthermore, management is committed to maintaining a harassment-free environment where all colleagues are treated with fairness, courtesy, and good faith.
(c) Open Communication
The SSG leadership operates in an “open door” manner, encouraging staff to reach out to supervisors or managers at any time regarding regulations, standards of care, or ethical business practices. Bi-directional communication is prioritized to streamline the flow of pertinent information between management, staff, and external stakeholders. Supervisors facilitate regular one-to-one and group meetings to provide a private forum for staff to discuss caseloads and any clinical or professional issues they encounter. Formal communication structures are also established between different leadership tiers to ensure organizational and systems-level standards are met.
(d) Mission and HFW Philosophy Compliance
SSG Leadership ensures a clear sense of mission by requiring all personnel to sign a formal agreement to adhere to the organization’s mission and values. To maintain compliance with HFW philosophy, supervisors are specifically tasked with monitoring team functions to ensure direct services follow the HFW process with fidelity. Leadership implements a High Fidelity Training Plan that includes “Wraparound 101” foundations and role-specific training for all team members. Ongoing coaching and apprenticeship are provided to emphasize Wraparound values, principles, phases, and activities. Supervisors also oversee the implementation of the Integrated Core Practice Model (ICPM) to ensure the delivery of trauma-informed care remains aligned with HFW standards. HFW Fidelity Coach/Clinical supervisor partners with HFW program manager in fidelity monitoring, providing feedback to the team and ensuring that the team adheres to required timelines from engagement to care planning and throughout the program.
(SSG General Programs & Clinical Operations, policy#100.#2200-2202 #3300.#2060.#2000; LACDMH-CWD Wraparound P&P, P15; PSE Children and Youth FSP-HFW, p21, 24.)
9.4 Hiring, Performance Evaluation, and Job Descriptions
Procedures provide clear guidance regarding the roles and responsibilities of all HFW team members, including the HFW Supervisor/Manager, Clinical Supervisor and Fidelity Coach, Facilitator, Family Specialist, Caregiver, and Youth Peer Partner. Job descriptions outline a role summary, essential functions, minimum qualifications, and other requirements, and are specific to the skills, knowledge, and experience required for HFW positions.
The hiring process—particularly the interview process—screens candidates for the necessary skills and knowledge and provides an opportunity for applicants to share specific experiences directly related to the job functions. A minimum of three employment references are contacted to further assess candidates’ competency. New employees are screened with live scan/finger print process for security and TB clearance for those who go to school sites. (SSG job descriptions)
During orientation and initial staff training, employees are provided with clear expectations for their duties and performance, as well as the necessary tools, supervision, and ongoing coaching to support successful performance. Staff performance is monitored on an ongoing basis through regular supervision, documented using supervision forms, and formally evaluated annually using the SSG employee evaluation form.
(LACDMH -CWD Wraparound P&P, p15-17; Forms 9.4 -Job Descriptions-FSP-HFW roles; SSG Programs&Operations policy 2200-2202 )
9.5 Workforce Stability
SSG has implemented a multi-faceted Workforce Stability Plan designed to reduce turnover and maintain a resilient workforce by addressing compensation, workload, and professional growth.
The specific strategies and processes implemented to meet these goals include:
(a) Matching Wages to Cost of Living
To ensure compensation reflects the economic reality of service areas, the organization utilizes:
Annual Market Analysis: A yearly review of regional salary benchmarks within the non-profit behavioral health sector.
Locality Pay: A geographic differential provided to staff working in high-cost-of-living areas to protect their purchasing power.
Cost of Living Adjustments (COLA): Regular budget integrations of COLA to mitigate the effects of local inflation.
(b) Maintaining Manageable Workloads
The organization prioritizes staff well-being and clinical quality over high-volume productivity through several mechanisms:
Weighted Caseload Models: A points-based system that adjusts for case complexity to prevent clinicians from being overburdened by high-acuity clients.
Productivity Caps: Billing targets are set at sustainable levels (60–65%) to allow for self-care and peer consultation.
Protected Administrative Time: Schedules include blocked “documentation hours” to ensure paperwork is completed within the standard workday.
Clinical Support: Standard schedules include regular one-on-one supervision, group consultation, and trauma-informed supervision.
(c) Accessible Advancement for those with Lived Experience
The organization fosters an inclusive culture where professional growth is transparent and removes traditional barriers:
Low-Barrier Pathways: Peer certifications and relevant field experience are weighted alongside traditional academic degrees to ensure leadership pipelines are open to those with lived experience.
Clear Advancement Criteria: Promotion requirements are made visible and objective through a defined list of competencies.
Internal First Policy: All vacancies are announced to current staff before beginning external recruitment to encourage internal movement.
(d) Wage Increases and Leadership without Position Changes
Strategies are in place to reward excellence and specialized skills without forcing staff into management roles:
Clinical Ladders: Staff can advance through tiers (e.g., Therapist I to III) by obtaining specialized certifications, which triggers an automatic wage increase while allowing them to stay in their direct-care role.
Merit-Based Increases: Annual base-pay increases recognize commitment to clinical quality and community impact.
Differential Pay: Extra compensation is provided for staff working non-traditional hours, providing multilingual services, or working in high-intensity crisis settings
(SSG Personnel Policy P.14-19; P21-23; P44-49;)
9.6 High Fidelity Training Plan
In the first phase of HFW implementation, SSG team members are trained by attending the UC Davis RCFFP and LACDMH when available. Staff also will receive specific EBP through external source when training funds is available and within SSG through SSG training site Relias. All SSG staff must complete Cultural Competency Training, safety training as part of their foundational requirements at SSG through the SSG training site Relias).
SSG team members also receive ongoing training in general Wraparound and in their specific roles through external sources UC Davis and LACDMH, and internally through coaching, individual and group supervision.
SSG Clinical Supervisors are responsible for training staff in culturally appropriate, person-centered plan development. They also support team members in specifically addressing issues of culture and race, advocating for resources to ensure all families have equal opportunities to thrive. (SSG P&P policy#2000. #2060a. #2100).
SSG supervisors and managers will attend general wraparound training and ongoing booster trainings as needed. They also are required to attend SSG training on leadership/supervisory role and safety training.
Tribal Responsiveness: For appropriate service for Indian children, SSG program incorporates cultural competence training that respects tribal sovereignty, traditions, and values. When necessary, SSG team invites partnership with tribal representatives to promote positive outcomes to the unique needs of the youth/family. (PSE Children and Youth FSP-HFW, p6-7; Wraparound Program SOW, p11)
9.7 Community-based Training Program
SSG youth, families and peer partners receive training from UC Davis and LACDMH to ensure their participation in the wraparound program is highlighted and empowering for youth and families. Community partners are encouraged to review and attend wraparound trainings if pertinent to strengthen their supporting role within the system of care. LACDMH offered ongoing trainings and support events that SSG teams share with partners and support their attendance if needed.
9.8 Coaching and Supervision
SSG Clinical Supervisors are responsible for training staff in culturally appropriate, person-centered plan development. They also support team members in specifically addressing issues of culture and race, advocating for resources to ensure all families have equal opportunities to thrive.
At orientation for each new SSG team member, they receive training on HFW principles, phases and activities and their respective roles. In individual supervision, the team supervisor provides coaching and supervision to ensure ethical and effective service. SSG HFW team meets weekly to identify needs, resources and support for the youth and families. The team conducts staffing meetings as needed to collaborate with other providers and ensure appropriate planning that correspond to the specific needs of the youth and family.
The on-call supervisor is available for coaching, support and supervision for all team members after hours 24/7.
(SSG Programs & Operations policy#2000.#2100.#3100-3110 )
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
SSG HFW programs collaborate with LACDMH to ensure timely collection of data that include the annual Consumer Service Surveys; quarterly WFI; monthly Plan of Care; CANS at admission, 6 months interval and at exit; Patient Symptom checklist at admission and exit; and Outcomes Measures Application (OMA) at admission, 3 months interval and at exit. Data is submitted to LACDMH for data analysis and program development at the county level.
SSG HFW program also completes case notes and crisis intervention notes that are reviewed in quarterly case audit.
SSG leadership reviews program cost/revenue monthly to ensure cost efficiency, program outcomes for individual/family for service improvement, program outcomes and satisfaction annually for program improvement, and agency data every 3 years for CARF accreditation. The review may include individual and family demographics, outcomes measures, monthly cost/revenue track. SSG HFW program director manage data and evaluation process within the HFW program and collaborate with SSG leadership for CARF outcomes. (SSG data collection matrix; sample Wraparound monthly revenue/cost report).
10.2 Evaluation Metrics & Outcomes
SSG HFW team has access to data that help inform and refine direct practice with youth and families. Team members review case notes, CANS, OMA, Plan of Care to identify specific progress, goals and resources that help support the youth and family for positive outcomes.
SSG team supervisor and manager review program wide outcomes, cost/revenue, and service survey to identify patterns of service that is cost-efficient and effective to direct future program development.
SSG leadership reviews program cost/revenue monthly to ensure cost efficiency, program outcomes for individual/family for service improvement, program outcomes and satisfaction annually for program improvement, and agency data every 3 years for CARF accreditation. The review may include individual and family demographics, outcomes measures, monthly cost/revenue track. SSG HFW program director manage data and evaluation process within the HFW program and collaborate with SSG leadership for CARF outcomes. (SSG data collection matrix).
Fidelity Indicators
1.1 Timely Engagement and Planning
Note to the reviewers: please note that we included a Glossary with a list of terms/titles that might be different from traditional terms. Thank you.
At River Oak Center for Children, Wraparound referrals are reviewed and assigned by program managers on the same day they are received. Each referral is promptly assigned to the following team members: a Wraparound Care Coordinator (Facilitator), a therapist, and a Family Advocate, who is a certified Peer Support Specialist. Program managers prioritize assigning staff who are able to meet the family’s linguistic and cultural needs to support effective engagement and culturally responsive services.
River Oak Center for Children does not partner with families participating in the Adoption Assistance Program (AAP).
a) Upon receiving a referral, the assigned Family Advocate (also known as a Certified Peer Support Specialist) contacts the family to schedule the initial face-to-face intake appointment within the same day or as soon as possible, but no later than 10 weekdays days from referral. Efforts to contact the family are documented in youth’s Electronic Health records. (See INTAKE PROCEDURE page 1; CO 3.1.2 Timely Access to Services page 1 table; CO 3.1 Intake Process page 1 para 2)
b) Initial Wraparound Team Meeting (WTM), also known as a Child Family Team Meeting (CFTM), occurs within 30 calendar days from intake and a Wraparound Plan of Care (POC) is developed with all team members during this meeting. (See Wrap Team Meeting Policy page 1-2 item B; HFW – Phase 2 Plan Development- Care Coordinator Expectations pages 1-2 table)
c) Teams convene for follow up WTMs every 30 calendar days to review the plan, evaluate progress and/or barriers toward meeting the needs, and measure and track progress accordingly. Teams update the plan together and updated plan is distributed to all team members within one week of the meeting occurring in the form of their choosing. In the event the youth/family is part of a Tribal Nations as defined under Indian Child Welfare Act (ICWA), the Care Coordinator ensures an identified representative is oriented and involved in the Wraparound process and their ideas and strategies are elicited during the WTMs. (See Wrap Team Meeting Policy page 1 item B; HFW – Phase 3 – Plan Implementation Care Coordinator Expectations pages 1-2; Tribal Engagement Guide labeled page 3)
d) The Plan of Care is reviewed and updated at each WTM (every 30 days) and distributed to families and other team members within 7 calendar days of the WTM occurring and filed in the youth’s electronic health records file. Copies are sent electronically (secured email) or in the form of hard copy depending on family and team members’ preferences. (See HFW – Phase 3 – Plan Implementation Care Coordinator Expectations page 2 table, page 3 blue header; ‘HOW TO’ Guide for HFW components page 22)
e) River Oak Wraparound referral process is tracked from the start: both referrals to outreach/engagement delays, as well as delays between engagement and intake using contact and service dates. For adjunct services, we track worker assignment date to date of contact, and date of contact to service dates, identifying reasons for delay and ensuring timely service delivery. Managers access Wrap Census to determine how many days until the 1st face-to-face appointment since the receipt of referral. Managers also retrieve data from Timely Access Data Tool (TADT) to track timeliness of access/first time the family was offered an appointment and whether the appointment was accepted. The Quality management team shares timely access data on a quarterly basis with managers to review with staff and provide coaching/training. Wraparound Care Coordinators receive weekly coaching and supervision with both the HFW coach and their direct supervisors to review the status and timeline of WTMs and timely updates of Plan of Care. (See CO 3.1.2 Timely Access to Services page 1; High Fidelity Wraparound Training and Coaching Plan page 13)
f) Each Wraparound staff receives instructor-led, online training courses provided by the National Wraparound Implementation Center (NWIC): Wraparound 101: Practice Essentials (3 full days) and Wraparound 102: Building Partnerships (1 full day). These training courses provide staff with foundational knowledge of Wraparound process, components, and core skills to implement HFW and lead the family and the team to navigate through the child serving systems. Staff also gain the techniques to engage youth/families and their support people through validation, reflective listening and other strategic tools. When/if contact with families becomes a challenge for staff, each staff addresses the issues in their weekly individual supervision with their direct supervisors. In addition, each individual Care Coordinator is provided with High Fidelity Coaching on a weekly basis for 1-1.5 to address engagement barriers as needed and participate in skills building activities through role playing and other methods. These skills transfer activities follow Coaching response to Enhance Skill Transfer (CREST) tool to individualize coaching and reflect identification of skill(s) to improve on, why the skill is needed and how they can do it using step-by-step guide developed with staff and coach together. In addition, Care Coordinators and Advocates receive group coaching for 1-2 hours each month with their respective groups and practice specific skills to have effective engagement with youth, families and team members throughout the Wraparound process. (*Please note that at River Oak, Wraparound Program Fidelity/Training Manager holds a dual role as High Fidelity Wraparound coach. This person is a certified supervisor-coach with the National Wraparound Implementation Center (NWIC) and will be referred as HFW coach throughout this certification process.) (See Glossary). In addition, all WRAP staff participate in ongoing monthly booster trainings to increase engagement and connection with youth/families and team members. Care Coordinators are offered and provided with HFW documentation 2-hour lab (weekly to monthly basis) for additional support as needed. They also receive ongoing feedback based on their scoring on Supervisor Checklist, a NWIC tool for coaching, which encompasses each HFW component. (See High Fidelity Wraparound Training and Coaching Plan page 3-4 table, page 6-8, page 13 table; NWIC – Coaching Tool Descriptions 2026 (002) page 1 items 1 and 3; Clinical – ICS – Program Fidelity-Training Manager – JD – 3.2026 pages 1, 2, 4)
1.2 Led by Youth and Families
River Oak Center for Children holds youth and family voice and choice in the highest regard. The family’s, including youth/family who is part of a Tribal Nations as defined under Indian Child Welfare Act (ICWA), unique experiences, cultures, values, worldview, strengths, interests, and needs drive the Wrapround process and decisions are not made without the youth and family.
a) During the Engagement phase, the Care Coordinator meets with the family to discover the youth and family’s strengths, needs, perspectives, and culture around the referral behaviors and builds their Family Vision with the family. The Family Vision refers to what life would look like when things are better for the entire family. It is future-oriented and does not focus on problem behaviors. If a youth is part of a Tribal Nation as defined under Indian Child Welfare Act (ICWA), their representatives’ perspectives are elicited as well. The Family Vision is developed prior to the initial Wrap Team Meeting (first 30 days). (See ‘HOW TO’ Guide for HFW components pages 5-6 Family Vision heading; HFW – Phase 1-Expectations – CC page 1 table, page 2 bullet 6; Tribal Engagement Guide labeled page 9). The Team Mission is developed during the initial WTM led by the Care Coordinator with collaboration from the whole team and captures what the Wraparound team hopes to accomplish together and how they will all work together. The Family Vision and Team Mission are reviewed, and progress is tracked at each WTM. Both are included in the Plan of Care, filed and documented in youth’s electronic health records (EHR). (See ‘HOW TO’ Guide for HFW components page 9-10; HFW – Phase 2- Plan Development Care Coordinator Expectations page 1 table, page 2 items 5 & 6)
b) The Care Coordinator explores family’s values, culture, strengths, expertise, skills, and interests along with how they have dealt with challenges in their life and include in their Family Story. During this process, the Care Coordinator and assessing therapist review the IP-CANS to highlight the family’s strengths and functional strengths (detailing how they use their strengths in times of crisis or need), culture, and needs to inform the Family Story. The Care Coordinator uses the Family Story tool and Family Story Timeline tool to capture various aspects of their life related to Wraparound referral behaviors. The family’s support people’s (both natural and formal) perspectives around family’s strengths, needs and culture are elicited by the Care Coordinator by using the Team Perspective tool. Everyone’s strengths are reviewed in WTMs and updated in the youth/family Plan of Care. Both the Family Story and Plan of Care are filed in River Oak Electronic Health Records for each youth/family. (See ‘HOW TO’ Guide for HFW components page 3-5; HFW – Phase 1-Expectations – CC page 1 table, page 2 bullet 5)
c) Staff documentation—including the Family Story, need statements, and Wraparound Plan of Care (POC)—is reviewed on a regular and ongoing basis and scored using the Supervisor Checklist document. The High‑Fidelity Wraparound Coach utilizes data gathered from these documentation reviews to identify strengths and areas for growth. This information is then used to provide targeted feedback and individualized coaching during weekly one‑on‑one coaching sessions, with a focus on strengthening fidelity, clinical quality, and alignment with Wraparound principles. Each Care Coordinator receives weekly individual and a monthly group coaching. In addition to document reviews, HFW conducts field observation which include observation of WTMS, follow up sessions with family and other team members to provide with live coaching and immediate feedback on specific skills demonstration using the CREST (Coaching Response to Enhance Skill Transfer Tool). (See ‘HOW TO’ Guide for HFW components page 22-23; High Fidelity Wraparound Training and Coaching Plan pages 13-16; NWIC – Coaching Tool Descriptions 2026 (002) page 1 items 1 and 3)
d) Feedback from families is elicited from TOMs and WFI-EZ surveys (administered quarterly), Consumer Perception Survey (annual), CFTM county survey (every month) and TOM observation is conducted during WTMs (quarterly). In addition, River Oak HFW coach uses HFW Satisfaction Questionnaire to gather feedback immediately after the WTM or via phone calls and utilizes the feedback for coaching and training. This questionnaire consists of seven questions to gauge what improvements the family has seen since the family’s involvement in the HFW process. We also hold a Wraparound Advisory dinner (quarterly) where families are invited and provide direct/in person feedback by answering a short survey. (See HFW Satisfaction Questionnaire-ROCC; The Wraparound Advisory Dinner Survey; Outcome Methods pages 1-2 bullet 6&7)
1.3 Strength-Based
At River Oak, the Wraparound Care Coordinator discovers the hobbies, interests, skills and expertise of the youth, family, and their identified support people, including tribal representatives if youth is part of a Tribal Nations as defined under Indian Child Welfare Act (ICWA). In addition, the CC ensures that their community is studied and the community resources and availabilities that relate to the families’ needs.
a) The Care Coordinator uses Team & Community Strengths Inventory tool to discover each team member’s strengths and Functional Strengths prior to the initial WTM including strengths/resources of the community. The strengths list is posted as visual and reviewed at each WTM, and new strengths are added as needed. The team also reviews the strengths of their community. During brainstorming part of the WTM: more community resources are explored and listed, so additional resources and strengths can be added to the team. During Implementation phase, Care Coordinators routinely assess with the family if the connection to community resources is working, and ensure the family knows how to utilize them upon graduation from Wraparound. All updates are added to the Plan of Care after each WTM. (See ‘HOW TO’ Guide for HFW components pages 8-9; Team & Community Strengths Inventory; Plan of Care – WTM minutes template blank ’24 page 1)
b) Upon completion of IP-CANS by the assessing clinician within 21 days of intake, the assessing clinician and Care Coordinator review the scoring together and highlight the areas of strengths for both youth and caregiver. The Care Coordinator then utilizes the strengths identified in the IP‑CANS to inform the development of the youth’s and caregiver’s Functional Strengths and to enrich the Family Story. While IP‑CANS strengths provide valuable insight, they are not the sole source of strengths identification. Additional strengths are gathered through family conversations, observations, and team input. Strengths scores from IP-CANS are highlighted at WTMs as well. (see HFW – Phase 1-Expectations – CC page 3; CO 1.1 Initial and Continuing Assessment page 1 item 4)
c) Care Coordinators address improving their use of strength-based and solution-focused services through weekly 1-1.5-hour individual coaching with the HFW coach, and monthly 2-hour group coaching led by HFW coach and supervisors. The HFW coach uses Care Coordinator Responsibilities and Supervision Response Tool (CCRSR) to identify areas of focus to support staff during coaching sessions. In addition, all River Oak Wraparound staff attend monthly all staff 1 hour booster training led by HFW coach and supervisors, and a staff member. Family and Youth advocates (Peer support Specialists) attend a monthly 1-hour coaching with the HFW coach. HFW coach follows the CREST (Coaching Response to Enhance Skill Transfer) to coaching staff on improving their skills. CCs are also offered and provided with HFW 2 hour-lab as needed. Staff are also encouraged to practice skills independently utilizing Explaining HFW Components document and flash cards with HFW components definitions and descriptions as well. (See High Fidelity Wraparound Training and Coaching Plan page 3 table, pages 13-17)
d) Feedback from families is elicited through HFW satisfaction questionnaire conducted via phone or in person by HFW coach every 3-6 months, TOMs and WFI-EZ administered quarterly, annual perception surveys, and County CFT survey administered monthly. HFW coach routinely observes WTMs to provide feedback at the next weekly coaching session and/or during a de-briefing soon after the WTM. The HFW coach conducts quality assurance phone calls to gather feedback from families on the HFW process and team meetings and uses the date to coach & train staff. (See Satisfaction-Perception Survey data – annual May 2025 pages 22&23; Outcome Methods pages 1-2 bullet 6&7; HFW Satisfaction Questionnaire-ROCC; Consumer Perception Survey -YSS_Youth_EN_2025; Consumer Perception Survey -YSSF_ParentFamily_EN_2025; TOMs Wraparound, WFI-EZ paper version YOUTH)
1.4 Needs Driven
At River Oak, the Wraparound Care Coordinator works closely with the youth, family, and their support people throughout the Engagement phase and learn their story around the referral behaviors. Based on the information gathered from the family, and IP-CANS, items scored at 2 or 3; the Care Coordinator develops ten need statements to identify the root cause of the behaviors that possibly brought the youth to the Wraparound process.
a) In order to identify the underlying needs, the Care Coordinator first develops Thoughts/Feelings list for the youth and parent (ten each) based on the family’s story and what challenges they have been experiencing related to the referral behaviors. Then translates them into possible underlying need statements. They focus on ‘why’ & ‘what is causing’ the behavior to happen. These possible Needs Statements (10 per youth and caregiver) are shared with the families, prior to the initial WTM, for them to choose the ones (possibly top 2-3) that they resonate with them the most. They then arrange to bring the selected 2-3 to the initial WTM to review with the team and further prioritize in the team setting. Once the family and team agree on a need, the team works to create a plan during the WTM to assist the youth and family to meet their needs. During the process of developing the needs, the Care Coordinator also ensures that the needs identified in IP-CANS scores are reviewed and reflected in the development of need statements. (See ‘HOW TO’ Guide for HFW components pages 10-11; Developing Need Statements; HFW – Phase 1-Expectations – CC page 1 table; CO 1.1 Initial and Continuing Assessment page 1)
b) Care Coordinators complete Wraparound 101 training to learn about identifying and developing underlying needs. This 3 full day foundational training course is conducted by NWIC at hire. (See High Fidelity Wraparound Training and Coaching Plan page 3 table and pages 6-7). Then, they receive weekly 1-1.5-hour individual coaching with the HFW coach, and monthly 2-hour group coaching led by HFW coach and supervisors (See High Fidelity Wraparound Training and Coaching Plan page 13 table). HFW coach follows the NWIC Supervisory Checklist and CREST (Coaching response to Skill Transfer) tool late to coaching staff on improving their skills. In addition, all River Oak Wrap staff attend monthly all staff 1 hour booster training led by HFW coach and supervisors, and staff member. Family and Youth advocates (Peer support specialists) attend a monthly 1-hour coaching by the HFW coach. In addition, CCs are offered and provided with HFW labs for additional support. (See High Fidelity Wraparound Training and Coaching Plan page 13-14; NWIC – Coaching Tool Descriptions 2026 (002) items 1 & 3)
c) When developing need statements, the Care Coordinator refers to the newly developed Family Story where they have captured the family’s strengths, unique culture and value, and needs around the behaviors that brought them to Wraparound. In addition, the CC and the assessing clinician who completes the IP-CANS assessment within 21 days of intake, reviews the elevated CANS scores (2 and 3) related to referral behaviors to inform the development of Need statements. This allows the CC to develop well informed and thorough need statement options (10 options each for youth and parent(s)) to bring back to the family to prioritize. The need statement focuses on identifying the root cause of the behaviors that brought the young person to Wraparound. (See HFW – Phase 1-Expectations – CC page 3; Developing Need Statements; ‘HOW TO” Guide for HFW components pages 10-11)
d) The Care Coordinator measures and tracks the family’s progress towards their Family Vision, Need, and Outcome statement at each WTM (every 30 days) and Transition is planned when the needs are met, or adequate progress made is maintained for at least 3-6 months during the Implementation phase. Transition is agreed upon by the youth, family, and team at a WTM (See HFW – Phase 3 -Plan Implementation Care Coordinator Expectations bottom of page 4; HFW – Phase 4 -Expectations page 1; Wraparound Transition Readiness Scales; CO 6.2 Discharge and Transition Planning page 1 item 2; Plan of Care – WTM minutes template blank ’24 pages 1 and 4)
1.5 Individualized
At River Oak, the Care Coordinator and Family/Youth Advocates are committed to ensuring that HFW process uniquely fits individual youth and family and are never one size fits all. The family and team’s individual strengths, culture, values, community, and needs to inform strategies at all times. This includes youth with tribal communities if youth is part of a Tribal Nations as defined under Indian Child Welfare Act (ICWA).
a) The Wraparound Plan of Care, Family Story tool, and Need Statements forms/templates are structured to support efficient development and consistent updating, allowing for individualized, family-centered planning. Each tool provides space to clearly document what strategies will work best for each family, while also tracking progress, challenges, and barriers throughout the Wraparound process across all phases. (See Plan of Care – WTM minutes template blank ’24; Developing Need Statements; Family Story Template; NWIC – Coaching Tool Descriptions 2026 (002) page 2 items 10-12).
b) Each Wraparound staff completes Wraparound 101 training upon hire and Wraparound 102, formerly known as Engagement in Wraparound, training within 6-8 weeks of completing Wraparound 101. These two training courses provide staff with fundamentals of HFW and tools to perform their duties. (See High Fidelity Wraparound Training and Coaching Plan page 3 table and pages 6-7). In addition, Care Coordinators receive weekly individual coaching for 1-1.5 hours, monthly 2-hour group coaching, and 1 hour booster training monthly. Advocates also receive monthly, 1 hour coaching sessions conducted by the HFW coach. All staff participate in monthly interactive ‘HiFi Corner’ during all staff meetings highlighting the operationalization of principles and activities of phases (See High Fidelity Wraparound Training and Coaching Plan pages 13-14; WRAP All-Staff Meeting Agenda – April)
c) Care Coordinators receive comprehensive training and coaching on a variety of methods to effectively engage youth, families, and team members in creative and flexible ways, meeting families where they are, individualizing services, and incorporating cultural considerations. In addition to attending Wraparound 101 and 102 trainings at hire, each Care Coordinator participates in ongoing skill development through weekly 1–1.5 hour individual coaching sessions with the HFW Coach and monthly 2-hour group coaching sessions led by the HFW Coach and supervisors. Additionally, all River Oak Wraparound staff attend monthly 1-hour all-staff booster trainings facilitated by the HFW Coach, supervisors, and a designated staff member. Family and Youth advocates (Peer support specialists) attend a monthly 1-hour coaching by the HFW coach. (See High Fidelity Wraparound Training and Coaching Plan pages 3, 6-7, 13 -14; WRAP All-Staff Meeting Agenda – April)
d) Throughout the Implementation and Transition phases, Care Coordinators update the Plan of Care following each WTM (every 30 days) to reflect the most current strengths, needs, outcomes, strategies, and tasks identified at each meeting based on team feedback. The family’s connection to natural and community support is continually assessed, with ideas gathered and incorporated into planning to strengthen support and promote long-term success. (See ‘HOW TO’ Guide for HFW components pages 24-25; Team & Community Strengths Inventory; My ‘GO TO’ People; Plan of Care – WTM minutes template blank ’24; HFW – Phase 3 -Plan Implementation Care Coordinator Expectations pages 1-2 table)
e) Feedback from families is elicited through TOM and WFI-EZ administered quarterly, annual Consumer Perception / Satisfaction Survey and County CFT survey administered monthly. HFW coach routinely observes WTMs to provide feedback at the next weekly coaching session or additionally scheduled de-briefing session. HFW coach also conducts HFW Satisfaction questionnaire (quality assurance) in person or via phone calls to gather families’ feedback on the meetings and uses the date to coach & train staff. (See Outcome Methods pages 1-2 bullet 6-7; High Fidelity Wraparound Training and Coaching Plan pages 13-14; HFW Satisfaction Questionnaire-ROCC; TOMs Wraparound; WFI-EZ paper version YOUTH; Consumer Perception Survey -YSSF_ParentFamily_EN_2025)
1.6 Use of Natural and Community Based Supports
At River Oak, the HFW team works diligently to explore natural support options in the community and within a youth/family’s extended network. Most of the efforts are made throughout the Implementation phase though the process starts during Engagement phase. These natural supports will be around longer than formal support and are seen as part of the family’s sustainable, long-term plan. In Transition phase, the team ensures that all the connections are working, and the family feels comfortable with the support in place.
a) Starting in the Engagement phase, the Care Coordinator takes an inventory of the family’s natural support and begins engagement as early as possible. Throughout the Wraparound process, the natural support inventory is reviewed, and the team explores ways to solidify the connection and add more culturally relevant natural support as needed. This process takes place in the ongoing WTMs and between meetings. Wraparound Youth and Family advocates hold a crucial part in this process as they also directly support the youth and caregiver and explore creative ways with the family to renew connection with existing support people or find ways to make new connections. HFW coach and Care Coordinator utilize a tracking spreadsheet to document the inclusion and number of natural supports on each family’s team, participation in the Wraparound process, and in WTMs. Based on the information gathered, the HFW coach supports staff with targeted coaching. (see ‘HOW TO’ Guide for HFW components pages 15-17; My ‘GO TO’ People; Team & Community Strengths Inventory; Natural, Formal, & Community Support Tracking, Plan of Care – WTM minutes template blank ’24 page 6)
b) Care Coordinators improve their engagement of natural supports through training, Wraparound 102, formerly known as Wraparound Engagement, training conducted by NWIC trainers. In this training they learn the OARS (Open-ended Questions, Affirming, Reflecting, and Summarizing) techniques focusing more on reflective listening which helps them engage effectively with youth and families. In addition, they receive weekly 1-1.5-hour individual coaching with the HFW coach, monthly 2-hour group coaching led by HFW coach and supervisors, monthly all-staff 1-hour booster training led by HFW coach and supervisors, weekly 1-hour supervision with direct supervisor. HFW coach follows the CREST (Coaching Response to Enhance Skill Transfer) NWIC coaching tool used to support skills transfer. (See High Fidelity Wraparound Training and Coaching Plan pages 3 table, pages 7-8, pages 13-14; ‘HOW TO’ Guide for HFW components pages 15-18; NWIC – Coaching Tool Descriptions 2026 (002) page 1 item 3)
c) Care Coordinators update the Plan of Care following each WTM (held every 30 days) to reflect the most current team members, community resources, natural support, and strategies. During the Brainstorming portion of the meeting, the team identifies additional natural, and community supports as needed and generates ideas to further engage existing supports. Because the Plan of Care is a living document, new and existing team members, community resources, strengths, strategies, and tasks are continually added or updated during WTMs. Care Coordinators also ensure that identified connections remain intact and effective by checking in with team members between WTMs to support ongoing engagement and collaboration. (See ‘HOW TO’ Guide for HFW components pages 12–17; Plan of Care – WTM minutes template blank ’24 page 6-7)
d) Care Coordinators lead the team in ensuring natural support involvement during Wraparound Team Meetings (WTMs) throughout the Implementation and Transition phases and facilitate brainstorming to strengthen connections when gaps are identified. More formal family feedback is collected through structured surveys, including the Team Observation Measure (TOM) and the WFI‑EZ, which are administered quarterly; the annual Consumer Perception/Satisfaction Survey; and the County Child and Family Team (CFT) survey, completed at the conclusion of each WTM. The Quality Management team aggregates and shares data with Wraparound Managers through the internal Electronic Health Record (EHR) system and during team meetings. Additionally, the HFW Coach routinely observes WTMs and provides timely, relevant feedback during weekly coaching sessions. The Care Coordinator and Coach jointly review and update the Natural, Formal, and Community Supports Tracking Form during these coaching sessions. The HFW Coach also conducts HFW Satisfaction Questionnaire quality‑assurance phone calls every 3–6 months to gather family feedback on the impact of Wraparound services in their lives. This feedback is used to inform coaching, training, and continuous staff development. (See Outcome Methods pages 1-2 bullets 6-7; HFW Satisfaction Questionnaire-ROCC; TOMs Wraparound; WFI-EZ paper version YOUTH; Consumer Perception Survey -YSSF_ParentFamily_EN_2025; Natural, Formal, & Community Support Tracking)
1.7 Culturally Respectful and Relevant
River Oak Center for Children is committed to highlighting family culture, values, and traditions and, whenever possible, building off the strengths of a family’s heritage and community connections to include in their story and prioritize what the family is prioritizing. Wraparound Care Coordinators ensures to make connection with tribal representatives if youth is part of a Tribal Nations as defined under Indian Child Welfare Act (ICWA).
a) Within the 30 days of intake, the Care Coordinators get to know the families in the areas of their strengths including their identified support people, natural and formal support people’s strengths as well. They also explore the parents’ upbringings, background, culture of the family, and each individual member’s cultural preferences, and the underlying need that is driving the referral behaviors. Care Coordinators use tools such as Family Story, Timeline, and Team Perspectives to capture all relevant information for their story including involvement of tribal representatives if youth is part of Indian Nations defined under ICWA. These tools are not to be used as a questionnaire or checklist but rather to facilitate meaningful conversations that support relationship‑building and engagement with the family. Additionally, the Wraparound therapist completes the IP‑CANS assessment within the first 21 days of service, and the results of the IP‑CANS inform identified strengths and needs and are coordinated with the Care Coordinator to ensure alignment and inclusion of relevant information in the Family Story. Information gathered through these conversations is compiled into the Family Story and reviewed with the family prior to the initial Wraparound Team Meeting (WTM). Portions of the Family Story selected by the family are shared with the team during the initial WTM using a strengths‑based, family‑driven approach to promote understanding, collaboration, and shared ownership of the Plan of Care. (See ‘HOW TO’ Guide for HFW components pages 3-5; HFW – Phase 1-Expectations – CC page 1; HFW – Phase 2-Plan Development – Care Coordinator Expectations page 2 agenda; Family Story Template; NWIC – Coaching Tool Descriptions 2026 (002) page 2 items 10-12)
b) Wraparound Care Coordinators and the team work diligently to meet families where they are and tailor service delivery to align with each family’s culture, strengths, and unique needs in a respectful and responsive manner. This process begins at intake, where Wraparound Managers prioritize staff assignments to best match the family’s cultural, linguistic, and relational needs whenever possible. When the agency is unable to directly meet a specific need, Care Coordinators collaborate with external partners and specialized providers to ensure appropriate support is in place. This includes utilizing services such as Language World for linguistic and interpretation needs, as well as partnering with culturally specific and community‑based organizations, including ICWA‑related resources, LGBTQ+ community supports, and other specialized services.
The River Oak Wraparound team has begun developing a partnership with the Central ICWA Field Office of Tribal Affairs to ensure staff receive the most current training, guidance, and resources related to ICWA compliance and culturally responsive practice. Staff receive a brief overview of ICWA during onboarding process and are now required to complete ICWA Echo Trainings starting 2026 and access webinars provided by California Department of Social Services (CDSS) and Indian Child Welfare Act (ICWA) to gain skills to partner with youth and family with various backgrounds. In addition, Wraparound Care Coordinators are routinely coached incorporating the families’ unique culture and values in their partnership with families. They receive regular support to enhance their skills in partnering with families in effective ways by attending weekly 1-1.5 hour individual coaching with the HFW coach, monthly 2-hour group coaching led by HFW coach and supervisors, monthly all-staff 1-hour booster training led by HFW coach and supervisors, weekly 1-hour supervision with direct supervisor. HFW coach follows the CREST template to coaching staff on improving their skills. In addition, all staff are required to take the Sacramento County Cultural Training with five series annually (See High Fidelity Wraparound Training and Coaching Plan pages 10-13; Tribal Engagement Guide labeled pages 11-12)
c) Feedback from families is elicited through formal surveys such as TOM and WFI-EZ which are administered quarterly, annual Consumer Perception / Satisfaction survey and CFT survey administered at the conclusion of each WTM. The survey results and data is made available by River Oak Quality Management team and shared with Wraparound management via EHR which allows the management to share data with staff and use for coaching/training purposes. In addition, the HFW Coach routinely observes Wraparound Team Meetings (WTMs) to assess practice quality and fidelity. Feedback from these observations is shared during the subsequent weekly coaching sessions. The HFW Coach also conducts quality‑assurance phone calls to gather families’ feedback regarding their experience with WTMs and overall Wraparound services. This feedback is reviewed with Care Coordinators and intentionally incorporated into coaching, training, and continuous quality improvement efforts to strengthen practice and enhance family engagement. (See HFW Satisfaction Questionnaire-ROCC; TOMs Wraparound; WFI-EZ paper version CAREGIVER; WFI-EZ paper version YOUTH; Consumer Perception Survey -YSSF_ParentFamily_EN_2025; Natural, Formal, & Community Support Tracking; High Fidelity Wraparound Training and Coaching Plan pages 13-17)
1.8 High-Quality Team Planning and Problem Solving
River Oak Wraparound values teamwork, collaboration, and communication at all levels across the agency and with community partners and youth/families to ensure that consensus is reached for decision making.
a) Care Coordinator creates Team Agreement, also known as, Ground Rules, the term used at River Oak, with the youth and family prior to the initial Wraparound Team Meeting (WTM) and enlist more ideas from the entire team during the initial WTM to ensure that everyone is on the same page in decision making and expectations for each other. Care Coordinator reflects HFW principles in the development of the agreement. These agreements are reviewed and updated at each WTM (every 30 days). During the WTM, Care Coordinators post the Ground Rules / Agreements in a place that is visible to all participants and update as needed with the entire team. The updated ground Rules are in the Plan of Care after each WTM and filed in youth’s chart. (See HFW – Phase 1-Expectations – CC page 4 bullet 4; ‘HOW TO’ Guide for HFW components page 6-7; Plan of Care – WTM minutes template blank ’24 page 1)
b) The Care Coordinator ensures that the Ground Rules/Team Agreements are honored and followed in each WTM to ensure the team’s cohesiveness. In addition, the Care Coordinator leads the team in developing a Team Mission at the initial WTM around how the team will work together throughout the Wraparound process and what they want to accomplish together. Progress and barriers are reviewed at each Wraparound Team Meeting (held every 30 days) to evaluate how effectively the team is collaborating toward shared goals. Family feedback is elicited directly during meetings, and their voice and choice—along with input from other team members—are reflected in measuring and tracking progress toward identified goals. In addition, the families provide the team with feedback through TOM and WFI-EZ administered quarterly, annual Consumer Perception /Satisfaction, and County CFT survey administered monthly. HFW coach routinely observes WTMs and conducts HFW Satisfaction questionnaire (quality assurance) phone calls to gather families’ feedback on the meetings and their overall satisfaction with HFW. (See Plan of Care – WTM minutes template blank ’24 page 1; ‘HOW TO’ Guide for HFW components page 9-10; HFW Satisfaction Questionnaire-ROCC; TOMs Wraparound; WFI-EZ paper version CAREGIVER; WFI-EZ paper version YOUTH)
c) River Oak Quality management team provides results of the TOM and WFI-EZ findings quarterly to Wraparound managers and this feedback is used to identify the areas of strengths or skill-deficiencies and informs topics of individual, group coaching and booster trainings. HFW coach also uses information gathered from conducting HFW Satisfaction Questionnaire to use for individual weekly coaching sessions. The coach and staff develop a plan together following the Coaching Response to Enhance Skills Transfer Tool (CREST) with clear steps for the Care Coordinator to practice the skills. The coach continually observes WTMs to ensure that the skill is being transferred, and Care Coordinators are performing tasks to fidelity. (See HFW Satisfaction Questionnaire-ROCC; Outcome Methods page 1-2 bullet 6-7; TOMs Wraparound; WFI-EZ paper version CAREGIVER; WFI-EZ paper version YOUTH; NWIC – Coaching Tool Descriptions 2026 (002) page 1 item 3)
d) The Care Coordinator reviews the Plan of Care / WTM meeting minutes (strategies and tasks assigned) weekly with both formal (paid) and informal (unpaid/natural) supports to ensure follow through on action items and address any barriers that arise that may hinder completion. Following up on tasks assigned occurs between WTMs, on a weekly basis. This allows the Care coordinator to ensure that everyone is working toward completing the tasks and purposefully engage both formal and natural support people while supporting them to address any barriers related to assigned tasks. (See Plan of Care – WTM minutes template blank ’24 pages 4-6; Care Coordination Meeting Structure; ‘HOW TO’ Guide for HFW components page 15; HFW – Phase 3 -Plan Implementation Care Coordinator Expectations page 2 table)
1.9 Outcomes Based Process
At River Oak, WRAP team members are continually tracking the progress of items in the Plan of Care (Need statements, Outcome statements, family vision, team mission, task completion) and through measurable assessments (IP-CANS, Pediatric Symptom Checklist-35, Patient Health Questionniare-9).
a) River Oak WRAP Care Coordinators create an initial Plan of Care for each youth/family which includes a measurable way of tracking progress/barriers for their Family Vision, Team Mission, Needs and Outcome statements. The team and family score each on a numerical scale (ex: 1-10) or a method of family’s choosing to compare each month’s progress to the previous months. In addition to tracking progress, Care Coordinator leads the team in developing strategies to meet the needs of the youth and caregivers to see positive outcomes based on the robust brainstorming takes place to address the identified need. Strategies are developed and divided into tasks that are assigned to each participating team member connected to their strengths, not only their role. The strategies and tasks reflect who, what, when, and how to ensure tasks completion and ensure smooth follow ups from the Care Coordinators. These action items are created at the conclusion of each WTM and reviewed for each team member to leave with clear tasks. (See ‘HOW TO’ Guide for HFW components pages 11-12; Plan of Care – WTM minutes template blank ’24 pages 4-5; HFW – Phase 3 -Plan Implementation Care Coordinator Expectations page 2)
b) The Care Coordinator follows up with each team member on tasks/action items assigned at the most recent WTM. The follow-ups occur between WTMs and updates on completion of tasks and Care Coordinator brings results to the WTM. The CC assists the team members in identifying the barriers of completing tasks and offer support to problem solve until the task is completed. Care Coordinator also schedules internal Care Coordination meetings to review tasks with internal Wraparound team members, if needed. (See ‘HOW TO’ Guide for HFW components page 15; Care Coordination Meeting Structure; HFW – Phase 3 -Plan Implementation Care Coordinator Expectations page 2 table)
c) The Plan of Care (POC) template is designed to allow for ongoing updates and adjustments without restriction. Care Coordinators update the POC after each Wraparound Team Meeting (WTM) to reflect progress related to the Family Vision, Team Mission, identified needs and outcome statements, completion of strategies, and action steps within the Safety Plan. Each updated Plan of Care is filed in the youth’s chart and distributed to all team members within seven (7) days following the WTM. (See Plan of Care – WTM minutes template blank ’24; ‘HOW TO’ Guide for HFW components page 22)
d) The assigned assessing therapist completes the initial IP‑CANS assessment within 21 days of intake. The therapist then coordinates and shares the assessment results with the Care Coordinator prior to the initial Wraparound Team Meeting (WTM), which occurs within 30 days of intake. At the initial WTM, either the Care Coordinator or the Therapist who administered the IP‑CANS provides the team with an overview of the assessment, with specific attention to elevated scores (ratings of 2 or 3). These items are reviewed to establish clear connections to referral behaviors, identified needs, and outcome statements, ensuring alignment with the Plan of Care. (See HFW – Phase 1-Expectations – CC page 3; HFW – Phase 2-Plan Development – Care Coordinator Expectations page 3)
c) Data from the IP‑CANS informs team decision‑making related to identifying underlying needs and Outcome Statements; however, it is not the sole source used to identify needs and outcomes. Both initial scores and updates to scores over time contribute to tracking progress and identifying barriers throughout the Wraparound process. Items most directly related to initial conditions (referral behaviors), particularly those with the highest scores, are reviewed at each WTM and linked to corresponding outcome statements. While IP‑CANS data is one indicator used to assess a family’s readiness for transition, the Care Coordinator leads the team in tracking all core components of the Wraparound process. This includes ongoing review of the Family Vision, Team Mission, Needs Statements, Outcome Statements, and overall progress to support informed, team‑based transition decisions. Care Coordinators also ensure accountability and continuity of care by tracking completion of action items and following up weekly with team members regarding progress on tasks assigned at the most recent Wraparound Team Meeting. (See HFW – Phase 3 -Plan Implementation Care Coordinator Expectations page 4; HFW – Phase 4 -Expectations page 1; CANS flyer-explaining CANS)
1.10 Persistence
River Oak Wraparound staff operate under the philosophy that youth and families do not fail; only plans do. At River Oak, HFW staff are encouraged to utilize their creativity to increase engagement and adjust plans to meet the needs of youth/families.
a) Wraparound team members are encouraged to continue to meet the families where they are at even when setbacks or crises occur. Rather than premature discharge when there is lack of progress or a crisis situation, Care Coordinators are supported in scheduling emergency WTMs within 72 hours of identified crisis or meeting more frequently (sooner than 30 days) with the family to identify areas of the plan that are no longer working and schedule internal Critical Case Reviews (CCR) for the team to brainstorming with Clinical Program Managers across the agency and ideas to bring back to the family for their approval. Staff are trained and coached to address cancellations and no shows during coaching and in large team meeting setting during ‘HiFi Corner.’ HFW coach conducts HFW Satisfaction Questionnaire every 3-6 months to provide the team with feedback related to engagement and the family’s satisfaction. (See Wrap Team Meeting Policy; INTAKE PROCEDURE page 5 item 9; HFW – Phase 3 -Plan Implementation Care Coordinator Expectations page 3-4; HFW Satisfaction Questionnaire-ROCC)
b) River Oak Center for Children encourages an open-door policy where staff can reach out to any supervisor when in need of additional coaching or supervision. Supervisors offer weekly 1-hour open office hours 3 times per week for staff to drop in and meet with a supervisor about any questions they have outside of their weekly 1-1.5-hour HFW coaching and 1-hour direct supervision. Their weekly CREST (Coaching Response to Enhance Skill Transfer) developed with HFW coach indicates when and how staff can ask for support if needed from their coach and supervisors (Open Agency Policy- HR 4.6; High Fidelity Wraparound Training and Coaching Plan page 13 table)
c) Care Coordinator are required to attend NWIC Intermediate training, Wraparound 202 and 203 to enhance skills around the components of safety planning. (See NWIC – Training Catalog – Training Descriptions and Calendar page 2; High Fidelity Wraparound Training and Coaching Plan page 9). Care Coordinators have ongoing trainings in crisis management, plan revision and safety planning by meeting weekly for 1-1.5 hour with a HFW coach, weekly 1 hour supervision with their direct manager, and monthly 2-hour group coaching with the HFW coach and supervisors. Care Coordinators are trained to follow up within 24 hours of a family speaking with on-call support, scheduling and emergency WTM (outside of the typical 30 days) within 3 days of a crisis, and updating the safety plan immediately after an incident. For any Incidents detailed in an Incident Report, a Critical Case Review is held where Clinical Program Managers across the agency can support the Care Coordinator with brainstorming. (See Wrap Team Meeting Policy page 2 item D; HFW – Phase 3 -Plan Implementation Care Coordinator Expectations page 3-4; HFW – Phase 4 –Expectations page 4)
1.11 Transitions as a part of the Fourth Phase of HFW
At River Oak, Wraparound staff celebrate big and small successes throughout the four phases of Wraparound process with the goal of transition discussed from the beginning. Once youth and families agree that their goals are met, transitions are planned 3-6 months in advance and Flex Funds are utilized so that youth and families can celebrate in a way that is meaningful to them.
a) River Oak Wraparound Teams discuss transition from the very beginning of the Engagement phase and Care Coordinators support families moving into the transition phase for the last 3-6 months of the WRAP process (the minimum timeframe for transition is 60-90 days). This timeline is determined at a WTM based on progress, the maintenance of progress, and family voice and choice. Care Coordinators and Advocates ensure the families maintain their strong linkage to natural supports and community resources during the transition phase so that they have adequate support after the formal WRAP team transitions out. The Transition Plan includes detailed plans for future needs and safety concerns as well (See HFW – Phase 3 -Plan Implementation Care Coordinator Expectations page 4; HFW – Phase 4 –Expectations pages 1-3; Wraparound Transition Readiness Scales; CO 6.2 Discharge and Transition Planning pages 1-2 para 1 and items 1-6)
b) The Care Coordinator works with the family and team on planning a graduation celebration that aligns with the family’s culture, preferences, and values at a WTM during Transition phase. This can include a culturally relevant gift or preferred food item, with the use of flex funds. The Care Coordinator invites any support people who will remain in the family’s life after WRAP transitions out, including community resources and partnerships that the family has made throughout the WRAP process, extended family, and long term formal and informal supports. The entire River Oak WRAP team (i.e. Therapist, Skills Trainer, Youth Advocate, Family Advocate) is also invited to the celebration. The youth and family are presented with successful graduation certificates. (See HFW – Phase 4 –Expectations bottom of page 3-top of page 4; Graduation – Certificate of Completion WRAP; ‘HOW TO’ Guide for HFW components bottom of page 21- top of page 22; CO2.5 Flex Fund Supports Policy page 1)
Expected Outcomes
2.1 Youth and Family Satisfaction
Providing high-quality care for youth and families is a cornerstone of River Oak’s mission. The Quality Management (QM) team administers multiple surveys throughout the year to assess satisfaction among families, their identified support individuals, and tribal communities when a youth is affiliated with a Tribal Nation as defined under the Indian Child Welfare Act (ICWA). Satisfaction measurement tools include the TOM survey, administered quarterly, and the WFI-EZ survey, also administered quarterly and completed by the youth, caregiver, Care Coordinator, and at least one additional team member. In addition, the Annual Consumer Perception Survey provides critical feedback to the Wraparound team and supports the identification of areas requiring improvement.
Data collected from the TOM and WFI-EZ surveys are provided to Wraparound Managers on a quarterly basis. Managers utilize this data to support staff development through weekly individual coaching, monthly group coaching, and booster training as needed. The Quality Management team also conducts monthly Utilization Reviews to ensure that the quality of care and service delivery is appropriately documented in youth records
Additionally, the High Fidelity Wraparound (HFW) Coach administers the HFW Satisfaction Questionnaire every 3–6 months following a Wraparound Team Meeting (WTM) observation conducted either in person or via telephone. Feedback collected through this process is used to provide individualized and targeted coaching to staff. Families and team members are also supported in monitoring satisfaction and progress throughout the Wraparound process. Progress is measured through team review of the Team Mission, identification of successes and barriers, and observed reductions in IP-CANS scores. The IP-CANS assessment is completed every six months in accordance with the Initial and Continuing Assessment Policy. Furthermore, a Child and Family Team (CFT) survey is administered at the conclusion of each Wraparound Team Meeting. Wraparound staff also present families with a brief two-question progress survey during the first week of each month, completed alongside Service Verification forms. This survey captures the family’s perception of progress toward their goals for the month. (See HFW Satisfaction Questionnaire-ROCC; Service VERIFICATION CARD_update 11.17.25-english page 2; Plan of Care – WTM minutes template blank ’24 bottom of page 6; TOMs Wraparound; WFI-EZ paper version YOUTH)
2.2 Improved School Functioning
At River Oak, school attendance and academic performance are routinely addressed through Wraparound Team Meetings (WTMs). When IP-CANS items related to School Attendance and School Achievement are elevated, these areas are shared with the team during WTMs and the team collaboratively identifies barriers and develops strategies and actionable interventions to address the youth’s educational needs. The IP-CANS assessment is administered by the Wraparound Therapist within 21 days of intake and is re-administered every six months to monitor progress and identify ongoing barriers across all domains, including school functioning. The River Oak Quality management team compiles Assessment Outcomes data and share the information with Wraparound supervisors via Electronic Health records (EHR) highlighting baseline and discharge scores.
The Annual Consumer Perception Survey provides valuable data regarding youth and caregiver satisfaction with the outcomes of services. Survey results include caregiver and youth perceptions of whether services have contributed to positive changes in the youth’s school functioning and academic performance. This survey serves as an additional method for monitoring and evaluating school-related outcomes and overall educational progress.
In addition, the High Fidelity Wraparound (HFW) Coach conducts the HFW Satisfaction Questionnaire with families every 3–6 months as part of quality assurance efforts. This tool includes specific attention to school attendance and academic performance to track family perceptions and outcomes over time. The Wraparound Family Advocate supports caregivers by linking families to educational resources and providing information related to Individualized Education Programs (IEPs), 504 Plans, and guidance on when and how to request additional educational supports, including coordination with foster youth liaisons and school counselors when applicable.
For youth ages 12 and older, the Wraparound Youth Advocate assists youth in exploring school-based clubs, interest groups, sports teams, and extracurricular activities. These efforts are intended to increase engagement, motivation, and school connectedness, which support improved attendance and academic performance.
The HFW Coach further emphasizes school attendance and school functioning during feedback sessions following the administration of the HFW Satisfaction Questionnaire. Findings from these reviews are used to guide coaching and support continuous staff improvement. Additionally, Wraparound staff present families with a brief two-question progress survey during the first week of each month, completed concurrently with Service Verification forms. This survey captures the family’s perception of progress toward educational and treatment goals for the month (see CO 1.1 Initial and Continuing Assessment page 1-2 item 4, 9; HFW Satisfaction Questionnaire-ROCC; Outcome Methods page 1 bullet 1; Satisfaction-Perception Survey data – annual May 2025 page 22-23 items 16-20; Clinical – All – Peer Youth Advocate and Peer Family Advocate – JD – 3.2026 page 1-2)
2.3 Improved Functioning in the Community
At the start of the Plan Implementation phase, the Wraparound team engages in collaborative brainstorming during Wraparound Team Meetings (WTMs) to identify community resources and connection opportunities that support youth and caregivers in building meaningful and sustainable relationships within their community. The Care Coordinator utilizes the Team and Community Strengths Inventory to identify the most beneficial formal and informal connections aligned with the family’s strengths, interests, and cultural context. Identified opportunities may include age-appropriate, engaging, and creative extracurricular activities, community-based programs, volunteer opportunities, and employment experiences designed to foster independence and independent living skills for youth. These activities are selected to promote social connectedness, skill development, and long-term community engagement.
River Oak Wraparound partners with Transition Age Youth (TAY) who benefit from intentional connections to community supports such as the Sacramento County Independent Living Program (ILP), Extended Foster Care orientations, volunteer opportunities, and other community-based resources that support successful transitions to adulthood.
The Wraparound team prioritizes cost-effective and sustainable options for each family and may utilize Flex Funds, when appropriate, to reduce financial barriers to participation. Flex Fund requests and decisions follow the Wraparound Flex Funds Policy and are documented through team discussion and consensus during WTMs. (See ‘HOW TO’ Guide for HFW Components page 11-12; Team & Community Strengths Inventory; CO2.5 Flex Fund Supports Policy (003) page 3-4; Plan of Care – WTM minutes template blank ’24 page 6; HFW – Phase 3 -Expectations -CC; Extended-Foster-Care-Program-Fact-Sheet page 1)
2.4 Improved Interpersonal Functioning
One of the indicators of improvement in the family’s interpersonal functioning within the family unit is progress toward their Family Vision. Family Vision is a statement that captures what the family’s life would be like when things are better for the entire family and what their shared hopes and overarching goals. The Vision is developed collaboratively by the family and the Care Coordinator during the Engagement Phase, and only the family has the authority to revise or update it over time.
The Family Vision is reviewed at every Wraparound Team Meeting (WTM), at a minimum of every 30 days. Progress and barriers are discussed collaboratively, and visual tracking of the Family Vision is displayed during WTMs using PowerPoint presentations or flip charts. Family Vision ratings focus on the family’s voice and perspective.
Additional outcome measures are used to track changes in interpersonal relationships and social functioning includes the IP‑CANS assessment which is administered within 21 days of intake and every six months to monitor progress in domains such as Interpersonal Relationships and Social Functioning. The scores are reviewed with the family and team, and plans are developed to address the need, if needed, in WTM setting.
The Wraparound Clinician also administers the Pediatric Symptoms Checklist (PSC) and Youth Pediatric Symptoms Checklist (Y‑PSC), each consisting of 35 questions completed by both the caregiver and youth. These tools are used to gauge progress and identify barriers related to interpersonal functioning. Findings from the PSC and Y‑PSC inform clinical interventions during individual sessions and are documented in the youth’s Plan of Care to support ongoing progress monitoring.
In addition, the High Fidelity Wraparound (HFW) Coach administers the HFW Satisfaction Questionnaire every 3–6 months to gather relevant family feedback on service delivery and outcomes, including family interactions and team effectiveness. Broader program-level feedback is also incorporated through the administration of quarterly TOM and WFI‑EZ surveys, as well as the annual Consumer Perception Survey. Results from these tools support continuous quality improvement and inform targeted coaching and training efforts to strengthen staff practice and fidelity to the Wraparound model. (See Outcome Methods page 1 bullet 1&6; ‘HOW TO’ Guide for HFW Components page 5-6; IP‑CANS template; Plan of Care – WTM minutes template blank ’24 page 1; HFW Satisfaction Questionnaire-ROCC; Pediatric-Symptom-Checklist-PSC-35)
2.5 Increased Caregiver Confidence
At River Oak, Care Coordinators identify parent/caregiver underlying needs related to the youth’s referral behaviors and reviewed at each WTM throughout the Wrap process. Progress is tracked in the same manner as youth. Also, the parent/caregiver’s desired outcome from the Wraparound process is developed, and progress is measured and tracked monthly alongside the young person to ensure their needs are being met throughout the HFW process. River Oak WRAP Family Advocates are assigned to each caregiver at the start of the HFW process (intake) and continually monitor caregiver’s confidence, check for progress, and connect the caregiver to community resources during their set sessions (at minimum 1-4 times per month). HFW coach administers HFW Satisfaction Questionnaire every 3-6 months either in person or via phone calls and uses the data for coaching and booster training. The clinicians conduct IP-CANS reassessment every six months to identify areas of needs for the caregiver, and results are shared with the family and the team. The results of the quarterly WFI-EZ caregiver survey are another way measuring caregiver confidence and data collected is shared with Wraparound managers and staff to use as a coaching tool to improve care for families (‘HOW TO’ Guide for HFW components page 10 tables 1, 2, 3; Plan of Care – WTM minutes template blank ’24 page 4; HFW Satisfaction Questionnaire-ROCC; WFI-EZ paper version CAREGIVER; CO 1.1 Initial and Continuing Assessment page 1 item 4)
2.6 Stable and Least Restrictive Living Environment
At River Oak, we strive to support our youth and families to maintain stability in the least restrictive environment possible, within their own community. To promote and sustain stability, the Wraparound team focuses on helping families identify the right team members and develop an individualized plan that reflects the family’s strengths, needs, and preferences. The Wraparound plan is reviewed and adjusted as needed during Wraparound Team Meetings (WTMs) or Emergency Wraparound Team Meetings (E‑WTMs). During these meetings, the team mobilizes both formal and informal supports to proactively manage crisis and support youth in remaining safely stabilized in their home and community.
When additional support is needed, the team explores short-term intensive services, such as Therapeutic Behavioral Services (TBS), to address the most concerning behaviors and prevent unnecessary placement disruptions. These interventions are utilized to enhance stability and reduce the risk of out‑of‑home placement and staff follow the referral process and eligibility criteria when needed.
If changes in a youth’s living environment do occur, all movements are tracked and documented in River Oak’s Electronic Health Records (EHR) system and reported through monthly Cross‑Systems (X‑Systems) reports, which are shared with Sacramento County. The Care Coordinator enters the type, frequency, and date of placement changes into the EHR within 24 hours of occurrence. Aggregated placement data generated from the EHR system are accessible to staff and managers and are used to monitor trends and inform service planning related to placement stability.
In addition, the quarterly TOM assessment provides program-level data regarding the number of youth who experience placement changes while receiving services at River Oak. This data supports ongoing evaluation of system effectiveness and guides quality improvement efforts focused on maintaining youth in stable, least restrictive settings. (See Outcome Methods page 1 bullet 4; Changes Update for Xsystems; TOMs Wraparound page 6 item 20)
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Ensuring the safety of youth and families is a top priority at River Oak. The Wraparound team develops, implements, and regularly updates individualized Safety Plans in collaboration with youth and families and in the WTM setting. These plans are designed to prevent or reduce behaviors that may lead to emergency room (ER) visits and/or psychiatric hospitalization. Families are also provided with 24/7 access to on-call crisis assistance, which supports early intervention and minimizes the risk of escalation that could result in behavioral health admissions.
When/if a youth experiences hospitalization, staff are required to submit an Incident Report (IR) detailing the reason for admission. Wraparound staff maintain consistent and close communication with the youth’s hospital-based treatment team, including the assigned case manager and treating psychiatrist. Staff actively participate in discharge planning and safety planning meetings to support a smooth and successful transition back home.
Hospitalization frequency is systematically tracked within the River Oak Electronic Health Record (EHR). In addition, the HFW Satisfaction Questionnaire captures any hospitalizations that occur during a youth’s involvement in the HFW process. This data is reviewed and used to inform staff of coaching, training, and quality improvement efforts.
Submission of IRs automatically alerts the organization’s Executive Management Team. The team conducts regular reviews of both individual incidents and aggregated data monthly, as well as cumulatively for the fiscal year.
Wraparound-specific Incident Reports (IR) and Adverse Incident Reports (AIR) are generated monthly to track the number of ER visits and hospitalizations. These reports are shared with Wraparound managers for ongoing oversight and program improvement. (See Outcome Methods page 2 last para; Safety Event Policy page 3, last para; WRAP IR Summary page 1&3; Form 10-01-13; 1. CO 3.4 On-Call Crisis Response System Policy page 1 para 1 and page 2 item 11; 2. On-Call Resources and Guidelines pages 1–2)
2.8 Reduction in Crisis Visits
In Wraparound, the youth and family’s Safety Plan is developed as a clear, step‑by‑step guide for immediate family members and natural support persons to use in order to minimize the need for formal services whenever possible. The plan outlines both proactive and reactive strategies designed to prevent crises or reduce the risk of escalation when a crisis occurs.
As part of the planning process, the Care Coordinator and Family Advocate (Certified Peer Support Specialist) support the family in using a three‑color system (red, yellow, green) to identify/prioritize natural support people who can assist during times of crisis.
– Red represents the support people the family contacts first, as they are known to be reliable and immediately available.
– Yellow includes individuals who can be contacted as backup supports if red supports are unavailable.
– Green identifies people with whom the family has regular contact and who provide ongoing encouragement, positive interactions, and shared successes.
In some families, the same individual may appear in more than one color category, reflecting their flexibility and consistent involvement in supporting the youth and family. The Care Coordinator reaches out to the support people and clearly documents helpful intervention they provide the youth and family with before, during, and after crisis. With direct support from their natural support network, families are often able to manage crises effectively and reach out to their Wraparound team for additional assistance, reducing the need to escalate to higher levels of care such as law enforcement involvement, emergency room visits, or hospitalization.
In addition, the family and natural support people have access to Wraparound team members during business hours and additional resources during evenings, weekends, and holidays through the on-call system or the Source Team. When a crisis is reported, staff are required to complete an Incident Report (IR) to document any situation involving law enforcement or emergency services. In addition, staff must enter crisis intervention notes in the Electronic Health Record (EHR) to capture the frequency and nature of crisis responses provided by River Oak professionals. Crisis-related visits and hospitalizations are tracked within the EHR, and Wraparound-specific IR/AIR reports are generated monthly to compare trends over time.
The Care Coordinator contacts the family within 24 hours of crisis to review their safety plan and steps they can maintain safety and schedule an Emergency Wraparound Team Meeting (E-WTM) to be held within 72 hours. During the E-WTM, the team focuses on the current crisis and develops a crisis plan or updates the existing plan to ensure that youth and family are stable and safe. The team schedules a follow up meeting to occur within 1-2 weeks of the crisis based on team preferences to ensure that the plan is working and update/change the plan if needed to reduce the likelihood of future crisis intervention.
The clinician and Care Coordinator also practice safety plan action steps with the family, and families provide ongoing feedback regarding the effectiveness of the plan. Clinicians conduct standardized assessments, including the PHQ‑9 and Columbia Suicide Severity Rating Scale, to evaluate and rule out suicide risk. The Quality Management team tracks hospitalization and ER visits through submission of IR and AIR and data is reviewed with Executive Leadership Team monthly. Wraparound specific data is shared with Wraparound managers to inform coaching and training staff when appropriate. (See My ‘GO TO’ People; CO 1.5 Suicide Risk Assessment page 1 para 1; 1. CO 3.4 On‑Call Crisis Response System Policy page 1 para 1; Plan of Care – WTM minutes template blank ’24 page 2)
2.9 Positive Exit from HFW
The River Oak HFW Team partners with youth and families to work toward achieving their Family Vision and addressing identified needs to support a hopeful and sustainable future. Transition planning begins at the very start of the Wraparound process and continues throughout services, with ongoing assessment and adjustment of the plan until the family’s needs are met, and meaningful progress is evident toward their Vision. River Oak operates from the belief that plans fail—not families. Consistent with this principle, HFW does not discharge youth and families based on adverse events. Instead, the team remains engaged and supportive, adapting strategies and services until the family is confident, stable, and ready for a successful transition.
The team continues to have WTMs every 30 days to ensure all connections, both natural and formal, are working, and the family is satisfied with the process. During the Transition phase, the HFW Coach administers the HFW Satisfaction Questionnaire to assess the youth and family’s level of satisfaction and to inform any necessary adjustments to interventions and supports. At the end of the Transition phase, the team finalizes the Transition Plan and celebrates youth/family’s success.
The Quality Management team at River Oak pulls aggregate data from the Electronic Health Records and X-System reports to record and evaluate the reasons for discharge, which youth/families were successful and unsuccessful at discharge, and length of time enrolled in the River Oak HFW process.
When services are ending and transitioning to a lower level of care, there are some requirements for sending a Notice of Adverse Benefits Determination (NOABD letter). Termination of services with step down to a Managed Care Plan (MCP) provider and they are not in agreement with discharge and/or they have not met their goals etc., (See CO 6.2 Discharge and Transition Planning page 1 para 1 and item #2; Outcome Methods page 1 bullet 5; NOABD letter template page 1; HFW – Phase 4 -Expectations page 2)
Engagement
3.1 Orientation
At River Oak, the HFW Team focuses the first 30 days of the process on orienting the youth/family to what HFW is, what families can expect from the WRAP process, introducing team members (their name and role) and including any natural supports or Tribal representatives if youth is part of a Tribal Nations as defined under Indian Child Welfare Act (ICWA).
A. River Oak Wraparound Family Advocate / Certified Peer Specialist makes the initial call to the family to schedule an intake appointment with the family. During this call, the Family Advocate provides the family with a brief description of the Wraparound process, introduction to principles and phases of Wraparound, and their role as the family advocate. Then the assigned Care Coordinator meets the family for an intake session and further explains the Wraparound process, its principles, phases, and legal and ethical requirements including confidentiality and mandated reporting status. (See Intake Procedure-WRAPAROUND-page 1, page 2; page 5)
a) At the intake appointment, the Care Coordinator meets the youth and family for the first time and is often accompanied by the family advocate and youth advocate (for youth ages 12 and up). They review the Wraparound Process User Handbook which includes the principles and phases and explains how they are operationalized in the Wraparound process. The family is provided with a copy of the handbook. (See Intake Procedure-WRAPAROUND page 2 and 5 and Wraparound Process User Guide pages 4, 8, and 13)
b) At intake, the Care Coordinator provides information on Informed Consent (which includes mandated reporting, confidentiality and its limits, client rights, risks and benefits, and exchange of information) and Mental Health Expectations. If an initial assessing Wraparound therapist (assigned for the first 60 days) is present at the intake appointment, they will also present the Notice to Clients related to their licensure number and supervisor information and how to file a grievance. Youth and family will sign the reviewed forms to show their consent and understanding (See Informed-Consent-ROCC page 1; Wrap Intake Procedure page 2)
c) During the initial call to the family, the Family Advocate explains their role on the team followed by the Care Coordinator and assessing therapist introduces their role on the team during the intake session. The CC provides the family with current team members’ name, title, description of their role, and contact information and contact information are added to their preliminary Safety Plan. At the initial WTM, if new team members are added to the team, their roles are introduced to the team. As the team grows, the “who is on my River Oak WRAP team” form grows to include important natural supports, tribal representatives if youth is part of a Tribal Nations as defined under Indian Child Welfare Act (ICWA), and formal supports (like social worker or probation). At the end of the initial Wrap Team Meeting (within the first 30 days), the Care coordinator sends the family the meeting minutes with the last page including the name, title, role and contact information of everyone in attendance (See ‘Who’s on my River Oak Wrap Team’ form; Wraparound Process User Guide page 7 for common Roles in HFW)
3.2 Safety and Crisis stabilization
At River Oak, the HFW Team supports the family in creating a Safety Plan at intake and updating and implementing and Plan throughout the WRAP process. The HFW Team responds to urgent family needs within 24 hours and the River Oak on-call number is available to families 24/7 for immediate crisis response.
During the first intake appointment, Care Coordinators collaborate with the youth and family to create a preliminary Safety Plan based on information gathered from the referral behaviors, conversation with the youth/family about their concerns, and completion of risk assessments (PHQ-9/Columbia) done by the WRAP therapist. The Care Coordinator provides a copy of the Safety Plan to the family at intake and continues to review and update that Safety Plan throughout the initial 30 days assessment period (See CO 1.1 Initial and Continuing Assessment page 1; Intake Procedure-WRAPAROUND page 2, HFW-Phase 1 Expectations page 2). The Safety Plan is a living document that is continuously reviewed and updated as needed with the family, at minimum, every 30 days during the Wrap Team Meeting or whenever a crisis occurs. Any time there is an update, the Care Coordinator offers a copy of the Plan to the family. Safety plan is also included in the Plan of Care (updated every 30 days following a Wrap Team Meeting) and is provided to the family and uploaded into their Electronic Health Record (See Plan of Care-WTM minutes template blank ‘24-page 2)
When a crisis occurs, the team convenes to have an E-WTM within 72 hours to address the crisis and prioritize reducing the harm. This planning ensures that the action steps are most helpful and doable for the family and supplement the existing Safety Plan. Crisis continues to be addressed until the risks are minimized and the team continually update Crisis/Safety Plan (updated/reviewed at least every 30 days in their Wrap Team Meetings and reflected in the Plan of Care document) and a copy is filed in their Electronic Health Records. (See Plan of Care-WTM minutes template blank ‘24 page-2 under Safety Plan, Wrap Team Meeting policy page 2)
The Care Coordinator, Family Advocate, and Youth Advocate inform the family at intake about the River Oak Intensive Community-based Services On-Call system and procedure. The family is given the number and instructions on how to access the service which is embedded in the Plan of Care under the Safety Plan. Throughout the WRAP process, families are reminded of the On-call number and procedure for 24/7 crisis response (See On-Call Resources and Guidelines page 1; On-Call System procedure-ICS-Flyer page 1, CO 3.4 On-Call Crisis Response System Policy)
3.3 Strengths, Needs, Culture and Vision Discovery
At River Oak, the Care Coordinator gathers information from the youth, family, and supports to inform the Family Story. This document details the family’s strengths, needs, culture/traditions, hope for their future, and ways they have overcome challenges in the past. The Family Story is provided to all team members when they join the HFW process to help orient them towards a shared team goal as they participate in brainstorming and planning.
The Care Coordinator introduces the Family Vision at intake (first appointment) and develops it with the family during the Engagement phase (initial 30 days after intake) prior to the initial Wrap Team Meeting. The Family Vision is reflected in the Family Story and is documented in the Plan of Care and Wrap Team Meeting Minutes which is filed in youth’s Electronic Health records (see ‘HOW TO’ Guide for HFW Components pages 5 and 6; HFW phase 1 Expectations page 1 and page 2 bullet 6)
The family’s strengths, needs, value, and culture are discovered during the Engagement phase. The Care Coordinator uses the Family Story Tool and Timeline to learn about their good times and ways they have bounced back from challenging times. The WRAP therapist also completes the IP-CANS (within 21 days) and coordinates with the CC to highlight the scores that might be impacting the youth and family and inform the need statements as well. Then the CC compiles the family’s story and reviews with the family to ensure they got their story right. With their permission, the CC arranges to share selected portions of the family’s story with the rest of the team at the initial WTM. Upon completion of the family’s story, the Care Coordinator develops underlying need statement (ten each) for the youth and parent to possibly identify what might be the root cause of the behaviors that brought the young person to Wraparound. The ten options are shared with the youth and the parent(s) to prioritize the top a few that resonate with them. Then the need is reviewed with the team in initial WTM for the team to further prioritize and decide on the most pressing need to be addressed int eh Wraparound process. During their ongoing Wrap Team Meetings (every 30 days), new strengths, needs and cultural considerations are identified for each team member and added to the Plan of Care which is distributed to each team member at the conclusion of each Wrap Team Meeting. (see ‘HOW TO’ Guide for HFW Components pages 3-5; HFW phase 1 Expectations page 2; NWIC Coaching Tool Descriptions 2026-Family Story Tool and Timeline page 2 bullets 10, 11 & 12)
3.4 Engage All Team Members
River Oak Wraparound acknowledges the importance of WRAP as a team-based model of support and recognizes the value that each person’s unique skills, knowledge and experience can bring. In this process, the Care Coordinator engages and invites tribal community support if youth is part of a Tribal Nations as defined under Indian Child Welfare Act (ICWA). The Care Coordinator draws upon each team member’s role and strengths when collaborating and planning as a group.
a) Care Coordinator utilizes the Family Story Tool and the Your Support System Tool to identify natural supports who have helped the family in the past. These identified supports are reflected in the Family Story and included in the Wraparound Plan of Care, ensuring that planning builds on existing relationships, strengths, and sources of support. The documentation is filed in youth’s EHR (Electronic Health Records). Once support people are identified, the CC uses the Team Perspectives Tool to engage the support people and get their perspectives. The natural supports are invited to monthly Wraparound Team Meetings and are clearly documented on Safety Plans and Care Coordinators to engage with them between WTMs. During coaching, the HFW coach uses excel tracking for Natural and Formal Support people for youth and families. (see Your Support System; NWIC Coaching Tool Descriptions, items 10&11, Team and Community Strengths Inventory)
b) Care Coordinators utilize the Team Perspectives Tool to engage identified formal support people/system partners. Formal support /system partners can include: CPS social worker, Probation, CLC, CASA workers, Mental health agencies, psychiatrists, school representatives, etc.), The Care Coordinator connects with identified support people to onboard them to the Wraparound process and engage them weekly to ensure all parties are actively involved in the wraparound process. These team members are invited to Wraparound Team Meetings and part of the planning and team decision making process. (See “HOW TO’ Guide for HFW Components page 17-19; NWIC Coaching Tool Descriptions #10)
c) In addition to system partners, the Care Coordinator closely works with the family to identify and engage other support people and community resources. The family’s natural and formal support people are properly introduced to the Wraparound process; their roles are clarified and invited to each WTM. Care Coordinators utilize tools such as Your Support System or Team and Community Strengths Inventory to identify natural or formal support people and resources. Then The CC uses the Team Perspectives Tool to identify potential team members’ own strengths, perspectives of the family’s strengths and challenges, and their agenda (what they are hoping to accomplish). If youth is part of a Tribal Nations as defined under Indian Child Welfare Act (ICWA), the Care Coordinator establish contact with tribal representatives to involve them in the Wraparound process. Once all identified support people are contacted and oriented, Care Coordinators provide the family with the “Who is on my River Oak WRAP team” document so they can easily understand each person’s role. All team members are also listed in the Plan of Care (POC) and a copy is provided to the family. (see ‘HOW TO’ Guide for HFW Components page 16 and 17; Your Support System; Team and Community Strengths Inventory; NWIC Coaching Tools Description #10, Who is on my River Oak Wrap team)
d) Care Coordinators set aside time at the start of the Wrap Team Meeting (WTM) agenda to connect and engage the youth/family and team members. Team building activities can include a fun ice breaker question or a quick game. Throughout the Engagement Phase (first 30 days), Care Coordinator, WRAP therapist, Family Advocate, and Youth advocate document in progress notes the creative ways they are engaging and building rapport with all team members and the youth/family (See Initial WTM agenda powerpoint page 2 slide 3, HFW Phase 2 Plan Development page 2 bottom box, top line: setting the stage for teaming).
3.5 Arrange Meeting Logistics
At River Oak, family voice and choice are prioritized to break down barriers that limit access to equitable treatment and services. The River Oak HFW team remains flexible and offers families various times, locations, and dates for sessions and meetings to occur and can offer telehealth if appropriate or arrange for transportation to and from appointments. The River Oak Wraparound team also ensures the family’s cultural and language needs are met by partnering with Language World for interpretation services.
River Oak Wraparound is an intensive, community-based process and staff do not have a set 9 to 5 daily schedule and instead are flexible to meet the needs of the youth/families that they partner with. For initial and ongoing Wrap Team Meetings, the Care Coordinator works with the youth/family and other team members (formal and natural supports) to identify a date, time, and location that works best for all. This includes times outside of 9-5 working hours and can be at a variety of locations (i.e. private park, the home, River Oak offices, school, CPS office, etc.) The WRAP therapist, skills trainer, Youth and Family Advocates also schedule individual sessions with the youth/family at a date, time and location that best meets their needs. In the event the family meets in the office setting, Wraparound staff offers gas cards as needed. (See Remote Work policy; Interpretation Service CO 33)
All River Oak WRAP staff are trained to gain techniques to work collaboratively with youth, families and other team members. Staff receive initial and ongoing trainings conducted by the National Wraparound Implementation Center (NWIC) trainings such as Wraparound 101 (3-days) and Wraparound 102 (1-day) for meaningful engagement with youth, family and other team members throughout the Wraparound process. In addition, staff are all trained in Collaborative Documentation Training, monthly all-staff 1-hour booster training led by HFW coach and supervisors, and weekly 1-hour supervision with direct supervisor. Care Coordinators receive additional weekly 1-1.5 hour individual coaching with the HFW coach and monthly 2-hour group coaching led by HFW coach and supervisors. HFW coach follows the CREST template to coaching staff on improving their skills. Family and Youth advocates meet monthly for 1-hour coaching with the HFW coach to address collaboration with families and ensuring the family’s needs and preferences are heard when scheduling meetings. (See High Fidelity Wraparound Training and Coaching Plan page 7; page 15)
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
1. During the Engagement phase, the Care Coordinator meets with the family to prepare them for the initial Wrapround Team Meeting. During this meeting, the CC reviews the purpose of the Ground Rules/Team Agreement and collaborates with the family to develop agreements that reflect their voice, preferences, and values. The Care Coordinator then brings the family’s list to the initial Wraparound Team Meeting (WTM) to invite input from other team members, incorporate additional ideas into the Team Agreement, and ensure shared understanding and agreement regarding team member roles, expectations, and the decision‑making process moving forward. The Wraparound principles are reflected in the development of Ground Rules. The Ground Rules/Team agreement is reviewed/updated at each WTM, which occurs every 30 days. During the Wrap Team Meeting, the Care Coordinator posts the Ground Rules in a place that is visible to all participants. This is included in the Plan of Care and filed in youth’s chart every 30 days. (See HFW – Phase 1-Expectations – CC page 4; ‘HOW TO’ Guide for HFW Components bottom of page 6 and page 7; Plan of Care – WTM minutes template blank ’24 page 1
2. At the initial Wraparound Team Meeting (WTM), the Care Coordinator reviews the previously identified strengths of each team member and works collaboratively with the team to identify and add additional strengths during the meeting. These strengths are visible in a shared space alongside other meeting components to ensure they remain central to the planning process.
3 The Care Coordinator also utilizes the Team and Community Strengths Inventory to highlight available community resources and invite more ideas for additional local resources during team brainstorming, including new team members and natural support. Identified strengths are intentionally used to inform the development of strategies and assigned tasks within the plan. (See ‘HOW TO’ Guide for HFW Components page 9; Team & Community Strengths Inventory; HFW – Phase 2-Plan Development – Care Coordinator Expectations page 2).
a) The Care Coordinator facilitates a collaborative discussion with all members in attendance at the initial Wrap Team Meeting (held within the first 30 days) to create a Team Mission. The Team Mission is the guiding force for the youth, family, natural support, formal support, and River Oak staff to follow throughout the WRAP process to help work towards what they want to accomplish together as a team. The Team Mission is inclusive of everyone equally, and everyone is held accountable for the success of the team. The team’s collaboration and teamwork contribute to the success of the family making progress towards their Vision and Needs. The Team Mission is agreed upon by the entire team consensus and written into the Plan of Care to be reviewed and scaled at every monthly Wrap Team Meeting (every 30 days). (See HFW – Phase 2-Plan Development – Care Coordinator Expectations page 1 bottom table; ‘HOW TO’ Guide for HFW Components page 9)
b) Prior to the first Wrap Team Meeting, the Care Coordinator is meeting with the youth and family, to explain the purpose of Ground Rules/Team Agreement and enlist a few ideas and lists them to bring to the initial WTM. At the initial WTM, the CC adds ideas from other team members to add to the list (see #1 above). The Care Coordinator also connects with identified support people, both natural and formal, and explores their strengths, functional strengths, and their perspectives of the family. These strengths for each team member are displayed, reviewed, and additional strengths are added at the initial WTM (see #2 above). At the initial Wrap Team Meeting, the team develops a Mission statement to guide the process (see #3 above). Care Coordinators lead the team to develop the family’s Wraparound plan during the initial WTM and enter the information onto the Plan of Care template immediately following the Wrap Team Meeting. The Plan of Care is distributed to relevant team members within 7 days of the meeting. And filed into the youth’s Electronic Health Record. (See ‘HOW TO’ Guide for HFW Components page 6-9; HFW – Phase 2-Plan Development – Care Coordinator Expectations page 2)
c) The Care Coordinator reviews the strengths and functional strengths for each team member in every Wrap Team Meeting (held at minimum every 30 days) and documents in the Plan of Care. Previously gathered strengths are listed and reviewed, and new strengths are added for each team member. The Care Coordinator identifies new strengths by using the Team Perspective Tool and Team and Community Strengths Inventory tool with family and support (formal and natural) people. The updated Plan of Care (updated within 7 days of the WTM), with the newly identified strengths, is entered into the youth’s Electronic Health Record. (see Plan of Care – WTM minutes template blank ’24 page 1, ‘HOW TO’ Guide for HFW Components pages 8-9; NWIC – Coaching Tool Descriptions 2026 (002) page 2 item 10; Team & Community Strengths Inventory)
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
The River Oak Care Coordinator supports the youth and family in identifying a Needs Statement which is developed with the family in the first 30 days and targets the underlying unmet need that is contributing to the symptoms and referral behaviors. The HFW Team continually brainstorms ideas to meet this Need and based on agreed upon ideas, the Care Coordinator assigns tasks to all team members.
a) When identifying possible underlying needs for the youth and caregiver, the CC collaborates with the assessing clinician to review IP-CANS scores that could potentially relate to underlying needs. The IP-CANS are completed by the clinician within 21 days of intake. Then Care Coordinator develops the Thoughts/Feelings Statements (10 per family member) based on information they have gathered for their Family Story during the Engagement Phase (first 30 days) with the youth/family about their concerns and reasons for referral. The Care Coordinator translates the Thoughts/Feelings statements into possible Needs Statements and brings the list of possible Needs to the youth/family. Review the list and invite them to choose the top 2-3 Needs statements that resonate with them most. At the initial Wrap Team Meeting (within 30 days from intake), the Care Coordinator explains the process of developing and selecting the top 2-3 with the family and team members votes/agrees on one prioritized Need for youth and one prioritized Need for the family member to address during the Wraparound process. These Need Statements are documented in the Wrap Team Meeting Minutes and, after the meeting, in the youth’s Plan of Care, to be uploaded into the youth’s Electronic Health Record. At every monthly Wrap Team Meeting, the Needs Statement is scaled to track progress. (See ‘HOW TO’ Guide for HFW Components page 10-11; Developing Need Statements, HFW – Phase 1-Expectations – CC page 1 table)
b) The Care Coordinator links the family’s identified needs to measurable scores on Pediatric Symptom Checklist-35 and the IP-CANS (administered in the first 21 days by the WRAP therapist) and creates with the family and team an Outcome Statement which directly addresses the most concerning behavior the family is experiencing. This process takes place during the initial WTM and is reviewed, and progress is tracked at each WTM. The improvement in Outcome is one of the indicators that the youth are making progress toward meeting their needs. A baseline is established, and the team decides whether an increase or decrease is desired. The Care Coordinator also partners with the family/team on creating and scaling their Family Vision – a goal or picture of where the family sees themselves when things improve. The identified Need statement, Family Vision, and Outcome are scaled each month by the youth/family to quantify and measure progress. (Plan of Care – WTM minutes template blank ’24 page 1 and 4; ‘HOW TO’ Guide for HFW Components page 11-12; HFW – Phase 2-Plan Development – Care Coordinator Expectations page 1 table)
c) Wraparound Care Coordinator only develops goals and outcomes collaboratively with the youth/family and entire Wraparound including natural and formal support. The Family Vision, Team Mission, Outcome Statement, and Finalized Needs Statement are all agreed upon in an initial Wrap Team Meeting (within the first 30 days) and reviewed collectively as a team at each follow up WTMs and updates are made based on team decisions and documented in the Plan of Care. (see HFW – Phase 2-Plan Development – Care Coordinator Expectations page 1 table; HFW – Phase 3 -Plan Implementation Care Coordinator Expectations page 1-2)
d) The Care Coordinator leads the team for a robust brainstorming activity to create helpful strategies to address the underlying need(s). The CC encourages and captures at least 10 ideas for each need and ensures that the list is visible for everyone to review and make selections from. These ideas are all documented in the Plan of Care which is uploaded into the youth’s Electronic Health Record. Individual staff (CC, therapist, youth advocate, family advocate, skills trainer) also include the tracking and brainstorming ideas to address the needs in their progress notes (See ‘HOW TO’ Guide for HFW Components page 12-13; Plan of Care – WTM minutes template blank ’24 page 7)
e) Each Wraparound Care Coordinator is trained by National Wraparound Implementation Center (NWIC) for Wraparound 101, formerly known as Introduction to Wraparound, training where they learn the tools and techniques on facilitating WTM and leading the team in identifying, prioritizing, and selecting strategies. To enhance their skills, Care Coordinators receive weekly targeted coaching with NWIC certified HFW supervisor-coach for 1-1.5 hours, bi-weekly to monthly lab hours, weekly 1 hour supervision with their direct manager, and monthly 2-hour group coaching with the HFW coach and supervisors (See High Fidelity Wraparound Training and Coaching Plan page 3-4 and page 13-14; HFW – Phase 3 -Plan Implementation Care Coordinator Expectations page 4-5)
f) Care Coordinators develop the individualized Plan of Care based on collaboration done by the team at the Wrap Team Meeting. Multiple Wraparound principles are operationalized throughout the planning phase, and each participant’s voice, ideas, concerns, and input are encouraged and reflected in the planning process. The initial Plan of Care is created after the initial Wrap Team Meeting and is updated at each follow up WTMs, every 30 days. River Oak Wrap staff creates an inviting and safe environment where the youth, family and other team members are able to share thoughts and ideas without being judged. The team is aware that all plans must be created within a WTM setting and no plans are made without the youth/family following ‘nothing about us, without us’ philosophy. (see ‘HOW TO’ Guide for HFW Components page 24-25; Care Coordination Meeting Structure)
4.3 Develop an Individualized Child or Youth and Family Plan
During the initial Wraparound team meeting, the Care Coordinator collaborates with the youth, family, system partners, natural supports, and tribal representatives if youth is part of a Tribal Nations as defined under Indian Child Welfare Act (ICWA) and create an initial Plan of Care. The initial WTM occurs within 30 days of intake. Based on input from all team members in an initial Wrap Team Meeting, the Plan of Care includes review of Family Vision, development of Team Mission, strengths of all team members, safety plan, Needs Statements, Outcome tracking, strategies and assigned tasks.
1. The team develops a plan that focuses on supporting the youth and family to make progress towards their identified Vision based on their family culture and where they see themselves when things are better and underlying/unmet needs they want to address during the Wraparound process. The plan also emphasizes what a positive Outcome would look like for the family by identifying and addressing the most concerning behavior the youth and caregiver identify, and Care Coordinator writes as an Outcome Statement including the baseline of the behaviors. To be successful, the team follows the Mission they have created together to achieve a shared goal while utilizing their strengths and finding the most culturally relevant and respectful ways to meet the family’s needs. A comprehensive Plan of Care is compiled after the WTM and distributed to each team member within 7 days of the meeting and filed in youth chart. (See HFW – Phase 1-Expectations – CC page 1-2; HFW – Phase 3 -Plan Implementation Care Coordinator Expectations page 1-2; ‘HOW TO’ Guide for HFW Components page 24-25)
2. The Plan of Care highlights a youth and family’s Need Statement that spans multiple life domains and suggests that if the underlying need was met, then symptoms and referral behaviors at home, school and community would decrease. The Plan of Care also addresses IP-CANS items and Outcomes (tracking measurable behaviors) throughout the WRAP process. Children’s System of Care partners (i.e. CPS social workers, probation officers) are included in the HFW Team, invited to all Wrap Team Meetings and are invited to actively participate in the brainstorm and tasking process. This ensures court requirements or Systems needs are being prioritized as well. These team members are engaged between team meetings for coordination of care and motivated to complete tasks and strategies. (See ‘HOW TO’ Guide for HFW Components page 10-11; HFW – Phase 1-Expectations – CC page 2-3; Plan of Care – WTM minutes template blank ’24 page 4)
3. The Plan of Care clearly documents each chosen strategy paired with tasks assigned to every team member based on their strengths and capabilities, and a due date for completion of assigned tasks. The Care Coordinator ensures to follow a format: Who, What, When, and How for the strategies and task to be clear for the team members to follow and complete. The Care Coordinator is coached to ensure that during the brainstorm, formal services and natural/community supports are offered, family culture informs the strategies, and there are more natural supports than formal services during the transition phase (See ‘HOW TO’ Guide for HFW Components page 14; HFW – Phase 3 -Plan Implementation Care Coordinator Expectations page 2; Plan of Care – WTM minutes template blank ’24 page 4)
4. The Plan of Care has a section where all ideas gathered during brainstorming activity in the WTMs, every 30 days. This provides the space for all team members (youth, family, natural supports, system partners, formal services) to be creative in sharing ideas to address the youth/family’s needs and tailor to their specific family culture. The Care Coordinator reminds the team of their strengths and what the team already has available and encourages ‘out of box’ ideas to support the family. Ideas can be a good mixture of formal services (i.e. trauma therapy, court mandated) or natural (i.e. one-on-one bonding time with a favorite aunt) and the youth/family choose the ideas that are important to them and will work best for their family. River Oak Wraparound sessions / appointments are always offered in locations that best fit the family’s preferences and at dates/times that the family agrees upon. (See ‘HOW TO’ Guide for HFW Components page 12-13 and page 24 items 15&16; Plan of Care – WTM minutes template blank ’24 page 6; HFW – Phase 2-Plan Development – Care Coordinator Expectations top of page 4)
5. The Care Coordinator ensures that the brainstorm and strategy portion of the Plan of Care always includes natural supports and sustainable community resources that are sustainable and long-term and will support the family after formal services and River Oak Wraparound transition out. If natural supports and community resources cannot be identified at the start of the wraparound process, the HFW Team brainstorms and strategizes ways to connect the family to these types of supports throughout the phases of Wraparound using the Team and Community Strengths Inventory tool and My ‘Go To’ People tool. The team ensures that the connections with natural and community resources are stable and working throughout the Transition phase and work toward resolving barriers prior to transition. (See Plan of Care – WTM minutes template blank ’24 page 6; ‘HOW TO’ Guide for HFW Components pages 12-13; Team & Community Strengths Inventory; My ‘GO TO’ People)
6. A successful graduation from River Oak Wraparound occurs when the youth’s living situation is more permanent, less restrictive, and supported by fewer formal services. River Oak Wraparound works to meet families where they are and to move at the family’s pace toward sustainable success. At each Wraparound Team Meeting (WTM), held every 30 days, the family’s progress toward their Family Vision, identified Needs, and desired Outcomes is reviewed and scaled throughout the Plan Implementation and Transition phases. As progress is demonstrated and consistently maintained for at least three to six months—or according to benchmarks established by the team—the team collaboratively determines whether the family is ready to move from the Plan Implementation phase into the Transition phase. The Care Coordinator refers to the Transition Readiness scale to lead the team in making decisions regarding transition. Once readiness is established, the team collectively decides on a tentative graduation date of at least 60-90 days or longer. During this time, the team continues to meet for WTM every 30 days, monitor progress, maintenance, and barriers and adjust strategies if needed. The team also decides to gradually phase out formal support while intentionally strengthening and replacing them with natural and/or community support. The Transition Plan and Post-Transition Safety Plan, both included in the final Plan of Care, outline potential future needs and clear strategies for how the family can address those needs after Wraparound services close. These plans are developed prior to closure to ensure remaining team members—primarily natural supports—understand their roles, responsibilities, and tasks in sustaining the family’s success moving forward. (See Wraparound Transition Readiness Scales; HFW – Phase 4 –Expectations page 1-2; Plan of Care – WTM minutes template blank ’24 page 6)
a) Wraparound Care Coordinators receive Wraparound 102, formerly known as Engagement in Wraparound, training within 3 months of hiring to learn techniques of effective engagement including reflective listening (See High Fidelity Wraparound Training and Coaching Plan page 3-4 table and page 8). In addition, the HFW coach provides 1-1.5-hour weekly coaching for each care coordinator to address engaging teams in planning, gathering perspectives, focusing on the shared vision, and other HFW principles using onboarding and coaching tools such as CCRSR (Care Coordinator Responsibilities and Supervision Response) tool and CREST (Coaching Response to Enhance Skills Transfer) to individualize coaching and skills transfers. (See High Fidelity Wraparound Training and Coaching Plan page 13 table; NWIC – Coaching Tool Descriptions 2026 (002) pages 1-2 items 3 & 9). In addition, Care Coordinators participate in weekly one‑hour supervision meetings with their direct supervisors and monthly two‑hour group coaching sessions led by the HFW Coach and Wraparound Supervisors. All Wraparound staff also attend a monthly one‑hour booster training focused on themes identified through youth and family satisfaction surveys and other feedback tools. These booster trainings are guided by the ten principles of Wraparound and address relevant activities across Wraparound phases to strengthen practice quality and fidelity. (See High Fidelity Wraparound Training and Coaching Plan page 13-14).
b) The Wraparound Care Coordinator skillfully integrates the goals and agendas of system partners (e.g., Child Protective Services, Probation, schools, tribal communities, and other identified partners) by onboarding them into the Wraparound process and exploring what each partner hopes to accomplish through collaboration and mandates they bring to the table. These conversations occur prior to the initial Wraparound Team Meeting (WTM) and the Care Coordinator brings their input to the initial WTM to where one unified Plan of Care is developed in collaboration with the family and the entire team. System partners’ perspectives and mandates are incorporated alongside the family’s voice, ensuring balanced and collaborative decision‑making. All team members actively contribute to the development of a shared Team Mission, which guides the Wraparound process. Ideas, strategies, and system requirements are documented in the brainstorming section of the Plan of Care to support the family in addressing their identified needs while maintaining fidelity to Wraparound principles. The CC leads the team in developing clear strategies and tasks at the conclusion of the WTM, and everyone in attendance leaves with a task to complete between WTMs. All information is documented in the family’s Plan of Care and WTM minutes, which are updated after each WTM held every 30 days to reflect ongoing progress, collaboration, and evolving needs. (See HFW – Phase 2-Plan Development – Care Coordinator Expectations page 3; ‘HOW TO’ Guide for HFW Components page 24-25 under Plan of Care)
c) The Plan of Care is updated and uploaded into the youth’s Electronic Health Record (MyEvolv) within one week after each Wraparound Team Meeting occurring. The Care Coordinator emails a soft copy securely to all team members that attended the meeting and can offer a hard copy if requested. The Plan of Care clearly documents the Family’s Vision, Team Mission, Strengths, Needs (of both family/youth and system Partners). In addition, the Plan of Care documents strategies and tasks (action items) with the name of the team member assigned to the task and the date in which they are expected to complete it. The Brainstorming section of the Plan of Care allows space for individualized, creative, and culturally relevant ideas that involve youth, family, natural support, community resources, formal system partners, and paid professionals. This way, the ideas can take into account the family’s schedule, needs, culture, trauma history, and voice, among other things. The Plan of Care documents various areas to scale (Family Vision, Team Mission, Outcome Statement, Needs Statements) so the team can visually track progress overtime and gradually prepare for transition when numbers improve and are maintained for 3-6 months. River Oak WRAP staff are guided by the “Do For – Do With – Cheer On” principle and overtime, gradually phasing out formal supports by encouraging the family to utilize their own resources at their pace. Each staff member in attendance of WTMs completes individual progress notes in youth file. (See ‘HOW TO’ Guide for HFW Components page 23 table and page 24-25 under Plan of Care; HFW – Phase 3 -Plan Implementation Care Coordinator Expectations page 3).
d) Care Coordinators are required to submit their initial Plan of Care to the HFW Coach for review in the first 6-12 months of employment for quality assurance. The HFW Coach uses the Supervisory Checklist for Documentation template to ensure all elements of Plan of Care are met (including Strengths, Family Vision, Team Mission, Needs, Outcomes, Strategies, Crisis/Safety Plan, and included support people). Per NWIC (National Wraparound Implementation Center) model, Care Coordinators meets 60-70% of threshold based on Supervisory Checklist scoring for the first six months and 90% after a year. The HFW coach provides feedback to the Care Coordinator weekly and ongoing at each of their 1-1.5-hour individual coaching meetings. (See ‘HOW TO’ Guide for HFW Components page bottom of 22- top of 23)
4.4 Develop a Crisis and Safety Plan
The River Oak WRAP Care Coordinator collaborates closely with the youth/family to create their own individualized preliminary Safety Plan that is created at intake (first appointment) and updated throughout the WRAP process until discharge. The River Oak Safety Plan includes detailed proactive and reactive strategies that the youth, family and team can use during a crisis incident based on the family’s needs and concerns. The steps in the Safety Plan are chosen by the youth and family and highlight their family culture (what will work for them) and include all natural and formal supports identified by the HFW team.
a) The initial, preliminary, Safety Plan is created at first intake appointment with youth and the family to ensure that they are safe and stable until the initial WTM occurs within 30 days of intake. This plan is reviewed at the initial WTM and updated with additional interventions and support people and resources that are identified prior to or during the initial WTM. The plan clearly indicates the most concerning behaviors that are causing concerns for the family and strategies begin from their Calm state to deescalation techniques that have been helpful for the family in the past or they would like to try out. In the Safety Plan, the Care Coordinator collaborates with the youth/family to list warning signs, triggers and ways to recognize a crisis could be developing using Crisis Cycle tool. Then the Care Coordinator and family list positive coping strategies, helpful distractions and reasons to continue living and thriving (motivators when things get hard). The Care Coordinator explores the family’s natural and community support that has been helpful in the past and currently to include in the plan by using My ‘Go To’ people tool where the family identifies their support people in 3 color-tier category (red, yellow, and green). Lastly, in the Safety Plan the family lists any social supports they can contact if all else fails. The Safety Plan also lists all River Oak team members and emergency supports including the River Oak 24/7 On-Call number, crisis numbers (i.e. 911, 988), resource line (211), and other resources. In the event a crisis occurs or the family contact any of the resources listed above, the Wraparound team contacts the family within 24 hours and the team convenes for an E-WTM (emergency-Wraparound Team Meeting) within 72 hours, as needed. (See ‘HOW TO’ Guide for HFW Components page 20; My ‘GO TO’ People; Crisis Cycle Visual; On-Call Resources and Guidelines page 1-2; Wrap Team Meeting Policy page 2 item D)
b) The Care Coordinator creates the initial Safety Plan with the family at intake (first appointment), and the Safety Plan is reviewed and updated at the initial WTM and each follow-up Wraparound Team Meetings to ensure that the entire HFW Team is part of the process. New team members become part of the plan, as the team ensures to have the right sized support when and where it is needed. (See CO 1.1 Initial and Continuing Assessment page 1 item 2; ‘HOW TO” Guide for HFW Components page 20; HFW – Phase 1-Expectations – CC page 1 para 2; My ‘GO TO’ People). The River Oak Care Coordinators receive ongoing coaching on collaborative safety planning during their weekly 1-1.5-hour individual meetings with a HFW coach, weekly 1 hour supervision with their direct manager, monthly 2-hour group coaching with the HFW coach and supervisors, and monthly 1-hour all staff HFW booster meeting. On top of the WRAP new hire trainings that address team-based safety planning (Wraparound 101, Wraparound 102, Wraparound 201, (formerly known as Introduction to Wraparound, Engagement in Wraparound, Intermediate Training). Care Coordinator completes Safety Overview Orientation with Wraparound Manager. (See High Fidelity Wraparound Training and Coaching Plan page 6-8, &13; Training Catalog-2026 page 6)
c) Care Coordinators submit their initial Safety/Crisis Plans to their HFW coach who uses the Supervisory Checklist as a guide to review the meaningful inclusion of all important aspects of effective Safety Plan which includes the most concerning behaviors, culturally relevant action steps- both proactive and reactive, and use of relevant team members and helpful community resources. In addition, the HFW coach provides Care Coordinators with weekly in 1-1.5-hour coaching sessions and monthly in 2-hour group coaching to enhance skills on building and updating safety plan when needed. Care Coordinators’ direct supervisor reviews their Safety Plans at minimum every 6 months as part of required re-assessment and updates. (See HFW – Phase 3 -Plan Implementation Care Coordinator Expectations page 4-5 table; NWIC – Coaching Tool Descriptions 2026 (002) page 1 item 1; WRAP 6 Month Bundle Checklist-MyEvolv page 1)
Implementation
5.1 Implement The Plan of Care
River Oak HFW Teams celebrate success regularly and ongoing throughout the process (built into ongoing Wrap Team Meetings agenda) and is based on how the family likes to be celebrated. Any progress is acknowledged in the Plan of Care including completing tasks, getting closer to goals/vision, and increased connections.
a) The Care Coordinator reviews strategies and action items/tasks every 30 days at Wrap Team Meetings. By reviewing and addressing, they can monitor the completion of tasks or facilitate a discussion with the team on ways to address the barriers to completion or adjust strategies/tasks as needed. Timelines/due dates (who, what, how, when) are documented on the Plan of Care to keep the entire team accountable and for Care Coordinators to track and follow up. The Care Coordinator also follows up weekly with all team members (i.e. youth/family, advocates, therapists, social workers, probation officers, skills trainers, etc.) prior to the next Wrap Team Meeting to ensure tasks are being completed in a timely manner or assess any barriers (See ‘HOW TO’ Guide for HFW Components page 12-14; HFW Phase 3 Plan Implementation Care Coordinator Expectations pages 1 and 2)
b) Wraparound Care Coordinators receive weekly individual coaching and monthly group coaching to enhance skills to effectively develop strategies and tasks and follow up with team members. The coaching session helps them to use the knowledge they gained from attending Wraparound 101, and Wraparound 102, formerly known as Introduction to Wraparound and Engagement in Wraparound, training courses conducted by National Wraparound Implementation Center upon hire. The CCs learn and practice ways to develop and implement the Plan of Care in alignment with the HFW principles. They also complete advanced HFW skill enhancement trainings: Wraparound 201, 202, 203. Staff are trained to celebrate success at every stage, even a small success, and acknowledge “what is going well” at each Wrap Team Meeting. HFW topics such as plan implementation, operationalization of HFW principles, and celebrating successes are reviewed and coached by the HFW coach and supervisors ongoing in the following ways: monthly 1-hour booster training, WRAP all-staff monthly meeting that includes a “HFW corner” to review and conduct team-based activities, weekly 1-1.5 hours individual coaching for Care Coordinators, monthly 2-hour group coaching for Care Coordinators, and 1-hour group coaching for Advocates. (High Fidelity Wraparound Training and Coaching Plan pages 3-9; pages 13-17; P Plan of Care – WTM minutes template blank ’24, page 1).
5.2 Review and Update The Plan of Care
The River Oak Care Coordinator is tasked with reviewing and updating the Plan of Care based on discussion and agreements at each Wraparound Team Meeting which occurs, every 30 days. Updates to the Plan of Care include progress towards Family Vision, Team Mission, Needs and Outcome for each family member reflected in the plan. In addition, completion of tasks, new ideas or strategies, new tasks assignments, community resources and natural supports to utilize, and agreements on flex funds usage. The Care Coordinator documents team attendance and sends a copy to each team member within one week of the WTM occurring.
a) The Care Coordinator leads the team every 30 days in a Wrap Team Meeting. During follow up WTMs, the team reviews completion of tasks assigned in the previous meeting and determines whether the task has been accomplished or needs continuation. The team recognizes that some strategies need more time to accomplish, but they evaluate whether the method is working or not working. After reviewing the strategies and tasks from the previous meeting, the team continues brainstorming and prioritizing additional strategies, as needed, and assigning tasks to team members. The Care Coordinator ensures that everyone has a clear understanding of how the strategies are developed to support the youth and family to make progress toward their Vision and needs. The Care Coordinator ensures that everyone present in the meeting is assigned with a clear task, completion timeframe, and aware of the Care Coordinator’s plan to follow up between meetings to support. (See HFW Phase 3 Plan Implementation Care Coordinator Expectations page 1 bottom table; ‘HOW TO’ Guide for HFW Components page 14-15; Plan of Care -WTM minutes template blank ’24 pages 4&5 under Strategies)
b) The Care Coordinator updates the Plan of Care after each WTM which occurs every 30 days and sends to the River Oak Health Information team for filing within 7 days of the WTM to file in youth’s Electronic Health Records, MyEvolv. The updates include adding new successes to the “what is going well” section, adding new strengths, scaling /progress tracking of Family Vision, Team Mission, Needs, and Outcome. The team also reviews tasks/strategies from the previous meeting, conduct brainstorming new ideas, natural and community support/connections, and develop new strategies and continue with some strategies. The Safety Plan is reviewed and updated toward the end of the meeting. The updated POC is also distributed to the family and the team within 1 week and Care Coordinator contacts team members to follow up on tasks completion. (See ‘HOW TO’ Guide for HFW Components page 21; HFW Phase 3 Plan Implementation Care Coordinator Expectations page 1)
c) The Care Coordinator documents assigned tasks and completion, team meeting attendance (both formal and natural supports), flex funds usage, and updates (brainstorm, needs, strengths) in the Plan of Care and Wrap Team Meeting minutes document. This is updated every 30 days and distributed to all team members within 1 week of the meeting occurring. Formal and natural supports are also included in the Plan of Care with tasks and action steps assigned. (See Plan of Care – WTM minutes template blank ’24 page 5 for strategies/tasks; page 6 Flex Funds Requirements; & page 7 Attendance Tracking; HFW Phase 2 Plan Development-care Coordinators Expectations, HFW Phase 3 Plan Implementation Care Coordinator Expectations, HFW Phase 4 Expectations page 1-2)
d) The Plan of Care is a living document that is updated at each WTM, both regular and E-WTMs with most recent and accurate information for the team to follow the plan. The Care Coordinator distributes and files the updated Plan of Care within 1 week of the WTM to team members via secured/encrypted email or a hard copy depending on the team members’ preferences. The POC/WTM minutes template is designed to be utilized to adapt to each family’s changing needs, unique culture and perspectives, and strengths. (See Plan of Care – WTM minutes template blank ’24, ‘HOW TO’ Guide for HFW Components page 22; HFW Phase 3 Plan Implementation Care Coordinator Expectations – page 1 and 2)
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
The River Oak Wrap Care Coordinator reviews and updates the Ground Rules/Team Agreements at the beginning of each WTM to ensure that the team is adhering to the expectations to have productive meetings. The CC and the team also review their Team Mission, which brings the HFW team together with a shared goal. The Care Coordinator reviews and tracks the Team Mission progress at each monthly Wrap Team Meeting to assess how well the team is working together. At River Oak, natural supports are always being explored, both in the community and in the extended family, to join in the WRAP process throughout the four phases of Wraparound. Once identified, the River Oak WRAP team orients the new team member by explaining the WRAP process, what to expect in a team meeting, sharing the Family Story, and eliciting their perspectives on the family’s strengths.
a) The development of Ground Rules / Team Agreement starts with the youth and family prior to the initial Wrap Team Meeting, during preparation for initial WTM time. Once elicited the family’s ideas of what to expect from each other and the team members, the Care Coordinator brings the list (written on the visual and posted), shares with the team and elicits more ideas from the team to compile a set of expectations for the team to follow during the WTM meetings. When leading the team to develop Ground Rules/Team Agreements, the Care Coordinator ensures the expectations are reflective of the Wraparound principles. During each follow up Wrap Team Meeting, Care Coordinators post the Agreements in a place that is visible to all participants (power point or poster) and update the Agreements as needed with the entire team present. CC also refers to the Ground Rules when/if there is conflict arises or the agreement is breached during the meeting. (See ‘HOW TO’ Guide for HFW Components page 6-7; Plan of Care – WTM minutes template blank ’24 page 1; HFW Phase 1 Expectations- CC)
b) Topics such as building and engaging teams are reviewed and coached by the HFW coach and supervisors ongoing in the following ways: monthly 1-hour River Oak all Wraparound staff meeting that includes a “HFW corner” to train and update teams, Care Coordinator’s weekly 1-1.5 hours individual coaching, monthly 2-hour group coaching and monthly booster trainings as well. In addition, all Care Coordinators are also required to complete more advanced trainings Wraparound 201, 202, 203 for skills enhancement and practice activities around completion of various tasks across four phases of Wraparound. (See High Fidelity Wraparound Training and Coaching Plan page 8 & 9; ‘HOW TO’ Guide for HFW Components pages 15-19). The NWIC tools used to coach/train staff include Coaching response to Enhance Skills Transfer (CREST), Supervisory Checklist and Wraparound Supervision Wheel. (See NWIC Coaching Tools Descriptions)
c) The HFW coach tracks the presence or absence of natural support on each youth/family’s HFW Team during weekly coaching and continues to provide specific feedback to Care Coordinators on ways to include more natural support people in the HFW process. The coach uses creative ways to support staff in gaining skills to explain the benefits of natural support to families and help them solve problems. The WFI-EZ survey and TOMs Observations are completed quarterly to track and provide Care Coordinators feedback on if natural supports are being included in the HFW process and invited to Wrap Team Meetings. The annual Consumer Perception Survey results are shared with leadership team, and the coach and managers use the data to inform coaching and supervision to increase caregiver satisfaction and identify more natural support or support the family to build new connections in the community. The Wrap team invites WTM members to provide feedback using the CFTM survey after each WTM as well. (See Natural, Formal, and Community Support Tracking form, ‘HOW TO’ Guide for HFW Components page 15-17; TOMs Wraparound form; Satisfaction Perception Survey Data-Annual May 2025 pages 4-8 & 22-23; Plan of Care – WTM minutes template blank ’24 page 6)
d) The Care Coordinator orients newly identified team members to the HFW process prior to Wrap Team Meeting by explaining the Wraparound process, their role on the team, and what to expect during the upcoming WTMs by reviewing with them portions of the Family Story, highlighting youth/family strengths, gathering agenda item topics, and eliciting feedback on their perspectives of the Needs and Strengths of the family. If the youth is part of Tribal Nations defined under the Indian Child Welfare Act, the CC ensures that the tribal representatives are orient to the Wraparound process and invited to WTMs with family’s permission. The engagement and onboarding process is guided by CC using the Team Perspective Tool to get to know them (See ‘HOW TO’ Guide for HFW Components page 14-17; HFW Phase 3 Plan Implementation Care Coordinator Expectations page 2-3; NWIC Coaching Tool Descriptions item #10; Tribal Engagement Guide pages 2-5, 9&10).
Each WTM starts with an introduction (name, role on the team etc.,) followed by a casual icebreaker activity which consists of a short game, fun questions, or an activity of youth/family’s choosing to get to know each other and onboard the new team members. New team members take part in the activity to learn about other team members and are invited to fully participate in the WTM and throughout the Wraparound process. (See HFW Phase 2 Plan Development- Care Coordinator Expectations; and HFW Phase 3 Plan Implementation- Care Coordinator Expectations page 2-3).
Transition
6.1 Develop a Transition Plan
At River Oak, the Wraparound Team works collaboratively with the youth/family on achieving their personal and individualized goals and gets them to a place where they feel ready to transition out of formal services. The Care Coordinator leads the team in planning the transition for over 3-6 months, at a minimum of 60-90 days. During this, the team confirms that the connection with natural and community support is reliable and continues to progress. The team also identifies additional support, if needed, least restrictive supports that will take place of River Oak Wraparound team members and other formal supports that will support the family long after Wraparound services end. Families moving towards adoption are provided linkage to long term AAP funded supports as River Oak does not partner with adoptive families.
a) The Care Coordinator leads the team in scaling and tracking progress of the Needs Statement, Family Vision, Team Mission, Outcome Statement) at each Wrap Team Meeting (every 30 days) and is documented in the Plan of Care each month so the team can visually see the progress over time. Care Coordinator or the WRAP therapist will administer an IP-CANS and Pediatric Symptom Checklist-35 every 6 months to measure progress in symptom reduction. During the Plan Implementation phase, the team uses the established Transition Readiness Scale to assess and decide on the start of Transition phase during a WTM. The team works together for successful graduation ensuring all the natural and community support in place are working and successful. The Wraparound team determines a tentative graduation timeline during the Wraparound Team Meeting (WTM). Transition planning begins 3–6 months prior to discharge, with a minimum of 60–90 days identified as required to support a well‑planned and successful transition from Wraparound services. This timeline is determined at a WTM based on progress, the maintenance of progress, and family voice and choice. Care Coordinators and Advocates ensure the families maintain their strong linkage to natural supports and community resources during the transition phase so that they have adequate support after the formal WRAP team transitions out. (See HFW – Phase 3 -Plan Implementation Care Coordinator Expectations page 4 towards bottom; Wraparound Transition Readiness Scales; HFW – Phase 4 -Expectations page 1)
b) After a Wrap Team Meeting where the youth, family and team agree upon a discharge/transition date, the Care Coordinator updates the Plan of Care to reflect the upcoming transition. This Plan of Care will include helpful interventions, ideas, and services that have worked for the family during the HFW process. The Safety Plan and tasks will focus more on the family and long term supports who will be around after transition and will depend less on the Wraparound staff and other exiting formal support people. This is a period where formal support cheers on the youth, family, and natural support taking on more tasks and completing. The team is there to support, as needed At the last meeting prior to discharge/transition, the Care Coordinator will provide the family with a copy of the Plan of Care which includes a thorough Post-Transition Safety Plan, and uploads it into the youth’s Electronic Health Record, and offer a copy to other team members. The CPS social worker (if still involved) receives a copy of a discharge summary letter which lists the reason for discharge, recommendations for the future, safety concerns, and ways to reconnect with services if needed. This letter is also uploaded to the youth’s Electronic Health Record. (See ‘HOW TO’ Guide for HFW components pages 20-22; HFW – Phase 4 -Expectations page 3)
c) Transition from Wraparound services is discussed and agreed upon by the youth, family, and the full team during a Wraparound Team Meeting (WTM). The team supports the family throughout the Transition Phase, which typically occurs during the final 3–6 months of the Wraparound process. The transition timeline and anticipated discharge date are determined collaboratively in a WTM and are based on: steady progress and sustained maintenance of progress, family voice and choice, readiness and confidence of the youth and caregivers, strength and reliability of natural and community supports, and the team agreement that the family is ready to transition. The team develops the Transition Plan together during WTM. This intentional, team‑based approach ensures a planned, supported, and sustainable transition from Wraparound services. Staff are coached and trained to support families to successfully transition from the Wrapround process. Care Coordinators are initially trained through NWIC in Wraparound 101; Wraparound 102: and Wraparound 201, 202, 203 (Intermediate Trainings) to enhance skills in transition planning and team collaboration The HFW coach and supervisors review transition planning ongoing in the following ways: monthly 1-hour River Oak all WRAP staff meeting that includes a “HFW corner,” weekly 60-90 minute individual coaching, monthly 2-hour group coaching. Feedback is provided to Care Coordinators by the HFW coach by using the CREST tool (See ‘HOW TO’ Guide for HFW components page 20-22; High Fidelity Wraparound Training and Coaching Plan page 13; CO 6.2 Discharge and Transition Planning; NWIC – Training Catalog – Training Descriptions and Calendar page 1).
d) Throughout the Transition Phase, the team confirms that the connections built with natural and community supports are successful, reliable, and sustainable. The Care Coordinator supports the family in identifying and confirming each natural support person who will assume roles and responsibilities previously carried out by River Oak Wraparound staff. This ensures that there are supports in place after transition happens (ie., someone to call for or lead family meetings/discussions in place of a Care Coordinator, someone to create a safe space for youth to talk when frustrated in place of a therapist, etc.). These support people are part of the transition planning and clear in their roles as support people and are all listed in the final Transition Plan of Care. The Care Coordinator updates the Team and Community Strengths Inventory and Your Support People documents to ensure that the family refers to it, as needed, to make new connections after Wraparound. In the Discharge Summary Letter and Plan of Care, families are given the BHS-SAC number as a resource to use if they need to re-engage in mental health services in the future. Families that are moving towards adoption are linked to AAP funded post-adoption services and resources. A post-discharge follow-up Questionnaire is administered by River Oak at 3, 6 or 12 months after a discharge to inquire if the family is still utilizing the WRAP safety plan (see Plan of Care – WTM minutes template blank ’24 page 6; Your Support System; Team & Community Strengths Inventory)
6.2 Develop a Post-Transition Safety Plan
The River Oak Care Coordinator collaborates with the youth, family and HFW Team in creating a final safety plan for the youth and family to utilize after formal River Oak WRAP services transition out. The Care Coordinator discusses possible future events and includes all the culturally relevant proactive and reactive strategies that the family has identified have worked during their time in the WRAP process. Natural support people, emergency services, and community resources are highlighted, and River Oak WRAP staff are removed from the Plan and replaced with long term support people of the youth/family’s choosing
a) The Safety Plan is embedded in the youth/family Transition Plan of Care. The Transition phase is decided by the team and is planned to be from approximately 3-6 months to at least 60-90 days. The team updates the existing Plan of Care to be utilized after graduation by youth and their support of people remaining on the team. The plan is focused on reduction in reliance on formal support and increase natural support and community resources – proactive and reactive from what worked throughout the Wraparound process. The Care Coordinator prepares families with “forecasting” and planned rehearsals to address and document what the team has identified as potential triggers during Wraparound and how to proactively and reactively manage the situation. During WTMs throughout the Transition phase, the Care Coordinator supports the family in confirming the natural support person who will be taking over roles that were previously assigned to River Oak staff to ensure that there are supports in place after transition happens (ie. who will facilitate family meetings in place of the Care Coordinator, who will create a safe space for youth to talk when frustrated in place of the WRAP therapist. (See ‘HOW TO’ Guide for HFW components pages 19-20; HFW – Phase 4 -Expectations page 3; CO 6.2 Discharge and Transition Planning)
b) The Transition Plan of Care which includes the safety plan is reviewed at a final Wrap Team Meeting and the family and remaining team members (natural and community support) are clear on what the plan is and what their role is after the Wraparound process officially ends. Wraparound staff receive weekly coaching to enhance their skills to prepare families for successful transition. They also complete relevant training such as NWIC Wraparound 201 (intermediate training) around transition and safety planning. Staff also use River Oak Open Agency policy to reach out to any manager to receive additional support as needed. Care Coordinators are initially trained through NWIC in Introduction to Wraparound, Engagement in Wraparound, and Intermediate Training to enhance skills in transition planning and safety planning. The HFW coach and supervisors review transition planning and safety planning ongoing in the following ways: monthly 1-hour River Oak all WRAP staff meeting that includes a “HFW corner,” weekly 60–90-minute individual coaching, monthly 2-hour group coaching. Feedback is provided to Care Coordinators by the HFW coach by using the CREST tool and able to refer to CREST to practice the skill discussed/practiced. (See High Fidelity Wraparound Training and Coaching Plan page 16-17; HFW – Phase 4 -Expectations page 2)
c) Care Coordinators submit their initial Safety/Crisis Plans to their HFW coach who uses the Supervisory Checklist (See NWIC – Coaching Tool Descriptions 2026 (002)) to ensure the Care Coordinator has included all necessary components including family voice/culture, referral behaviors, step-by-step, reactive and proactive strategies, and use of team/community. In addition, the HFW coach follows up on safety plans with Care Coordinators weekly in 1-1.5-hour coaching sessions and monthly in 2-hour group coaching to provide additional support as needed. In addition, Care Coordinators’ direct supervisor reviews their Safety Plans at minimum every 6 months (See ‘HOW TO’ Guide for HFW components page 19-21; High Fidelity Wraparound Training and Coaching Plan page 13; WRAP 6 Month Bundle Checklist-MyEvolv page 1)
6.3 Create a Commencement and Celebrate Success
At River Oak, WRAP teams value celebrating families during the Transition Phase in ways that align with the family’s culture and values.
a) The team collaborates with the youth and family at the conclusion of formal HFW to plan a celebration that matches and respects the family’s cultural preferences, life circumstances, and values. The Care Coordinator and the Family Advocate use Flex Funds to purchase various items to highlight the end of formal HFW (i.e. a gift of the youth’s choosing (with family approval), a food/dessert item of the family’s preference, etc.). Any purchases made for the purpose of celebrating transition are agreed upon by the entire team at a Wrap Team Meeting (WTM) prior to the celebration and documented in the youth Plan of Care. Staff will refer to Flex Funds section of the Plan of Care to make proper documentation. The youth and family are awarded a Wraparound Graduation Certificate at the celebration. (See ‘HOW TO’ Guide for HFW components page 20-22; CO2.5 Flex Fund Supports Policy pages 1-2; Plan of Care – WTM minutes template blank ’24 page 6; Graduation – Certificate of Completion WRAP)
b) The River Oak Flex Fund policy allows the HFW Team to make purchases to celebrate HFW successes that are meaningful and specific to the preferences of each family. In addition, the Care Coordinator invites to the celebration all natural support people who will remain in the family’s life after transition, the entire HFW Team to say goodbye, external community resources and partners, and anyone else the family voices they want to attend. At the final Wrap Team Meeting, the youth and family are presented with a Graduation Certificate and ensure all HFW Team members schedule final sessions to say goodbye individually to the youth and family and ensure resources are in place to replace them when formal services end. The Family and Youth Advocates highlight the community resources and natural supports the team has accumulated during their time in the HFW process and reinforce with the family that they can use these ongoing (See CO2.5 Flex Fund Supports Policy pages 1-2; ‘HOW TO’ Guide for HFW Components page 20-22)
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
River Oak Wraparound uses various methods (questionnaires, externally and internally developed surveys) to elicit feedback from youth, families, and team members. This feedback is valuable to provide River Oak with relevant data which can lead to changes at all levels.
a) Service Verification Form: completed by the families in the first week of every month. The process allows families to confirm services were rendered while also informing them if the services offered during the month helped make progress towards their goals (See Service VERIFICATION CARD_update 11.17.25-english)
-Behavioral Health Consumer Perception Survey: Sacramento County Behavioral Health offers this annual survey to families. The survey measures client satisfaction with services, access to care, and treatment quality to improve services. (See Consumer Perception Survey -YSSF_ParentFamily_EN_2025)
-Team Observation Measures (TOM): The TOM is administered by River Oak Quality Management Team or external evaluators or local-level supervisors during Wraparound Team Meetings on a quarterly basis (1-2 families per Care coordinator) and is designed to assess adherence to standards of high-quality Wraparound observed during the session. The TOM consists of 36 indicators, organized into seven subscales which evaluate the following: Full Meeting Attendance, Effective Teamwork, Driven by Strengths and Families, Based on Priority Needs, Use of Natural and Community Supports, Outcomes-Based Process, Skilled Facilitation (See TOMs Wraparound)
-Wraparound Fidelity Index – EZ (WFI-EZ): The Wraparound Fidelity Index, Short Form (WFI-EZ) is a brief, self-report survey that measures adherence to the Wraparound principles and practice. The caregiver and youth versions of the survey assess participant satisfaction in services (see WFI-EZ paper version for CAREGIVER, YOUTH, FACILITATOR, and TEAM MEMBER)
-Quarterly Advisory Dinner: The Quarterly Advisory Dinner offers the family a night out to enjoy a meal and provide direct feedback on their services. Families have the option to participate in an open discussion about services, answer questions confidentially or participate in both (See The Wraparound Advisory Dinner Survey)
-Child and Family Meeting Survey: California Department of Social Services (CDSS) offers a confidential link to complete a survey after every Child and Family Team Meeting. The survey measures family and youth satisfaction with their support team’s process, goals, and inclusivity, helping to align practices with Child and Adolescent Needs and Strengths (CANS) assessments. Responses are analyzed by (CDSS) and shared with Counties, Tribes, and other partners to ensure responses remain anonymous. River Oak Center for Children has incorporated this survey link on all client Care Plans. (See Plan of Care – WTM minutes template blank ’24 page 6 for CFTM hyperlink & QR code)
-HFW – Satisfaction Questionnaire is conducted by HFW coach on a 3–6 months basis to gather feedback on how the family’s functioning has improved since their involvement in HFW (See HFW Satisfaction Questionnaire-ROCC).
-River Oak participates in DART workgroup and is in the process of certifying Quality Management team and Wraparound management team members as reviewers
b) River Oak Quality management team compiles the feedback received form youth, families and team members and provide the management and agency executive leadership with aggregate data at quarterly to annual basis.
-Unscheduled Service Verification Phone Calls: Clinical Program Managers make random unscheduled service verification phone calls to families and inquire about their satisfaction with services. Feedback is received and discussed with Executive Leadership to develop a plan for possible implementation. (See Service Questionnaire)
-Quarterly Advisory Dinner: The Quarterly Advisory Dinner offers the family a night out to enjoy a meal and provide direct feedback on their services. Families have the option to participate in an open discussion about services, answer questions confidentially, and/or participate in both. Feedback received during the Advisory Dinner allows for policy change and highlights gaps in services while fostering collaboration. (See The Wraparound Advisory Dinner Survey)
-Sacramento County Behavioral Health Services Grievance Procedure: Families who are not satisfied with their services are supported with connecting to Sacramento County Member Services to file a grievance orally or in writing. The feedback is received and appropriate changes are made. In some instances, a staff member may be removed from working with a family; this information is documented within our internal Incident Report Form. (See Incident Report Form Fillable Form-Roll Out December 2018, Sacramento County Grievance Form -FM-BHS-SUPT-Grievance-Brochure-English)
-Sacramento County Community Feedback Sessions: Community Feedback Sessions are open to the public. Information collected informs initiatives like projects identified by the Mental Health Services Steering Committee
7.2 Community Leadership Team
River Oak Center for Children prides itself on its active involvement in the System of Care at local, state and national level. River Oak is represented by three leadership team members that actively participate in the Community Leadership Team and Interagency Youth Collaborative Workgroup.
1. Sacramento County Behavioral Health Services has implemented the Interagency Youth Collaborative Workgroup. The Workgroup meets for two hours every other month to coordinate county and community partners to shift dialogue around mental health and substance use prevention/treatment, broaden the utility of the current SUD/BHS Collaborative, share and leverage multi-sector insights, and improve access/navigation of services for youth and families. The first hour of the meeting is dedicated to workgroup tasks, system needs, referral updates, access coordination, and individual program highlights. The second hour is reserved for All-County High Fidelity Wraparound Plan. This session reviews plan elements and operational alignment with Child Protective Services (CPS) and Probation. Per their May 11, 2026 meeting the workgroup made a decision to rename it ‘Community Leadership Team’ (See Interagency Youth Collaborative Workgroup 5.11.26 page 1; Interagency_Youth_Collaborative_Workgroup_Agenda_Jan26_2026)
2. The Interagency Youth Collaborative Workgroup provides an opportunity to remove system barriers that interfere with collaboration and effective service delivery to families. The Workgroup allows open discussion about what’s working and problem-solve potential gaps in services. The Workgroup offers a strength-based approach to address communication barriers across agencies while sharing proven effective procedures. (See Interagency_Youth_Collaborative_Workgroup_Agenda_Jan26_2026; Interagency Youth Collaborative Workgroup 51126 page 1)
3 High Fidelity Wraparound (HFW) Trainings are provided throughout Sacramento County by UC Davis Human Services Resource Center for Family-Focused Practice. UC Davis offers cross-agency training, coaching, and communities of practice for staff, including supervisors and peer partners. Training offers ensure adherence to High Fidelity Wraparound Principles. Providers across the county share experiences, discuss barriers, and collaborate to problem-solve concerns. Training is individualized to meet a family’s needs, including family finding and enhancing cultural competence across child welfare, probation, and behavioral health. (See attached link: Training Wraparound | Continuing and Professional Education | Human Services). UC Davis Human Services Resource Center for Family-Focused Practice hosts learning sessions that include the Indian Child Welfare Act (ICWA) and Tribal Engagement.
River Oak Wraparound partners with the National Wraparound Implementation Center (NWIC) and staff are trained by NWIC trainers for High Fidelity Wraparound onboarding and ongoing training. (See NWIC – Training Catalog – Training Descriptions and Calendar; High Fidelity Wraparound Training and Coaching Plan pages 3, 6-9)
4. At River Oak, HFW process and Wraparound Team Meetings (WTM) are inclusive of relevant community and systems partners that are identified as support people for the family. With the family’s permission (signed Release of Information), these external partners are involved in the process of developing the families’ plan based on the values and principles of HFW in WTM setting. River Oak also shares selected success stories at System of Care level (county provider meetings etc.) to highlight the effectiveness of HFW processes and the benefits families experience. (See ‘HOW TO’ Guide for HFW Components page 17-18; Plan of Care – WTM minutes template blank ’24 page 7)
5. Flex Funds provide immediate, individualized support to families. Funds commonly cover emergency needs which include rent, food, utilities, clothing, transportation, household items, or work-related needs. The use of non-emergency Flex Funds is discussed during the Child and Family Team Meetings (see CO2.5 Flex Fund Supports Policy pages 1-3; Plan of Care – WTM minutes template blank ’24 pages 6-7).
6. Wraparound Implementation Standards-Program (WISP): A coaching tool designed to evaluate and track progress on key indicators of Wraparound implementation and practice quality at the organizational level. It provides a structured framework for monitoring these indicators across three critical stages: pre-implementation, implementation, and sustainability, ensuring organizations maintain alignment with established standards for successful Wraparound care coordination (See NWIC Coaching Tool Descriptions, item 6).
Wraparound Implementation Meeting: River Oak Center for Children hosts an internal Wraparound Implementation Meeting for an hour, one time per month. This meeting allows the managers, along with one staff member from each role which includes a Care Coordinator, Skills Trainer, Peer Youth Advocate, Peer Family Advocate and Therapist, to openly discuss what’s working well and what we should do differently within the program based on staff members’ feedback. If changes are made, they are implemented for thirty days before reviewing during the next scheduled meeting and once perfected, rolled out to the program. (See HFW Implementation Meeting agenda template)
Certified Coaching Recordings: In our partnership with The National Wraparound Implementation Center (NWIC), our internal Certified Coach-Supervisor is required to securely submit recordings of Wraparound Team Meetings (aka CFTM) to the NWIC Innovative Practice portal. The recordings are utilized by NWIC to ensure fidelity measures are consistently met. The national coach and River Oak coach co-score the WTM recordings and staff documentation such as Family Story and Plan of Care using Supervisory Checklist monthly. (See NWIC Coaching Tools Descriptions for items 1, 10, 11, and 12)
a) River Oak representatives for the Interagency Youth Collaborative Workgroup and Community Leadership Team are Amy Fierro, Chief Program Officer; Rene Oliver, ICS Division Director; Noelani Villasenor, Lead Clinical Program Manager. Per the Interagency Collaborative Workgroup meeting on May 11, 2026, the team is dedicating/renaming the second hour of the monthly meeting for Community Leadership team. (See Interagency Youth Collaborative Workgroup 51126 page 1; Interagency_Youth_Collaborative_Workgroup_Agenda_Jan26_2026)
7.3 Eligibility and Equal Access
River Oak Center for Children Mission Statement highlights that we help children and youth who need support, coaching, and treatment to thrive in school, at home, and in the community. Through innovative and evidence-based programs, River Oak strengths children, youth and families to manage life challenges and achieve their full potential. To align with our Mission, River Oak Wraparound partners with youth and families from various backgrounds, culture, and needs and provide them with equal access to resources and services.
a) High-Fidelity Wraparound (HFW) at River Oak is designed for youth, typically between the ages of 3-21 with complex needs, and their families. Services are provided regardless of the severity of their symptoms. River Oak Wraparound falls under Specialty Mental Health Services (SMHS) classification and any youth under 21 years old is eligible if they are a Medi-Cal beneficiary and have impairment that cannot be managed by Managed Care Plan (mild to moderate distress). Eligible youth are placed or at risk of placement in long-term specialized care, are involved in the child welfare system, have juvenile justice involvement, or are experiencing homelessness (see Policy & Procedures – Specialty Mental Health Services, page 2 & 4). High-Fidelity Wraparound provides intensive, team-based planning with the primary goal of keeping children in their homes and communities. High-Fidelity Wraparound emphasizes inclusion, and services are tailored to meet individual needs. (See River Oak Program and Services Brochure pages 1-2; Wraparound Process User’s Handbook)
b) The High-Fidelity Wraparound Program with River Oak Center for Children monitors staff census of 1:12. A lower census allows for high-intensity interventions to meet the immediate needs of families, which could include daily contact to prevent out-of-home placement. Staff members include a Care Coordinator, Skills Trainer, Therapist, along with a Peer Youth Advocate and Family Peer Advocate, both with lived experience. Staff members provide trauma-informed care and are trained in Crisis Prevention Training (CPI) to support de-escalation and conflict resolution. (See High Fidelity Wraparound Training and Coaching Plan page 13)
River Oak Center for Children maintains an On-Call Policy which provides 24/7 support to youth and families and requires responding by phone or in-person after regular business hours and on weekends. To prevent burnout, staff rotate On-Call one week every three months and are supported by an On-Call manager with the same rotation cycle. On-Call Staff and Managers have access to the Director at all times of the day and weekend. (See On-call Crisis Response System policy, On Call Resources and Guidelines policy pages 1-2)
By implementing the above strategies, River Oak Center for Children ensures we provide the necessary intensity of service while maintaining staff well-being
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
River Oak Center for Children Wraparound provides care to youth and families under contract with the County of Sacramento. Our practices are designed to consistently meet Wraparound standards and County requirements, ensuring services are delivered with fidelity, accountability, and a commitment to high-quality, family-centered care.
a) Per Sacramento County Negotiated Rate Agreement # No. 7202400-26-142, Section 2. CONTRACTOR will enter all services in the COUNTY Electronic Health records (EHR), which will be utilized as back up documentation to pay for those services. Per Quality Management (QM) documentation guidelines, CONTRACTOR shall be reimbursed for services supported clinically and by the Child and Family Team (CFT) and entered into the EHR. Section 3. Flexible funds used to purchase goods and services will be paid at dollar-for-dollar actual expenditures and included in the invoice submitted to BHS. CONTRACTOR shall enter all expenditures in the COUNTY EHR, which will be utilized to pay for those services. No expenditures will be reimbursed for any expenses not entered into the COUNTY EHR or supported clinically by the CFT / WTM.
At River Oak, the Care Coordinator and Family/Youth Advocates are committed to ensuring that HFW process uniquely fits individual youth and family and are never one size fits all. The family and team’s individual strengths, culture, values, community, and needs to inform strategies at all times. This includes youth with tribal communities if youth is part of a Tribal Nations as defined under Indian Child Welfare Act (ICWA). (See CO 2.5 Flex Fund Support policy pages 2-3, BHSA Flex Funds-page 12-13 slides 24, 25; Plan of Care-WTM minutes template blank ‘24 page 6).
b) At River Oak, we utilize a comprehensive approach to build a skilled Wraparound team while monitoring the ongoing needs of the community we partner with. River Oak boasts an extensive internal onboarding process and requires regular annual training. River Oak’s annual training calendar lists required training per staff role within the agency. As part of the staff’s initial introduction to Wraparound, they attend specialized training through the National Wraparound Implementation Center (NWIC). (See High Fidelity Wraparound Training and Coaching Plan pages 3, 6-8). River Oak offers several Evidence Based Practices (EBP’s) that require intensive training and certification. EBP’s support services for family’s and increases professional development amongst staff. (See River Oak Program and Services Brochure (FINAL) page 2). Twice a month, Wraparound staff participate and regularly co-facilitate booster trainings and a “HiFi Corner” in staff meetings to review and revisit the Wraparound Principles. (See Wrap All Staff Meeting agenda-April). The Wraparound High-Fidelity Coach supports staff by shadowing their services provided to our families and scheduling individual supervision with staff to review their progress and concerns relative to service delivery and fidelity. The coach provides weekly 1-1.5 hours of individual coaching, monthly two-hour group coaching to all Care Coordinators, and monthly one-hour coaching to Youth and Family Advocates. (See High Fidelity Wraparound Training and Coaching Plan page 13 table) Performance Evaluations are written for each member of staff annually. The Wraparound leadership meets weekly with the Sacramento County Contract Monitor to provide program census numbers and staffing.
Per Sacramento County Negotiated Rate Agreement # No. 7202400-26-142, STAFFING REQUIREMENTS
CONTRACTOR shall:
A. Maintain the following employment staffing requirements:
1. Staffing levels maintained based on the frequency and intensity of service needs of members. Staffing shall be reviewed during monthly contract monitor meetings, quarterly monitor meetings, and contract amendment or renewal periods in relation to member need as indicated by Child Assessment of Needs and Strengths (CANS) reports.
2. Overall staffing ratio 1 LPHA/LPHA Waived for every 8 MHRS and/or OQP staff. Ratios are considered either as an average or weighted based on the frequency or intensity of services that are clinically necessary.
3. Medical staff ratio based on intensity of members’ needs. Ensure appropriate supervision by a Psychiatrist for Nurse Practitioners and Physicians’ Assistants as per COUNTY policy and California Business and Professions Code section 2836.1 (e) and in accordance with professional codes and standards.
4. Licensed Practitioner of the Healing Arts (LPHA) or LPHA Waived clinicians, Graduate Students, Mental Health Rehabilitation Specialists (MHRS) or Other Qualified Providers (OQP) and Peer Staff to provide medically necessary interventions as allowable by COUNTY QM Classification and as coordinated by an LPHA or LPHA Waived staff. The number of LPHA and/or LPHA Waived staff shall be sufficient to meet QM requirements.
5. LPHA or LPHA Waived clinicians provide the primary responsibility of assessment, therapy and member plan development for every member. Caseloads assigned to LPHA/LPHA Waived staff will be dependent on the intensity of services.
a. LPHA or LPHA Waived staff role shall be distinct from the program director/clinical director/manager/supervisor. Exceptions may be granted upon consultation with COUNTY.
b. LPHA/LPHA Waived shall be responsible as the Intensive Home-Based Services (IHBS) treatment team coordinator. Exceptions may be granted upon consultation with COUNTY. Coordination will include but is not limited to:
i. Coordinating with MHRS, OQP and/or Peer staff by identifying goals and appropriate interventions.
ii. Conducting intervention coaching with the MHRS and OQP staff to provide clinical recommendations, intervention support, and feedback. Intervention coaching may occur more frequently depending on need. Coaching may include real time observations of MHRS, OQP and/or Peer staff with member and/or family as training opportunities. Feedback will be reviewed with the MHRS and OQP.
c. Consult with Youth and Family Peers who will provide feedback and guidance, from the perspective of someone with lived experience, based on the youth and caregiver voice.
6. OQP staff provide social rehabilitation, models behaviors and teaches/demonstrates skills to member and family, provides feedback on interventions to the team, as well as crisis intervention and support, as a part of the coordinated care plan/treatment plan.
7. Clinical supervision and peer mentoring to all direct care staff, licensed and unlicensed. Staff seeking licensure shall receive clinical supervision in accordance with the appropriate State Licensure Board. All staff shall receive weekly group or individual clinical supervision, sufficient to support staff practice.
8. Peers with lived experience providing supportive services unique to the members and family. Peer services shall be in accordance with the COUNTY Policy and Procedure and shall adhere to State Peer Certification Requirements.
c) At River Oak, data is captured and managed in several different ways; all data collected is securely stored and meets (Health Information Portability and Accountability Act (HIPAA) Requirements. Internal data collection tools include myEvolv, our mental and behavioral health Electronic Health Record: myEvolv by Netsmart is a cloud-based EMR/EHR software with integrated Practice Management, Patient Portal and Medical Billing services. Key Performance Indicators (KPI): measures qualifiable key metrics to effectively manage performance of the program and/or individual staff. Timely Access Data Tool (TADT): is a tool utilized to track timeliness of services; important timeliness is established by the state to ensure engagement and services are provided in a timely manner. The Integrated Practice-Child and Adolescent Needs and Strengths (IP-CANS) Assessment: The IP-CANS is an assessment tool utilized across multiple agencies to identify the youth and family’s strengths and needs. The IP-CANS provides valuable information related to a decrease or increase in symptoms for the youth related to referral behaviors and their overall functioning. SmartCare is an external data collection tool utilized by Sacramento County: SmartCare EHR is an electronic health record platform for behavioral health and public health organizations. It is used by clinicians, administrative staff, and billing teams to manage documentation, billing, and compliance with workflows. Othe data collection methods include surveys such as quarterly TOM, WFI-EZ, annual Consumer Perception/Satisfaction and HFW Satisfaction Questionnaire which is administered to families directly by HFW coach at 3-6 basis (See CO 3.1.2 Timely Access to Services page 2; CO 1.2 Initial and Continuing Assessment page 1; HFW phase 1 Expectations page 3 (IP-CANS integration); Outcome Methods, HFW Satisfaction Questionnaire-ROCC)
8.2 Equitable Funding Across System Partners
River Oak Center for Children is a provider in Sacramento County. Therefore, this section, 8.2, is not applicable.
8.3 Cost Savings are Reinvested
River Oak Center for Children is a provider in Sacramento County. Therefore, this section, 8.3, is not applicable.
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied., (c) N/A (AAP funded Wraparound)
a) At River Oak, Flex Funds are available to be utilized through the team agreement during a Wraparound Team Meeting. All staff are trained in the usage of flex funds as part of the onboarding process. The Care Coordinator leads the team in a discussion and plan around sustainability to overcome barriers. Prior to using Flex Funds, the team explores natural support and community resources; once Flex Funds are utilized, the information is documented in the Plan of Care and within the agency’s electronic health record. Flex Fund usage is discussed monthly with our Contract Monitor during the Wraparound Provider Meeting. The Wraparound Contract Monitor must pre-approve any Flex Funds over the amount of $5,000 in a single purchase or $5,000 spent for a family during a three-month quarter. Approvals are completed quickly, often less than twenty-four hours. No Flex Funds usage over $5,000 has ever been denied once the need is explained in an email. (See pages 1-3, Plan of Care-WTM minutes template blank ‘24 page 6, New BHSA Training-Coley-wrap specific slides 21-22)
b) 1. Once the need for Flex Funds has been identified, agreed upon during Wraparound Team Meeting (WTM), and approved, funding is immediately available for use. Wraparound managers along with several staff hold credit cards issued by the agency to expedite purchases. In the event an urgent check request is submitted, on most occasions, River Oak can issue the check on the same day or within twenty-four hours (See CO 2.5 Flex Fund Support policy page 2 bullet 5; Plan of Care-WTM minutes template blank ‘24 page 6)
b) 2. (See CO 2.5 Flex Fund Support policy pages 1-3, Plan of Care-WTM minutes template blank ‘24 page 6)
b) 3. (See CO 2.5 Flex Fund Support policy page 3 & 4)
8.5 Collaborative Oversight of Flex Funds
a) At River Oak, Flex Funds are available to be utilized through the team agreement during a Wraparound Team Meeting. The Care Coordinator leads the team in a discussion and plan around sustainability to overcome barriers. Prior to using Flex Funds, the team explores natural support and community resources; once Flex Funds are utilized, the information is documented in the Plan of Care and within the agency’s electronic health record. (See Plan of Care-WTM minutes template blank ‘24 page 6) Flex Fund usage is discussed monthly with our Contract Monitor during the Wraparound Provider Meeting. The Wraparound Contract Monitor must pre-approve any Flex Funds over the amount of $5,000 in a single purchase or $5,000 spent for a family during a three-month quarter. Approvals are completed quickly, often less than twenty-four hours. (See CO 2.5 Flex Fund Support policy page 3)
b) Section V. 5 of the Sacramento County Negotiated Rate Agreement # No. 7202400-26-142 5. Provider is allowed to maintain an internal Wraparound Trust Fund account with a quarterly activity threshold of $25,000 after projected services and supports identified in the service plan are accounted for. Unused funds will go to a trust and can be utilized per County Fiscal Letter No. 20/21-94 as follows: Wraparound Trust Fund account can be used to pay for services that are identified in the individual service plan of the child/nonminor dependent until the child/nonminor dependent no longer needs services or emancipates from foster care.
At River Oak, youth and family’s needs are discussed during Wraparound Team Meetings (WTMs) to determine whether flex funds should be utilized. During these meetings, the team discusses other available community resources, sustainability plans, and makes a team-based decision regarding the use of flex funds. The Care Coordinator documents the agreed-upon plan in the Plan of Care and submits the request for funds. Once approved, funds are available immediately, either through a direct check request or by staff using agency-provided credit cards to support the family’s identified needs (See CO 2.5 Flex Fund Support policy pages 1-3; Plan of Care-WTM minutes template blank ‘24 page 6).
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
In alignment with High Fidelity Wraparound (HFW) principles, flex funds reflect creativity, cultural responsiveness, family partnership and must be directly connected to the young person’s Plan of Care (POC). Flex fund supports are time‑limited and intended to promote stabilization, skill‑building, and long‑term sustainability by empowering caregiver and family to increase their capacity to find long term solutions to meet household needs over time.
a) The Wraparound Team discusses Flex Funds supports in Wraparound Team Meetings, as needed, and the Care Coordinator leads the team in creative brainstorming for utilization or access to other funding resources available. Example: Department of Child and Family Services (DCFS), Probation Department, Children’s Law Center (CLC), Court Appointed Special Advocate (CASA) resources, Foster Family Agency (FFA), school districts, River Oak Helping Hands, natural support people, and other possible community resources. If the need is related to housing support, the team also creates a Housing Care Plan. Any plan related to flex fund support requires a sustainability plan for the team to implement. (See CO 2.3 Housing and Homelessness Support policy pages 1, 6-7, CO 2.5 Flex Fund Support policy pages 2-3, CO 2.4 Helping Hands Fund policy page 1)
b) Wrap team recognizes that Flexible support services may be funded through multiple sources, including but not limited to Behavioral Health Services Act (BHSA), Full-Service Partnership Funds, Child Welfare Realignment Funds, FFPSA Part IV Aftercare allocations, Foster Care Tiered Rates Structure Immediate Needs Program Funding, River Oak’s Helping Hand Fund, or other funding resources, as applicable, to the child, youth and family’s needs. Notable other funding sources include Wraparound Achieved Savings kept in a trust by the County, resulting from State CFL 51/21-94. All funding sources shall be used in accordance with applicable federal, state and county regulations and may be braided but not duplicated. (See CO 2.3 Housing and Homelessness Support policy pages 1, 6-7, CO 2.5 Flex Fund Supports Policy pages 1-2, CO 2.4 Helping Hands Fund policy, Helping Hands Request form)
c) Families’ needs are assessed and addressed in a manner that is helpful to them. In the event, any single funding source does not meet the needs; the team convenes and discusses Flex funds options (see A & B). If/when the team agrees the flex funding support is needed, the plan is clearly documented in Wraparound Plan of Care, and the CC follows the process to request funds. Per Section of the Sacramento County Negotiated Rate Agreement # No. 7202400-26-142: The requirements of any single funding source shall not limit the availability of flexible funding. (see Plan of Care-WTM minutes template blank ‘24 page 6); CO2.5 Flex Fund Supports Policy pages 1-2)
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
River Oak Center for Children is committed to ensuring a structured, equitable, and culturally responsive recruitment and hiring process for the Wraparound Program. Our staffing strategies aim to reflect the diversity of the communities served and promote equitable representation across roles. All recruitment practices will be conducted in alignment with Equal Employment Opportunity and nondiscrimination policies.
a) At River Oak Center for Children, the process of data collection allows us to assess the needs of the community. Demographic data is gathered to ensure we are developing a diverse workforce to support the reduction of health disparities. During the intake process information collected includes age, gender, race/ethnicity, language and communication preferences, along with socioeconomic factors. Creative recruiting efforts are conducted at college/university and community job fairs, college campus organizations like The Black Student Union, in addition to familiar platforms, Indeed and LinkedIn. River Oak Center for Children offers a unique opportunity for current employees who refer a candidate that is hired and maintains employment for a minimum of six-months; the referring staff will receive a $500 bonus. (See Recruiting SOP-WRAP pages 1-3; Neighbor Relations EC 3 8_4.24; HR 1.1 Equal Employment)
b) All efforts are made to recruit employees that represent the community we serve. When a cultural or linguistic match is requested by a youth or family, River Oak Wraparound managers work diligently to assign staff that will meet the family’s needs. Through the teaming process of Wraparound, there are opportunities for staff to be assigned to meet the family’s cultural request. If there are no staff available to be assigned, the HFW Team works to include natural supports from the community (i.e. local places of worship, LGBTQ centers, Language World, CPS-appointed Cultural Brokers, Tribal representatives, community centers, mentorship programs). Additional accommodations are discussed at intake or anytime during the process and decisions made in Wraparound Team Meeting WTM) setting. The Care Coordinator assigns tasks to appropriate team members to ensure proper connections are made. While efforts are made to match families with culturally relevant staff, language interpretation services are offered only through qualified professional interpreters to ensure accuracy and confidentiality. (See Intake Procedure page 1; Interpretation Services CO 3.3 pages 1-2; ‘HOW TO’ Guide for HFW Components page 18; Tribal Engagement Guide)
c) For occasions when River Oak WRAP is unable to provide a staff who speaks the native or preferred language of the youth/family, Interpretation Services are utilized including Language World, NorCal Services for Deaf and Hard of Hearing, and Southeast Asian Assistance Center. Interpretation services are confidential and can be provided in-person, via telehealth, or via phone. All written material is also translated for families via Language World. (see Interpretation Services CO 3.3; “HOW TO” Guide for HFW Components page 17)
9.2 Tribally Responsive Workforce
River Oak Center for Children respects tribal sovereignty, traditions, and values and ensures respectful communication, collaboration, and advocacy.
(a) River Oak Wraparound team is building a partnership with Central Indian Child Welfare Act (ICWA) field office in the greater Sacramento region and receives the most updated educational information for staff development. Staff members will be required to attend ICWA Tribal Engagement Training. In addition, agency leadership participates in the monthly Native Youth Mental Health Partner’s Meeting. The Wraparound Program follows the Tribal Engagement Guide and utilizes our ICWA Resource List to ensure comprehensive support and partnership is provided throughout the Wraparound process if youth is part of a Tribal Nations as defined under Indian Child Welfare Act (ICWA). Based on experience, Family Advocates and Training Manager/HFW coach plan to conduct booster training for Wraparound staff. Wraparound Care Coordinators intentionally engage and invite tribal representatives to onboard them to the Wraparound process, providing them with the Wraparound Process User’s Handbook to become more familiarized with the process as a support person. The representatives are invited to every Wrap Team Meeting to ensure they are included in all decision making and that the Tribe can be utilized to explore additional tribal natural supports and resources. (See High Fidelity Wraparound Training and Coaching Plan page 4 table and pages 10-11; Tribal Engagement Guide labeled pages 6-7; Wraparound-process-users-guide-ENGLISH page 7 and page 20 para 1)
(b) If youth is part of a Tribal Nation as defined under Indian Child Welfare Act (ICWA), the team utilizes the support of the Tribal Engagement Guide. We ensure that the proper communication protocols are followed, and approach with a willingness to learn and understand. Building on cultural strengths, River Oak Wrap recognizes that tribal traditions and ceremonies are used as protective factors. By utilizing tribal resources, we walk with the family to compliment supports that are already in place. Staff are coached regularly on engaging team members, including tribal community representatives. (Tribal Engagement Guide labeled page 4-6 and 11, ‘HOW TO’ Guide for HFW components pages 18-19)
9.3 Flexible and Creative Work Environment
River Oak Center for Children values cohesive collaboration and open dialogue throughout the agency. We encourage staff of all positions to voice suggestions, brainstorm constructive approaches to model our mission and philosophy, and report any concern to the appropriate parties in a flexible and professional manner. River Oak Wraparound supervisors meet individually with their assigned staff for a minimum of one hour weekly. River Oak proudly has an “Open Agency Policy” that allows staff to speak with leadership at all levels about ideas for program improvement and quality, questions they have on effective service delivery, and growth and learning opportunities. River Oak Wraparound staff meet twice a month for one hour and have a space to provide feedback to Wraparound managers on barriers and program quality. (See General Supervision Practices; Open Agency Policy- HR 4.6 page 1; Wrap All Staff Meeting agenda)
a) River Oak Wraparound Program managers recognize that quality and improvement involve continuous assessment of current performance and creating a clear performance plan forward while fostering an ongoing evaluation and feedback loop. River Oak Center for Children hosts an internal Wraparound Implementation Meeting for an hour, one time per month. This meeting allows the managers, along with one staff member from each role which includes a Care Coordinator, Skills Trainer, Peer Youth Advocate, Peer Family Advocate and Therapist, to openly discuss what’s working well and what we should do differently within the program based on staff members’ and family feedback. If changes are made, they are implemented for thirty days before reviewing during the next scheduled meeting and once perfected, the new process is rolled out to the program. (See HFW Implementation Workgroup Meeting Agenda)
b) During the Wraparound All Staff Meetings held two times per month for one hour, managers include team building activities, potlucks, and formal acknowledgements to publicly recognize the great work of staff. Managers set the cultural tone of transparency and active listening ensuring everyone’s voice is heard. River Oak’s Employee Recognition Committee is comprised of staff at all levels throughout the agency. Every month, the committee meets to pick from a host of acknowledgements for a job well done and honors three individuals with a certificate and $100.00. (See Recognize; ERC flyer; WRAP All Staff Meeting agenda)
c) River Oak’s “Open Agency Policy” allows staff to communicate with anyone in leadership. Leadership actively listens and encourages staff to share thoughts and concerns. Increased communication helps eliminate misunderstandings while building connections. Wraparound staff are equipped with Microsoft TEAMS on their agency laptop and work cell phones to communicate quickly and effectively with their teams and are encouraged to schedule TEAMS video calls or connect with each other on their work cell phones. Microsoft Outlook calendars of all Wraparound staff and managers are shared among each other to increase communication during available times. Each staff meets with their direct manager for an hour of weekly supervision and can join a manager’s open-office hours (held 3 times per week) to get additional support as needed. (See Open Agency Policy- HR 4.6; General Supervision Practices)
d) River Oak’s Wraparound Program aligns team activities with HFW core principles including monthly booster training. River Oak Wraparound holds one-hour All-Staff Meetings twice a month, with one of the meetings dedicated to the “HFW corner” (Wraparound managers review the HFW philosophy) and one of the meetings being a Booster training to focus on HFW implementation. During one of the Wraparound All Staff Meetings, the HFW staff met to create their own shared Wraparound Team Mission to clarify a shared goal among team members. In addition, Care Coordinators meet with the HFW Coach weekly for (60-90) minutes individually, group coaching once a month, and Peer Advocates meet with the HFW Coach monthly for an hour. These coaching sessions are intended to highlight the HFW model, monitor compliance, and skills transfer utilizing NWIC coaching tools such as CREST & CCRSR and similar agenda and templates are used (See High Fidelity Wraparound Training and Coaching Plan pages 11, 13; Wrap All Staff Meeting agenda; NWIC – Coaching Tool Descriptions 2026 (002) page 1 item 3 and page 2 item 9; Care Coordinator Monthly Coaching)
9.4 Hiring, Performance Evaluation, and Job Descriptions
River Oak Center for Children’s standards for hiring ensure that the staff that are filling the various roles in Wraparound are equipped to meet the needs of our youth and families. Our job descriptions attached will demonstrate how each role supports our Wraparound youth and families with the specific attitudes and essential skills necessary.
a) River Oak WRAP Teams include a Care Coordinators (HFW Facilitator), Family Advocates/Peer Specialist (Parent Partner), Youth Advocate/Peer Specialist (Youth Partner), Skills Trainer, Wraparound therapists, Program Fidelity/Training manager who provides HFW Coaching, HFW supervisors, Licensed Clinical Supervisors (LMFT), Lead Clinical program Manager (LCSW), Intensive Community Based Services (ICS) Division Director (LMFT). (See Clinical – ICS – Clinician I-II – Care Coordinator – JD – 8.2025; Clinical – All – Peer Youth Advocate and Peer Family Advocate – JD – 3.2026; Clinical – All – Skills Trainer – JD – 9.2025; Clinical – ICS – Program Fidelity-Training Manager – JD – 3.2026; Clinical – All – Clinical Program Manager I – JD – 9.2025)
b) Each WRAP team member has unique and specific skills, functions, and qualities that contribute to the HFW team (See Clinical – ICS – Clinician I-II – Care Coordinator – JD – 8.2025; Clinical – All – Peer Youth Advocate and Peer Family Advocate – JD – 3.2026; Clinical – All – Skills Trainer – JD – 9.2025; Clinical – ICS – Program Fidelity-Training Manager – JD – 3.2026; Clinical – All – Clinical Program Manager I – JD – 9.2025)
c) Each WRAP team job description reflects HFW core principles and aims to recruit those that embody those qualities (See Clinical – ICS – Clinician I-II – Care Coordinator – JD – 8.2025; Clinical – All – Peer Youth Advocate and Peer Family Advocate – JD – 3.2026; Clinical – All – Skills Trainer – JD – 9.2025; Clinical – ICS – Program Fidelity-Training Manager – JD – 3.2026; Clinical – All – Clinical Program Manager I – JD – 9.2025; Clinical – All – Clinical Program Manager II.III – JD – 9.2025)
d) River Oak hiring process includes a formal interview for candidates to demonstrate their skills in scenario-based questions as well as their attitudes towards youth/families and community-based mental health. River Oak supports creative recruiting efforts which are conducted at college/university and community job fairs, college campus organizations like The Black Student Union; Historically Black College and University’s (HBCU) in addition to familiar platforms, Indeed and LinkedIn. Outside recruiting is also conducted by the AMI Network. (See Recruiting SOP-WRAP pages 1-3; Interview 1-Care Coordinator & Therapist (WRAP))
e) At River Oak, all staff are provided with and must sign Performance Evaluation expectations upon hire. Performance Evaluations are provided to staff after their first six months upon hire, at first year, and annually thereafter. In addition, staff meet weekly for one hour supervision to receive ongoing feedback from their direct supervisor. In some instances, a staff member may need a Performance Improvement Plan (PIP) which outlines steps to help support staff in being successful in their position. (See General Supervision Practices; PIPTemplate_Updated8.2025; River Oak Clinician Performance Evaluation Tool)
9.5 Workforce Stability
River Oak Center for Children proudly maintains a high staff retention rate by offering a competitive salary, comprehensive benefits package and focus on morale within the teams by maintaining manageable workloads for staff.
a) All employees of River Oak receive a 4% annual salary increase for the cost of living and minimum wage increase adjustment. (See Pay Increase – Cost of Living Adjustment)
b) HFW Care Coordinators partner with 10-12 families at a time. Each staff census (caseload) is closely monitored by their Wraparound Supervisor, and adequate support is provided by weekly supervision and coaching (See General Supervision Practices)
c) Timely promotion and advancement within the agency are available to all staff regardless of lived experience. River Oak does not discriminate in hiring and follows the Equal Employment Opportunity policy. To support promotions within the agency, River Oak initially offers an internal hiring process prior to seeking outside candidates. (See HR 1.1 Equal Employment; Internal Application – Fillable)
d) All River Oak staff receive an annual wage increase of 4%. Each staff member could earn an incentive of $1,000 per month for meeting agency requirements of Client Service Accountability (CSA) and Progress Note Timeliness. Staff members could earn a referral bonus of $500 if someone they have referred is hired and maintains employment with River Oak for six months. River Oak promotes non-monetary professional development opportunities to include agency-paid training, certifications, and attendance at conferences (See Pay Increase – Cost of Living Adjustment; Updates to Monthly Incentive Program 4.24.26 page 1)
9.6 High Fidelity Training Plan
River Oak Wraparound team partners with the National Wraparound Implementation Center (NWIC) and utilizes their training platform for initial, annual, and ongoing training. Trainings are delivered in online and instructor-led formats. In addition, River Oak Wraparound program ensures that staff development and skills are enhanced by monthly booster training around HFW components, ongoing coaching, and lab sessions. Furthermore, all Wraparound staff are required to complete various onboarding, role specific and ongoing trainings that are offered through our internal training portal at hire and on an annual basis.
a) River Oak Wraparound staff receive initial training, Wraparound 101 (previous title: Introduction to Wraparound), 3 full day foundational training within one month of hire. This training is led by NWIC national trainers in an online setting. Prior to enrolling in the Wraparound 101 training, employees complete 3 self-paced, online pre-requisite training modules using the NWIC portal to orient the Wraparound process. Those courses are An Introduction to System of Care, Wraparound Overview, and Team Roles in Wraparound. Staff then completes Wraparound 102, previous title: Engagement in Wraparound, 6-8 weeks after completing the Wraparound 101 course to gain effective engagement skills with youth, family, and their support people. (See High Fidelity Wraparound Training and Coaching Plan page 3 table and page 5; NWIC – Training Catalog – Training Descriptions and Calendar page 1)
b) In addition, all Wraparound Care Coordinators are required to attend additional NWIC instructor-led, trainings such as Wraparound 201 (Strengthening Practice) and Wraparound 202 (Beyond Behavior) enhance their skills and learn more in depth techniques around team building and effective planning etc., All Wraparound staff are also required to complete internal onboarding and ongoing trainings within 90 days of hire and beyond. These trainings are offered online and in person based on their role and responsibilities. The trainings are pre-populated in the agency’s training portal, My Learning Point (MLP), and staff and their supervisors receive notification of upcoming trainings for staff to complete. In the first 60-90 days of hire, River Oak staff are also required to attend four or more shadowing opportunities. All Wraparound staff are required to attend at minimum weekly 1-hour supervision with their direct manager. Care Coordinators receive an additional 60-90 minute individual coaching and 2-hour group coaching with the HFW Coach and develops their CREST (Coaching Response to Enhance Skills Transfer) together with a plan to practice skills throughout the phases of Wraparound. Advocates and therapists meet monthly for 1-hour to learn ways to operationalize HFW principles, provide feedback on implementation of HFW throughout the Wraparound process and in WTM setting. (See High Fidelity Wraparound Training and Coaching Plan page 3 table, pages 8-9 and pages 12-13 table; NWIC – Training Catalog – Training Descriptions and Calendar pages 1-2; New Employee 90 Day Program Orientation Checklist)
c) Wraparound Care Coordinators are required to attend the following training annually: “Wraparound 203 – Supportive Planning” for effective crisis planning, assessing safety, and addressing crisis situations. This training is offered by NWIC. In addition, all Wraparound staff are now required to attend annual ICWA Echo trainings hosted by the UCD starting in 2026. Staff are also provided with monthly booster trainings that address High Fidelity Wraparound components and program areas for growth identified by youth and families on completed WFI surveys and HFW Consumer Satisfaction Questionnaires. The Wraparound Training Manager/HFW coach and a rotating staff member team up to lead the monthly boosters. Role specific trainings and groups are offered for staff skill enhancement. (See High Fidelity Wraparound Training and Coaching Plan pages 9-10 and pages 12-13; NWIC – Training Catalog – Training Descriptions and Calendar pages 1-2).
d) Wraparound managers and leadership attend general Wraparound trainings including initial, ongoing, booster, and intermediate trainings such as Wraparound 101 (practice Essentials), Wraparound 102 (Building Partnerships), Wraparound 201 (Strengthening Practice), Wraparound 202 (Beyond Behavior), Wraparound 203 (Supportive Planning) and to enhance their supervisory skills, they also receive Wraparound 401 (Applied Supervision) and Wraparound 402 (Strengthening Supervision) courses. (See NWIC – Training Catalog – Training Descriptions and Calendar; High Fidelity Wraparound Training and Coaching Plan pages 3-10 and page 12 table). Wraparound trainer/coach attend NWIC led, quarterly Wraparound Virtual Coaching Collaboration (WVCC) where coaching best practices are highlighted and presented by national and local coaches from various states.
e) River Oak Wraparound is building a partnership with the Tribal Affairs office, Central ICWA (Indian Child Welfare Act) field office, in our pursuit to educate and train our staff on an ongoing basis. Our goal is to train staff on annual basis to learn about the tribal community, engagement of tribal representatives in Wraparound process and Wraparound Team meetings and connecting our youth and families with resources and supports the tribal community offers. All Wraparound staff are required to attend ICWA training upon hire and on an ongoing basis as needed. In addition, staff are provided with an overview of ICWA and booster training regarding including tribal community representatives in Wraparound process and Wraparound Team Meetings and support the families to make meaningful connections with their community. (see High Fidelity Wraparound Training and Coaching Plan pages 10-11; ‘HOW TO’ Guide for HFW components page 18-19; Tribal Engagement Guide labeled pages 6-7)
9.7 Community-based Training Program
Quarterly completion of WFI and TOM Wraparound tools by youth, caregivers, and relevant team members which includes the System of Care partners allow River Oak Wraparound to use the feedback to inform ongoing / monthly booster trainings and develop updates to service delivery and policies. Wraparound managers and staff onboard and engage community partners in individual and team settings to ensure that their voice and ideas are elicited in the teaming process throughout the Wraparound process. Wraparound families are invited to a quarterly advisory dinner where they can provide direct feedback to River Oak WRAP leadership.
a) River Oak Wraparound is proud to have Youth and Family Advocates (Certified Peer Support Partners (CPSP)) as integral members of our team. PSPs often become trusted partners for families and serve as a crucial source of support—particularly for youth and families who may feel uncertain about HFW components or reluctant to engage initially. Through their leadership, insight, and advocacy, CPSPs play a vital role in strengthening engagement, responsiveness, and family-centered practice across River Oak Wraparound. CPSPs are selected to participate in the HFW Implementation Workgroup, which meets monthly brainstorm strategies for effective HFW implementation and to foster meaningful connections with youth and families that support positive outcomes. PSPs actively contribute to the planning and development of monthly booster trainings, ensuring that curriculum reflects real-life experiences and remains relevant and practical for youth and families. Training content is also informed by data from previously administered quarterly surveys (including TOM, WFI, and the internal HFW Satisfaction Questionnaire), feedback from community partners during One Stop delivery presentations and direct feedback gathered from quarterly Youth and Family Advisory Dinner Survey. (See High Fidelity Wraparound Training and Coaching Plan page 11 and 13 table; HFW Implementation Workgroup Meeting Agenda; CO 4.1 Peer Specialist page 1 items 5-6; The Wraparound Advisory Dinner Survey)
b) In collaboration with the Sacramento County Contract Monitor, Wraparound providers participate in One Stop delivery presentations at Child Protective Services and Probation offices (main referral sources) to introduce and promote the High Fidelity Wraparound process. During these one-hour presentations, probation officers, social workers, and supervisors receive an overview of HFW components, eligibility criteria for Wraparound services, and the importance of their role and active participation in Wraparound Team Meetings (WTMs). Participants are also provided with the Wraparound Process User’s Handbook (in English and Spanish) for further reference and to share with youth and families as needed. River Oak Wraparound actively incorporates feedback from community partners into the development of booster trainings and invites partners to attend monthly booster training sessions. In addition, Wraparound team members maintain consistent communication with community partners to continue education about the Wraparound process and to address questions or concerns. At the beginning of services, when a Care Coordinator receives a referral, the Care Coordinator and a Youth and Family Advocate conduct a one-on-one session with the referring partner. This session provides an opportunity to orient them to the Wraparound process, clarify the partner’s role on the team, and gather information regarding the partner’s strengths, priorities, agenda, and perspectives of the family. This information informs the Family Story and promotes effective teaming throughout the Wraparound process. These collaborative connections are intentionally maintained across all phases of Wraparound. (See Wraparound One Stop Presentation ppt; High Fidelity Wraparound Training and Coaching Plan page 11; ‘HOW TO’ Guide for HFW components page 17-18; HFW Implementation Workgroup Meeting Agenda; Wraparound Process User Handbook -English)
9.8 Coaching and Supervision
River Oak Wraparound utilizes a comprehensive wraparound onboarding process to ensure all newly hired staff are introduced to the High Fidelity Wraparound (HFW) model within their first week of employment. During this onboarding period, staff meet with an HFW Coach to gain an overview of the core components of High Fidelity Wraparound, understand their specific role on the team, and review expected responsibilities. New staff are also oriented to required onboarding trainings through the National Wraparound Implementation Center (NWIC). They also receive a brief overview of the Integrated Core Practice Model (ICPM), from the HFW coach, highlighting its alignment with wraparound principles and family-driven care.
a) The High Fidelity Wraparound (HFW) Coach meets with each new staff member to provide a comprehensive overview of the High Fidelity Wraparound model. This overview includes the phases, principles, key elements, and role-specific Wraparound activities staff are expected to carry out as part of their job responsibilities. During this onboarding process, the HFW Coach invites new staff to create a profile in the National Wraparound Implementation Center (NWIC) portal to begin required HFW online prerequisite courses and to register for three live trainings facilitated by NWIC trainers. These trainings include Wraparound 101 and Wraparound 102 which is required to be completed within 1 month and 3 months of employment, respectively. Staff are also required to complete a minimum of 3 peer-to-peer shadowing during the onboarding process. All staff are required to attend Flex Funding / Behavioral Health Services Act (BHSA) training, upon hire, to learn how Flex Funds can be used to meet family needs when appropriate. Staff are informed that Flex Fund requests and decisions are discussed and approved within Wraparound Team Meeting (WTM) settings. To ensure a successful onboarding experience, the HFW Coach schedules a follow-up session with the new staff member to answer questions, provide guidance, and support completion of prerequisite trainings and onboarding requirements. The HFW Coach then schedules ongoing weekly or monthly coaching sessions based on staff role. (See Wraparound Team Meeting Shadowing; High Fidelity Wraparound Training and Coaching Plan pages 3, 13-14, 17; BHSA -Flex Funding pages 12-13 slides 24-25)
b) River Oak Wraparound Program Fidelity/Training Manager holds a dual role as HFW coach and provides the team with internal trainings and coaching to all staff. River Oak Wraparound utilizes the National Wraparound Implementation Center (NWIC) model, and the coach is certified supervisor-coach with NWIC. Coaching occurs in individual, small, and large group settings. HFW meets with team members from various roles to receive feedback, highlight strengths, support in areas of need and practice skills for staff to increase their confidence. HFW Coach and direct managers follow the River Oak Open Agency policy to ensure someone is always available to support staff, and offer additional open office hours during the week for staff to drop in to check in or ask questions as needed. Wraparound Care Coordinators are provided with mandatory weekly coaching lasting 1-1.5 hours with the HFW Coach. The tools used in weekly coaching is Coaching Response to Enhance Skills Transfer (CREST) and Care coordinator Responsibilities and Supervision Response Tool (CCRSR) where the coach and staff review the areas of strengths and need and what, why, and how of the skills and develop a plan to follow. Youth and Family advocates receive 1-hour monthly coaching by the HFW Coach. All staff can reach the Coach and other Wraparound managers during business hours via phone calls, email, Microsoft Teams messages, or in person. For after hours, holidays and weekends, staff can connect with an assigned on-call manager by direct phone call, email or Microsoft Teams messaging. (See Open Agency Policy- HR 4.6; High Fidelity Wraparound Training and Coaching Plan page 13-14; NWIC – Coaching Tool Descriptions 2026 (002) page 1-2 items 3 & 9; CO 3.4 On-Call Crisis Response System Policy page 2 item 9; CO 3.4 On-Call Resources and Guidelines (1) pages 4-5 items 1-4)
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
River Oak Center for Children is a provider in Sacramento County. Therefore, this section is not applicable.
10.2 Evaluation Metrics & Outcomes
At River Oak, the Quality Management team compiles data collected in the Electronic Health records system and KPI dashboard regarding timeliness, and the quality of care and service delivery is evidenced by the records of youth. The data is shared with program management team and Wraparound supervisors use this data as feedback and/or benchmarks of the program’s effectiveness which then informs HFW coaching and training needs for River Oak staff.
a) The High‑Fidelity Wraparound (HFW) Coach utilizes a data‑driven approach to inform training and coaching activities. This approach is grounded in direct observation, documentation review (including Utilization Reviews), and aggregate data provided by the Quality Management Team over a 3–12‑month review cycle. The HFW Coach regularly reviews and discusses this data with Care Coordinators and other Wraparound team members during weekly individual coaching sessions and monthly group coaching. This data is used to strengthen staff practice by ensuring skillful, responsive, and individualized approaches to meeting youth and family needs, and by reinforcing adherence to Wraparound principles. Data and interpretation findings are shared by the Quality Management Team with River Oak Wraparound supervisors, who use this information to guide training, supervision, and coaching efforts. In addition, the Quality Management Team administers and analyzes Wraparound Fidelity Index‑EZ (WFI‑EZ) results quarterly, Team Observation Measure (TOM) results quarterly, and the annual Client Satisfaction (Consumer Perception) Survey. These data sources provide valuable feedback regarding Wraparound fidelity, service quality, and youth and family experiences, supporting continuous quality improvement across the program.
In addition, direct supervisors run weekly reports to coach staff on timely documentation (written within 24 hours and no more than 72 hours from the service time) and monthly reports to assess how often youth are getting face to face, direct services from River Oak staff (See Outcome Methods pages 1-2; High Fidelity Wraparound Training and Coaching Plan pages 13 and 15; Utilization Review policy page 1)
b) The HFW team is provided with data at 3-12 months intervals to identify the areas of strengths and needs of the River Oak WRAP program. Data includes: the time it takes from River Oak receiving a referral to scheduling and rendering a first appointment with youth/family, the trends in reasons for discharge from HFW and correlations between unsuccessful discharges and other metrics (i.e. demographics, length in River Oak HFW program, number of River Oak team members assigned, presence or absence of advocate or therapy). River Oak has a HFW Implementation group that is composed of both supervisors and representatives from each River Oak HFW role (Care Coordinator, therapist, skills trainer, youth advocate, family advocate) and meets monthly to discuss data, brainstorm ways to improve on program effectiveness, and ensure program needs are addressed timely. In addition, the Quality Management team and program managers conduct an internal Utilization Review (UR) by selecting charts from different phases of Wraparound to fully examine the quality of care being provided and documented properly in youth file and results are used for coaching/training purposes. (See Outcome Methods pages 1-2; Utilization Review Policy page 1; High Fidelity Wraparound Training and Coaching Plan page 11)
c) Data gathered by the Quality Management Team is regularly shared with River Oak program leadership and organizational leadership to identify trends and address system‑level barriers impacting service delivery. Within River Oak Wraparound, review of natural support tracking data indicates that the identification, engagement, and consistent involvement of natural support people in the Wraparound process and Wraparound Team Meetings (WTMs) tends to be an area in need of improvement. These findings are elevated to the Community Leadership Team, which reviews the identified barriers and shares emerging trends with staff and managers. This collaborative process supports idea‑sharing, feedback, and targeted action planning to strengthen staff practice, improve engagement of natural supports, and enhance fidelity to Wraparound principles. Though the Community Leadership Team is established recently, River Oak is represented by three members, our Chief Operations Officer, Intensive Community-Based Services (ICS) Division Director, and the ICS Lead Clinical Program Manager (CPM) and they meet to address HFW implementation barriers, develop action steps and share changes with the River Oak WRAP staff. The group meets for two hours every other month to coordinate county and community partners to shift dialogue around mental health and substance use prevention/treatment, broaden the utility of the current SUD/BHS Collaborative, share and leverage multi-sector insights, and improve access/navigation of services for youth and families. The first hour of the meeting is dedicated to workgroup tasks, system needs, referral updates, access coordination, and individual program highlights. The second hour is reserved for All-County High Fidelity Wraparound Plan. This session reviews plan elements and operational alignment with Child Protective Services (CPS) and Probation. Per their May 11, 2026 meeting, the workgroup renamed the second hour and dedicating the hour for Community Leadership Team (See Outcome Methods pages 1-2; Interagency Youth Collaborative Workgroup 51126; Interagency Youth Workgroup Collaborative Meeting Agenda; Natural, Formal, & Community Support Tracking 1)
Fidelity Indicators
1.1 Timely Engagement and Planning
a) Providers must complete first initial contact within 24 hours of receiving the referral. If unsuccessful, all outreach attempts must be documented and consultation with the DMH Wraparound SA Liaison must occur within 72 hours. Masada’s HFW Facilitator contacts the family via telephone within 24 hours from receiving the referral. Then they provide the rest of the Wraparound team and the client’s DCFS worker and or Probation officer with updates pertaining to meeting with the client and enrolling the client. In addition, they complete documentation in the client’s clinical record. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Referral Procedures Policy #2, page 7.
b) A Child and Family Team Meeting must occur within 30 days of first initial contact. The purpose of the CFT meeting is to create a service plan identifying goals, interventions, and supports. Masada’s HFW Facilitator and team collaborate with client, family and natural and formal supports in creating the care plan. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Child and Family Team (Policy 8) p.21
c) After the initial CFT meeting, client, family and team collaborate on the dates of the following CFT meetings. Follow-up CFT meetings must occur every 4–6 weeks, or more frequently as needed. Every time there is a CFT meeting, the HFW Facilitator prepares (reviews the agenda, sets the expectations with the client and family and reviews current goals and progress; coordinates with DCFS and Probation) the client, family and team prior to the CFT meeting. The Care Plan is reviewed and updated during the CFT meeting. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Child and Family Team (Policy 8) , page 21.
d) During the planning phase of the CFTM, the HFW Facilitator documents the specific action steps that will be taken, and which team member is responsible for following up on that particular action item. This ensures that everyone on the team is clear about their identified tasks and how they will assist in implementing the care plan that was created and agreed upon by all members of the CFT. At the conclusion of the meeting, all members of the CFT review the FSP-HFW Plan of Care (POC) and sign the form indicating they are in agreement with the care plan. The child and family receive a copy of this plan on the same day. A copy of the FSP-HFW Plan of Care (POC) is sent to the assigned CSW and or DPO. All documents are filed in the client’s clinical record. After the initial CFT meeting, client, family and team collaborate on the dates of the following CFT meetings. Follow-up CFT meetings must occur every 4–6 weeks, or more frequently as needed. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Child and Family Team (#8) p.21, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
e) DMH conducts monitoring and technical assistance reviews that assess implementation of California Wraparound Standards and ICPM, including chart reviews, interviews, and data analysis, with feedback provided to providers and including timeliness for CQI processes. In addition, Masada has built in monitoring through clinical supervision, staff meetings, coaching and QA/QI chart reviews. HFW Team reaches out to Liaisons for support as needed. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Program Monitoring (#40) p. 42 Clinical supervisor monitors timeliness and provides feedback to HFW teams. Clinical Supervisor is responsible for (1) monitoring team functions to ensure that operational targets (e.g., weekly client visits, field-based services) are met; (2) facilitating team meetings to discuss the status of each client; (3) monitoring the size and relative level of acuity of FSP-HFW Clinical team caseloads; (4) allocating the work of the FSP-HFW Clinical Team to meet each client’s needs; organizing meetings with the FSP-HFW Clinical service team at least once per month to review and identify clients who may require a transition to a different level of care; (5) distributing FSP-HFW Clinical Team members into pairs or team to conduct outreach and engagement and deliver ongoing services; serving as the point of contact for the FSP-HFW Clinical Team throughout the day to address emergency needs; and (6) ensuring that necessary program monitoring data is submitted in a timely manner and charts entries are up to date. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Program Monitoring (#40) p. 4 & Children and Youth Full-Service Partnership High Fidelity Wraparound Program Service Exhibit #1700 p.23-24
f) The Wraparound Program Manager assigns the case to a Wraparound team of staff that best matches the client and family’s cultural and linguistic needs and gives the
necessary information and paperwork to the team’s HFW Facilitator. The Wraparound Program Manager provides the Facilitator with the documents received from the DMH Liaison. The HFW Facilitator must make contact with the parent/caregiver within 24 hours of receiving the referral, and schedule the Wraparound Enrollment meeting as soon as possible. If the Facilitator has difficulty making contact or scheduling the Enrollment and Intake, all attempts are documented on a call log in CareLogic. The County Social Worker (CSW), Supervising CSW (SCSW), Deputy Probation Officer (DPO), and the DMH Liaison are sometimes enlisted to help with securing enrollment of the family. HFW staff are trained during their onboarding process on timely engagement strategies that include encouraging alternate strategies when contact with the family is difficult. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Training Requirements (#5) p.13 & Masada Wrap Intake Procedure p.1 & Child and Family Team Facilitator Guidebook p.11
1.2 Led by Youth and Families
a) Youth and caregivers, including Tribes in the case of an Indian child, play a central role in CFT meetings, including sharing goals, selecting team members, setting ground rules, and guiding planning. The CFT FSP-HFW Plan of Care (POC) includes development and documentation of the Family Vision and Team Mission statement. HFW staff are required to complete training focused on serving the Tribal population. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Child and Family Team (Policy 8) p. 21-22, Training (#5) p.13, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
b) HFW Facilitator gathers and updates information regarding the family’s strengths, needs, history, cultural identity, and past traumatic experiences, and makes this information available to all team members. HFW Facilitator empowers the child or youth and family by highlighting their strengths, assets, cultural background, and discussing the child or youth’s identification with their cultural norms, values, beliefs, and practices. HFW Facilitator coordinates and schedules staff and family engagement meetings and facilitates team engagement activities to promote a positive and collaborative Child and Family Team (CFT) culture. HFW Therapist utilizes CANS-IP to identify client’s strengths and needs. All gathered information is clearly documented in the client’s clinical record (progress notes, assessments, CFT meeting progress note and the FSP-HFW Plan of Care (POC), CANS-IP). See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Wraparound Staffing #6 p.15, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
c) Clinical Supervisor: Clinically licensed staff who provide clinical supervision and direction in delivering optimal intensive mental health services to children, youth, and families served. Supports Wraparound team members in addressing culture and race and advocating for mobilizing resources to ensure that all families have access to equal opportunities and resources needed to thrive. Oversees implementation of the California Wraparound Standards and the Integrated Core Practice Model (ICPM) to ensure the team is providing trauma-informed care. Assists teams in identifying needed trainings and ensures completion of trainings. Clinical Supervisor is responsible for (1) monitoring team functions to ensure that operational targets (e.g., weekly client visits, field-based services) are met; (2) facilitating team meetings to discuss the status of each client; (3) monitoring the size and relative level of acuity of FSP-HFW Clinical team caseloads; (4) allocating the work of the FSP-HFW Clinical Team to meet each client’s needs; organizing meetings with the FSP-HFW Clinical service team at least once per month to review and identify clients who may require a transition to a different level of care; (5) distributing FSP-HFW Clinical Team members into pairs or team to conduct outreach and engagement and deliver ongoing services; serving as the point of contact for the FSP-HFW Clinical Team throughout the day to address emergency needs; and (6) ensuring that necessary program monitoring data is submitted in a timely manner and charts entries are up to date. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Wraparound Staffing #6 p.17 & Children and Youth Full-Service Partnership High Fidelity Wraparound Program Service Exhibit #1700 p.23-24
d) Caregiver and Child or Youth Satisfaction Surveys:
Parent Advocates within the eight (8) Service Areas routinely conduct telephone surveys of active Wraparound program participants, including biological parents, caregivers, and the child or youth. Participation is voluntary and informed consent is obtained from each participant.
The surveys are brief and include questions that are aimed at measuring fidelity to the Integrated Core Practice Model and Wraparound Principles, participant satisfaction with the services provided by the Wraparound Teams, and some outcome indicators like client well-being, school functioning, and frequency of hospitalization. The resulting data is analyzed, and data trends are shared countywide with Wraparound Providers, as available. At the discretion of Wraparound Administration, other program monitoring tools may be utilized. Masada’s QA/QI department conducts routine client satisfaction surveys. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Program Monitoring (#20) p.42 & Masada’s CSS (Consumer Satisfaction Survey) Protocol and blank copy of the surveys.
1.3 Strength-Based
a) HFW Facilitators are responsible for gathering and updating information regarding the youth and family’s strengths and cultural identity and sharing this information with team members at the CFT meeting and throughout treatment. Child and Family Specialists and Parent Partners reinforce strengths-based skill building and support caregivers in recognizing strengths. HFW Facilitator utilizes outcomes measures (i.e. CANS) to identify, prioritize and track case goals and projected outcomes. HFW Facilitator provides families with the necessary tools to help support their child or youth’s strengths, talents, and positive contributions to society. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Wraparound Staffing #6, page 15 and 16.
b) HFW Therapists utilize a mental health assessment (Universal Assessment) to assess and evaluate the child’s or youth’s and family’s strengths. The HFW therapists update the entire HFW team on the child’s or youth’s and family’s identified strengths and the entire HFW team continuously assesses any new strengths. The HFW Therapists utilize outcomes measures (i.e. CANS) to identify individualized strengths, prioritize and track the child’s or youth’s and family’s goals and projected outcomes. The HFW team works together to integrate required services and supports into a plan of care (incorporating information from the youth’s Child Adolescent Needs and Strengths (CANS) assessment) that aligns with the youth and family’s goals and values, using individualized, strengths-based planning. While the CANS is intended to inform the youth’s plan of care, the needs, strengths, and strategies identified in the youth’s plan of care are ultimately determined by the child or youth and family. CANS assesses the needs and strengths of youth and is a flexible and evolving tool supporting open discussion and collaborative decision-making regarding care coordination and planning, levels of care, services, and placement. HFW Facilitator utilizes the FSP-HFW Plan of Care (POC) to facilitate identification of the child’s or youth’s and family’s strengths – this process includes formal and informal supports and the entire Child and Family Team (CFT). The FSP-HFW Plan of Care (POC) is reviewed and updated at least every 30 days or more often as needed. The entire HFW Team participates in eliciting, modeling and observing the child’s or youth’s and family’s strengths. The HFW team utilizes a variety of creative modalities (interviews, self report, psychoeducation, psychosocial skills coaching, observation, story telling, play, art, role play) to assist the child or youth and family to identify their strengths. CFTs develop and document the child or youth and family’s goals, team agreements, mission statements, individualized care plans, and the functional strengths that will support the child or youth and family in reaching their goals. At each CFT meeting, the HFW Team reviews the child’s or youth’s and family’s strengths, debriefs outcomes of the meetings and highlights any additional strengths. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Wraparound Staffing (# 6); Service Delivery (#7), p.16, 18-19. Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care; High Fidelity Wraparound (HFW) Policy Manual (p 5,.8,11,22; Behavioral Health Information Notice No: 26-XXX (p.7, 29); Universal Assessment (p.13, 22)
c) Required trainings include California Wraparound Standards, ICPM, Underlying Needs training, and Trauma-Informed practice. Clinical Supervisors support fidelity to strengths-based practice through supervision and training oversight. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Training Requirements (# 5); Wraparound Staffing (# 6) p.13, 14, 17.
d) Caregiver and Child or Youth Satisfaction Surveys:
Parent Advocates within the eight (8) Service Areas routinely conduct telephone surveys of active Wraparound program participants, including biological parents, caregivers, and the child or youth. Participation is voluntary and informed consent is obtained from each participant.
The surveys are brief and include questions that are aimed at measuring fidelity to the Integrated Core Practice Model and Wraparound Principles, participant satisfaction with the services provided by the Wraparound Teams, and some outcome indicators like client well-being, school functioning, and frequency of hospitalization.The resulting data is analyzed, and data trends are shared countywide with Wraparound Providers, as available. At the discretion of Wraparound Administration, other program monitoring tools may be utilized. Masada’s QA/QI department conducts routine client satisfaction surveys. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Program Monitoring (#20), p.42, Masada’s CSS (Consumer Satisfaction Survey) Protocol and blank copy of the surveys.
1.4 Needs Driven
a) HFW Wraparound services must be crafted based on the underlying needs and trauma history of the child or youth and family. Planning occurs through ICPM-informed processes that emphasize underlying needs rather than surface behaviors. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Service Delivery (#7) p.18-19
b) Required trainings include Underlying Needs: A Strengths/Needs-Based Service Crafting Approach, ICPM foundational training, and ongoing clinical supervision to support needs-driven practice. Clinical Supervisor: Assists teams in identifying needed trainings and ensures completion of trainings. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Training Requirements (#5,) Wraparound Staffing (#6) p. 13, 14, 17
c) HFW Therapists utilize a mental health assessment (Universal Assessment) to assess and evaluate the child’s or youth’s and family’s needs. The HFW therapists update the entire HFW team on the child’s or youth’s and family’s identified needs and the entire HFW team continuously assesses any new needs. The HFW Therapists utilize outcomes measures (i.e. CANS) to identify needs, prioritize and track the child’s or youth’s and family’s goals and projected outcomes. The HFW team works together to integrate required services and supports into a plan of care (incorporating information from the youth’s Child Adolescent Needs and Strengths (CANS) assessment) that aligns with the youth and family’s goals and values, using individualized, strengths-based planning. While the CANS is intended to inform the youth’s plan of care, the needs, strengths, and strategies identified in the youth’s plan of care (POC) are ultimately determined by the child or youth and family. CANS assesses the needs and strengths of youth and is a flexible and evolving tool supporting open discussion and collaborative decision-making regarding care coordination and planning, levels of care, services, and placement. HFW Facilitator utilizes the FSP-HFW Plan of Care (POC) to facilitate identification of the child’s or youth’s and family’s needs – this process includes formal and informal supports and the entire Child and Family Team (CFT). The FSP-HFW Plan of Care (POC) is reviewed and updated at least every 30 days or more often as needed. The entire HFW Team participates in eliciting the child’s or youth’s and family’s needs. The HFW team utilizes a variety of modalities (interviews, self report, psychoeducation, observation) including utilization of the Child/Youth and Family Needs Domains tool to assist the child or youth and family to identify their needs. This tool is to be utilized during each CFT meeting. CFTs develop and document the child or youth and family’s goals, team agreements, mission statements, individualized care plans, and the functional strengths and needs that will support the child or youth and family in reaching their goals. At each CFT meeting, the HFW Team reviews the child’s or youth’s and family’s needs, debriefs outcomes of the meetings and highlights any additional needs that must be addressed. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Wraparound Staffing (# 6); Service Delivery (#7), p.16, 18-19; Plan of Care Policy p.1-2, FSP-HFW Plan of Care; Instructions for Completing the FSP-HFW Plan of Care; High Fidelity Wraparound (HFW) Policy Manual (p 5,.8,11,22); Behavioral Health Information Notice No: 26-XXX (p.7, 29); Universal Assessment (p.1, 2,5,13,22,23) ; FSP Child and Youth High Fidelity Wraparound Child/Youth and Family Needs Domains tool.
d) During every CFT meeting, the HFW Team evaluates the child’s or youth’s and family’s progress on each identified goal and need in the FSP-HFW Plan of Care (POC). The HFW Team elicits feedback regarding progress from the child, youth, family and the entire CFT, including formal and informal supports. In addition to the identified goals, the HFW Team tracks additional overarching goals such as school engagement, reduced number of hospitalization, reduced number of crisis responses, increased placement stability, increased natural supports, caregiver’s self sufficiency and confidence in supporting child’s or youth’s needs. Transition is a formal HFW phase – during this phase, the HFW team meets to prepare the child or youth and family for transitioning out of HFW, continuing to shift responsibility to the family and natural supports. The HFW Team collaborates with the child or youth and family to elicit voice and choice in terms of their readiness to graduate from HFW and to come to an agreement regarding the child’s or youth’s and family’s identified needs being met sufficiently enough to transition from HFW. The HFW Team reviews the FSP-HFW Plan of Care (POC) and the progress made. The child/youth and family work toward taking a leadership role in facilitating their CFT meetings and the entire team creates a transition plan with the child/youth and family with specific timelines. The Transition plan includes assessing child’s, youth’s and family’s appropriate level of care after HFW, safety planning and linkage to any additional resources needed. During the Transition Phase of HFW, it is especially important that the HFW team plan for the range of supports and care coordination needs that persist beyond HFW as a glidepath towards improved functioning in the community. The CFT meets to prepare the youth and family for transitioning out of HFW, continuing to shift responsibility to the family and natural supports; and organizes one closing ceremony at the end of HFW, celebrating success to facilitate a positive transition in a way that is meaningful to the youth and family. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Service Delivery (#7); Exit from Wraparound Services (#18) p.18, 39; FSP-HFW Plan of Care; Instructions for Completing the FSP-HFW Plan of Care; High Fidelity Wraparound (HFW) Policy Manual (p 10, 24)
1.5 Individualized
a) Wraparound services are crafted and delivered as individualized services based on the underlying needs, trauma history, strengths, culture, and preferences of the child or youth and family. The Wraparound process is described as dynamic and non-linear, allowing teams to revisit phases as family needs evolve. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Service Delivery (#7) p.18, 19
b) All HFW staff must complete required training, and receive ongoing coaching from the supervisor (supervisor identifies ongoing training needs). See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and ProceduresTraining Requirements (#5) Wraparound Staffing (6) p.13, 14, 17
c) HFW Facilitators receive ongoing training and coaching in leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences. HFW Facilitators must complete required training, and receive ongoing coaching from the supervisor (supervisor identifies ongoing training needs). See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Training Requirements (#5) Wraparound Staffing (6) p.13, 14, 17 Masada’s Care Plan training
d) HFW Facilitators gather and update information regarding strengths, needs, cultural identity, and trauma history; facilitate individualized CFT meetings; and support youth and families in leading planning and decision-making. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Wraparound Staffing (#6) p.15, 16
e) Caregiver and Child or Youth Satisfaction Surveys:
Parent Advocates within the eight (8) Service Areas routinely conduct telephone surveys of active Wraparound program participants, including biological parents, caregivers, and the child or youth. Participation is voluntary and informed consent is obtained from each participant.
The surveys are brief and include questions that are aimed at measuring fidelity to the Integrated Core Practice Model and Wraparound Principles, participant satisfaction with the services provided by the Wraparound Teams, and some outcome indicators like client well-being, school functioning, and frequency of hospitalization.
The resulting data is analyzed, and data trends are shared countywide with Wraparound Providers, as available. At the discretion of Wraparound Administration, other program monitoring tools may be utilized. Masada’s QA/QI department conducts routine client satisfaction surveys. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Program Monitoring (#20) p.42 & Masada’s CSS (Consumer Satisfaction Survey) Protocol and blank copy of the surveys.
1.6 Use of Natural and Community Based Supports
a) All HFW team members are required to complete a set of required training within the first year of employment. A formal Child and Family Team is developed to include formal and informal supports. Informal supports are identified by the child/youth and family to help address the needs and strengths of the family and develop an individualized care plan that addresses their underlying needs (Policy 8). Training; including “The 2 Day Child and Family Team Facilitator Training” (Policy 5) See Masada Wraparound Natural Supports Inventory and County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Child and Family Team Policy 8, Training Requirements For Wraparound Providers Policy 5. Pg 13 from Policies and Procedures. Child and Family Team Facilitator Guidebook. from “The 2 Day Child and Family Team Facilitator Training” Pg 17 Practice Guide: Family and Team Engagement. Preparing the Family for Teaming; #12, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
b) All HFW team members are required to complete a set of required trainings within the first year of onboarding; including “The 2 Day Child and Family Team Facilitator Training” Child and Family Team Facilitator Guidebook from “The 2 day Child and Family Team Facilitator Training”; it includes Ecomap. Pg 17 of the Practice Guide: Family and Team Engagement. Preparing the Family for Teaming; #12 Identify the Team List-encourage natural supports. HFW team completes Natural Supports Inventory with the client and family. The inventory includes guidance pertaining to engaging and integrating natural supports. The HFW teams receive ongoing coaching from their supervisor. HFW Supervisors complete a Quality of Care Tool that includes the presence of natural supports. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures: Training Requirements For Wraparound Providers Policy 5. Pg 13 ; Child and Family Team Facilitator Guidebook from “The 2 Day Child and Family Team Facilitator Training” Pg 17 Practice Guide: Family and Team Engagement. Preparing the Family for Teaming; #12. Identify the Team List-encourage natural supports(Policy 5) Child and Family Team Facilitator Guidebook; Quality of Care Tool; Masada Wraparound Natural Supports Inventory
c) Follow-up CFT meetings are occurring every 4–6 weeks, or more frequently as needed. Child and Family Team Facilitator Guidebook from “The 2 day Child and Family Team Facilitator Training”; Staff engagement worksheet Question at the end of the form: Support System (Formal/Informal) “Who can support this child/youth and family? How can we assist child/youth and family in identifying natural support systems? See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Child and Family Team (Policy 8) p.21 and 22 & Child and Family Team Facilitator Guidebook p.13, 17 & Masada Wraparound Natural Support Inventory
d) A variety of tools are utilized to monitor quality of services and family’s feedback on their experience having natural supports on their team. The feedback is provided to the HFW team to strengthen the program. Tools include technical reviews (conducted by the county); the review includes interviews with the family, staff and natural supports, Caregiver and Child/youth Satisfaction Surveys (internal and county) and Quality of Care Tool (internal) used by supervisors during observations). Masada Wraparound Natural Support Inventory elicits the family’s feedback on their experience specifically having natural supports on their team.
In addition, the HFW Team will utilize the short version of WFI-EZ – a self-report survey that assesses foundational HFW elements; fidelity to HFW; and satisfaction. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Program Monitoring (Policy 20) p.42 Chart Review Audit Tool, Masada’s Consumer Satisfaction Surveys; High Fidelity Wraparound (HFW) Policy Manual (p. 41); Masada Wraparound Natural Support Inventory.
1.7 Culturally Respectful and Relevant
a) HFW team members are required to complete a set of required training within the first year of onboarding; including “The 2 Day Child and Family Team Facilitator Training” (Policy 5) Prior to developing the Care Plan, HFW Facilitator meets with the team to conduct a case exploration. During the case exploration, the team develops hunches of underlying needs and creates a genogram, ecomap and timelines as well as identifies strengths. Following the case exploration, HFW Facilitator coordinates a staff engagement meeting with the DCFS or DPO to identify the youth and family strengths and underlying needs and explore the impact of culture. Finally, the HFW Facilitator and team meets with the youth and family to prepare them for the CFT meeting and assists them in articulating their family story and goals (includes a planning sheet). See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures :Training Requirements For Wraparound Providers Policy 5. P.13; Child and Family Team Facilitator Guidebook “The 2 Day Child and Family Team Facilitator Training”; Case Exploration: Elicits information, creates genogram, ecomap and timeline. p.3, Staff Engagement: Explore the impact of trauma and ask for a family’s long term view. Staff Engagement worksheet. p.9, Family and Team Engagement. Preparing the Family for Teaming; prepares the family to identify goals, family story, strengths, and identify the Team list. p.15
b) HFW team members are required to complete a set of required training within the first year of onboarding; including “The 2 Day Child and Family Team Facilitator Training” (Policy 5) Prior to developing the Care Plan, HFW Facilitator meets with the team to conduct a case exploration. During the case exploration, the team develops hunches of underlying needs and creates a genogram, ecomap taking into consideration clients’ culture, and timelines as well as identifies strengths. Following the case exploration, HFW Facilitator coordinates a staff engagement meeting with the DCFS or DPO to identify the youth and family strengths and underlying needs and explore the impact of culture. Finally, the HFW Facilitator and team meets with the youth and family to prepare them for the CFT meeting and assists them in articulating their family story and goals, taking into consideration the client’s culture. All staff are required to complete annual cultural competency training as well as bi-annual TGI Transgender, Gender Diverse, or Intersex (TGI) evidence-based cultural competency training for the purpose of providing TGI-inclusive health care for individuals who identify as TGI. HFW Supervisor utilizes the Quality of Care tool to provide feedback to HFW team during observations of CFTs and team consults focusing on cultural competency. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures :Training Requirements For Wraparound Providers Policy 5. P.13; Child and Family Team Facilitator Guidebook “The 2 Day Child and Family Team Facilitator Training”; Case Exploration: Elicits information, creates genogram, ecomap and timeline. p.3, Staff Engagement: Explore the impact of trauma and ask for a family’s long term view. Staff Engagement worksheet. p.9, Family and Team Engagement. Preparing the Family for Teaming; prepares the family to identify goals, family story, strengths, and identify the Team list. P.15 Quality of Care Tool; LACDMH QA/QI Bulletin No: 25-08.
c) Parent Advocates within the eight (8) Service Areas routinely conduct telephone surveys of active Wraparound program participants, including biological parents, caregivers, and the child or youth. Participation is voluntary and informed consent is obtained from each participant. The surveys are brief and include questions that are aimed at measuring fidelity to the Integrated Core Practice Model and Wraparound Principles, participant satisfaction with the services provided by the HFW Teams, and some outcome indicators like client well-being, school functioning, and frequency of hospitalization. The resulting data is analyzed, and data trends are shared countywide with Wraparound Providers, as available. At the discretion of Wraparound Administration, other program monitoring tools may be utilized. Masada’s QA/QI department conducts routine client satisfaction surveys. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Program Monitoring (#20) p.42 & Masada’s CSS (Consumer Satisfaction Survey) Protocol and blank copy of surveys.
1.8 High-Quality Team Planning and Problem Solving
a) Masada’s HFW Facilitator completes the CFT FSP-HFW Plan of Care (POC) (identifies underlying needs, and goals) every time a CFT meeting is conducted and documents agreements from each participant. All participants that attended the meeting sign the form and client and caregiver receive a copy. The original is documented in the client’s clinical record. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
b) Tools utilized to monitor quality of services and provide feedback to Wraparound providers to strengthen the program. Tools included technical reviews (conducted by the county); the review includes interviews with the family, staff and natural supports, Caregiver and Child/youth Satisfaction Surveys (internal and county) and Quality of Care Tool (internal; used by supervisors during observations). Masada’s Internal Chart Reviews. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Program Monitoring (Policy 20) p.42 Masada Chart Review Audit Tool, Masada’s Consumer Satisfaction Survey
c) Masada’s QA/QI Department conducts consumer perception surveys; chart reviews and overall focuses on the quality improvement process. Data is collected, analyzed and shared with the HFW management and teams. Identified gaps are closed with ongoing training booster/refreshers. Any corrective actions are documented and completed. Staff receives ongoing coaching. HFW Supervisor utilizes the Quality of Care Tool to assess the competency of the HFW team and provides feedback and ongoing coaching. Masada’ CSS and protocol; Chart Review Audit Tool and Protocol; Quality of Care Tool.
d) During the planning phase of the CFT meeting, the specific action steps that will be taken are documented, and it is clearly identified which team member is responsible for following up on that particular action item. This ensures that everyone on the team is clear about their identified tasks and how they will assist in implementing the care plan that was created and agreed upon by all members of the CFT. At the conclusion of the meeting, all members of the CFT review the FSP-HFW Plan of Care (POC) and sign the form indicating they are in agreement with the care plan. The child and family receives a copy of this plan on the same day. A copy of the FSP-HFW Plan of Care (POC) is sent to the assigned CSW and or DPO and filed in the client’s clinical record. The plan is continuously reviewed and assessed. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
1.9 Outcomes Based Process
a) PSC-35 and CANS are used to demonstrate outcomes for children and families receiving HFW Services, and OMAs are used for HFW FSP cases (Policy #21). An individualized written document is created by the members of the CFT during CFT meetings. The CFT FSP-HFW Plan of Care (POC) is used in conjunction with the agenda. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Outcomes Measures Policy #21 pg. 43, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
b) The CFT will follow the CFT FSP-HFW Plan of Care (POC) that is completed and tracked by Masada’s HFW Facilitator and have follow up meetings every 4 to 6 weeks; the CFT FSP-HFW Plan of Care (POC) is updated every time there is a CFT meeting (every 4-6 weeks). See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures The Child and Family Team Policy #8, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
c) The CFT will follow the CFT FSP-HFW Plan of Care (POC) and have follow up meetings every 4 to 6 weeks; the CFT FSP-HFW Plan of Care (POC) is updated every time there is a CFT meeting (every 4-6 weeks). Masada’s HFW Facilitator reviews each goal and action items that are flexible and can be adjusted as needed. Any updates are communicated to the entire team during CFT meetings. Corresponding progress notes are documented in the client’s clinical record along with the CFT FSP-HFW Plan of Care (POC). See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
d) HFW Therapist is responsible for completing CANS-IP (all therapists are trained and certified in CANS-IP and re-certified annually). The CANS-IP is part of the client’s clinical record and all team members have access to the CANS-IP. It is utilized during the CFT meetings to inform the creation of the client’s Care Plan. The HFW Facilitator creates the CFT FSP-HFW Plan of Care (POC), which includes strengths and needs based on the input from all team members and the CANS-IP. Incorporating CANS into the conversation is a recommended training in the LACDMH Wraparound training requirements policy. See Masada’s Intake Checklist, County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Training Requirement for Wraparound Providers (Policy #5) p.13, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
e) The HFW Facilitator creates and updates the CFT FSP-HFW Plan of Care (POC) which includes strengths and needs based on the input from all team members and the CANS-IP. CANS-IP data is utilized for decision making; however, tracking of needs, goals and all action items, progress on goals and completion of goals are documented in the CFT FSP-HFW Plan of Care (POC), client’s Care Plan and client’s progress notes. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Care Plan, Progress Note, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
1.10 Persistence
a)Typically, the concerns from the child or youth and family are addressed in the CFTM. If the concern cannot be resolved at the Provider level or through the CFT process, then the HFW Provider or Department representative should bring it to the attention of the DMH Wraparound SA Team. The HFW Provider and DMH Wraparound SA Team will determine the next steps, as appropriate. Masada’s HFW Supervisor completes the Quality of Care Tool and provides HFW team with support to work with clients and families when experiencing setbacks or limited progress. LACDMH offers Support Calls to address any of the above mentioned challenges. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures # 23 Wraparound Issue Resolution p.47; Quality of Care Tool; Follow up Child and Family Teaming Process (flyer)
b) Masada’s HFW team is trained on how to access additional support via coaching and supervision. Typically, the concerns from the child or youth and family are addressed in the CFTM. Masada’s HFW team consults with Masada’s HFW team supervisors and administrators and QA/QI Liaison when any support, additional needs and guidance is needed. Each team member receives weekly supervision based on their specific role. If the concern cannot be resolved at the Provider level or through the CFT process, then the HFW Provider or Department representative should bring it to the attention of the DMH Wraparound SA Team. The HFW Provider and DMH Wraparound SA Team will determine the next steps, as appropriate. Masada’s HFW Supervisor completes the Quality of Care Tool and provides HFW team with support to work with clients and families when experiencing setbacks or limited progress. LACDMH offers Support Calls to address any of the above mentioned challenges. LACDMH has a clear standard process pertaining to FlexFund. CRSS Supplemental Information Form (SIF) Contractor shall submit a completed SIF via the Wraparound Tracking System (WTS) for the following:1. For any SFC 70, 71, or 72 expenditure in the amount of $1,500 or above; 2. Upon the request of DMH, when additional information is required to validate and complete a CRSS invoice; 3. For *pre-approval of exceptional SFC 72 expenditures specific to non-DMH clinical consultations, specialty experts, or private therapists. Completed SIFs shall provide clear documentation demonstrating how the expenditure was individualized to the child or youth and family’s care plan and/or recovery goals (i.e. Child and Family Team FSP-HFW Plan of Care (POC), as well as what steps have been taken to secure alternative sources of funding for the expenditure, as appropriate. The date of the SIF shall match the date of the expenditure and accompanying receipt(s), (except when used for *pre-approval as stated above). Masada developed an internal flex fund app to facilitate easy access for our staff. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures # 23 Wraparound Issue Resolution p.47; # 27 Case Rate Services and Supports, p.52-57; Quality of Care Tool; Follow up Child and Family Teaming Process (flyer), Masada’s FlexFund app, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
c) HFW Facilitator completes a 2 day training for facilitators, which includes crisis teams training. Ongoing coaching is offered by LACDMH 1x/month and Coaching through UC Davis Center of Excellence is offered as well. HFW Facilitator facilitates debrief meetings with Wraparound team members, including the CSW and/or DPO. Safety Plan: An individualized and collaborative written document that is culturally and linguistically
accommodating, which provides strategies the child or youth and family can utilize to address safety concerns. A Safety Plan is initiated by the HFW team and updated and developed further by the Child and Family Team (CFT), based on the individual needs of the child or youth and family. The Safety Plan will serve three primary functions: 1) provide the necessary information to help prevent a crisis from occurring, 2) provide information to guide effective responses by the Child and Family Team when a crisis
does occur, and 3) help with planning for crisis resolution. HFW Facilitator facilitates all CFT meetings. Masada developed an internal flex fund app to facilitate easy access for our staff. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Safety Plan- Policy 10, p.25 &
Training Requirements for Wraparound Providers -Policy 5, p.13, Wraparound Staffing – Policy 6, p.15 Masada’s FlexFund app
1.11 Transitions as a part of the Fourth Phase of HFW
a) The HFW team prepares the child and family for the conclusion of HFW services by creating an individualized transition plan including a celebration of the family’s success that supports the child and family’s continued stability. The HFW Team plans the client’s graduation with the client and family. Masada’s HFW team collaborates with LACDMH Wraparound to approve graduation and then client’s exit from the program. Client’s celebration is planned with client and family based on client’s cultural considerations (this could include food, activities and transitional items). This is documented during the last CFT meeting and in the client’s clinical record. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and ProceduresService Delivery #7 p.18
b) Masada incorporates community resources and partnerships and utilizes flex funds to support celebrations (adoptions, graduations). The HFW team invites community partners to CFT meetings for planning and exploration of celebratory activities for HFW clients/families, and documents in the CFT FSP-HFW Plan of Care (POC). See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and ProceduresService Delivery #7 pg 18 and CRSS-Policy # 27 pg. 32, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
Expected Outcomes
2.1 Youth and Family Satisfaction
a) The HFW Youth, Family, and Tribal Satisfaction Survey and Program Policy is operationalized by collecting, documenting, and evaluating feedback from youth, families, and when applicable Tribes participating in the High Fidelity Wraparound (HFW) program. Satisfaction is measured using multiple tools, including program satisfaction surveys, and observations of Child and Family Team (CFT) meetings. In addition, Parent Advocates within the eight Service Areas routinely conduct telephone Caregiver and Child or Youth Satisfaction Surveys with active Wraparound participants, including biological parents, caregivers, and the child or youth. Participation in these surveys is voluntary and informed consent is obtained from each participant. The surveys are brief and include questions designed to measure fidelity to the Integrated Core Practice Model and Wraparound Principles, participant satisfaction with services provided by the Wraparound Team, and key outcome indicators such as client well-being, school functioning, and frequency of hospitalization. Survey results are analyzed and data trends are shared countywide with Wraparound providers when available. At the discretion of Wraparound Administration, additional program monitoring tools may also be utilized. Internally, Masada’s Quality Assurance and Quality Improvement (QA/QI) Department conducts routine client satisfaction surveys in accordance with Masada’s Consumer Satisfaction Survey (CSS) Protocol. Satisfaction data from these various sources is documented, reviewed by program leadership, and incorporated into the program’s Continuous Quality Improvement process to identify strengths, address concerns, and improve service delivery. See the County of Los Angeles Department of Mental Health Child Welfare Division Wraparound Program Policies and Procedures Program Monitoring (#20), page 42. HFW Youth, Family and Tribal Satisfaction Survey and Program Monitoring Policy 1-2
2.2 Improved School Functioning
a) HFW team members will continue to collaborate and consult with school formal supports to review school attendance and performance records (Monitoring IEP, 504 plan, etc.). HFW team will support with vocational and occupational support/linkage to reinforce skill building with youth. HFW team tracks client’s school attendance and performance via CANS-IP, Care Plan, CFT FSP-HFW Plan of Care (POC) and OMAs. All are recorded and documented in the client’s clinical record. See County of Los Angeles – Department of Mental Health Child Welfare Division, Wraparound Staffing Policy 6, p.13, Care Plan, CANS-IP, OMAs, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
2.3 Improved Functioning in the Community
a) This section outlines required outcome data collection for HFW services to demonstrate effectiveness to the State, DMH, DCFS, and Probation, including use of standardized tools such as the PSC-35 and CANS, with coordination across agencies to avoid duplicate assessments. For HFW FSP providers, outcomes are tracked in the Outcome Measures Application (OMA) through timely baseline, quarterly, and key event assessments, with specific procedures for transfers, re-enrollment, and exits to ensure accurate and continuous outcome reporting. Engagement with community activities is recorded on OMAs and through the CANS-IP. See County of Los Angeles – Department of Mental Health Child Welfare Division,Outcome Measures policy 6, p.15. PSC-35, CANS-IP, OMAs, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
2.4 Improved Interpersonal Functioning
This section outlines required outcome data collection for HFW services to demonstrate effectiveness to the State, DMH, DCFS, and Probation, including use of standardized tools such as the PSC-35 and CANS-IP, with coordination across agencies to avoid duplicate assessments. For HFW providers, outcomes are tracked in the Outcome Measures Application (OMA) through timely baseline, quarterly, and key event assessments, with specific procedures for transfers, re-enrollment, and exits to ensure accurate and continuous outcome reporting. CANS-IP and PSC-35 and OMAs record and measure interpersonal functioning. See County of Los Angeles – Department of Mental Health Child Welfare Division, Outcome Measures policy 21, p.43. PSC-35, CANS-IP, OMAs.
2.5 Increased Caregiver Confidence
Masada offers one on one support through the use of the HFW Parent Partner and a parent support group as well as coaching. HFW Parent Partner utilizes a variety of outcome measures (KEC’s, PSC 35, CANS-IP) and Motivational Interviewing to assess the caregiver’s needs and level of confidence to access community resources. HFW Parent Partner collaborates with caregivers on developing positive parenting interventions and confidently accessing services within the community. Progress is tracked and documented in the client’s clinical record. See County of Los Angeles – Department of Mental Health Child Welfare Division, Outcome Measures policy 21, p.43. CANS-IP, PSC-35, OMA KEC.
2.6 Stable and Least Restrictive Living Environment
HFW team utilizes Key Event Changes (KEC) to record and evaluate the frequency of and types of placement changes when they occur. See County of Los Angeles – Department of Mental Health Child Welfare Division, Outcome Measures policy 21, p.43. OMA KEC.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
a) The HFW CFT team collaborates with the client and family on creating a Safety Plan to reduce risk of hospitalizations. HFW team provides ongoing intensive speciality mental health service to prevent/reduce hospitalizations. In the event of a hospitalization, the HFW team modifies the Safety Plan and evaluates new strategies to reduce risks. This section outlines required outcome data collection for HFW services to demonstrate effectiveness to the State, DMH, DCFS, and Probation, including use of standardized tools such as the PSC-35 and CANS-IP, with coordination across agencies to avoid duplicate assessments. For HFW providers, outcomes are tracked in the Outcome Measures Application (OMA) through timely baseline, quarterly, and key event assessments, with specific procedures for transfers, re-enrollment, and exits to ensure accurate and continuous outcome reporting (see Policy 21 Outcome Measures).This policy requires HFW Providers to complete and submit a Special Incident Report (SIR) for any incident involving safety concerns, threats, injury, property damage, or serious behavioral events affecting a child, youth, or family. Reports of abuse, neglect, runaways, or death must be submitted the same or next business day, while all other incidents must be reported by the next business day using the DCFS/Probation SIR form (see Policy 13 Special Incident Report). OMA is used to track hospitalizations, and SIRs also track hospitalizations. See County of Los Angeles – Department of Mental Health Child Welfare Division, Outcome Measures policy 21, p.43, Special Incident Report Policy 13, p. 30. PSC-35, CANS, OMA Baseline, KEC 3M, SIR.
2.8 Reduction in Crisis Visits
a) The HFW CFT team collaborates with the client and family on creating a Safety Plan to reduce risk of crisis. HFW team provides ongoing intensive speciality mental health service to prevent/reduce crisis. In the event of a crisis, the client and family are coached to activate their Safety Plan. The HFW team reviews the Safety Plan and evaluates new strategies to reduce risks. The HFW team utilizes KEC (Key Event Change) and SIR (Special Incident Report) to record frequency of crises and level of involvement of professional support (HFW team, PET team, Law enforcement, etc.) when crises occur that are shared with probation /social workers and documented in the client’s clinical record. See County of Los Angeles – Department of Mental Health Child Welfare Division, Outcome Measures policy 21, p.43, Special Incident Report Policy 13, p. 30. OMA KEC, SIR, Safety Plan.
2.9 Positive Exit from HFW
a) The HFW team collaborates and consults with the child and family, and HFW Liaison to discuss child exit from HFW. In the exit process, the HFW Facilitator documents exit reasons and linkages in the last CFTM FSP-HFW Plan of Care (POC). The HFW Facilitator completes the pre-exit checklist, which must be approved by the HFW Supervisor and LACDMH Liaison, and it is recorded in an appropriate system (WTS, client’s clinical record). See County of Los Angeles – Department of Mental Health Child Welfare Division, Exit from Wraparound policy 18, p.39., pre-exit checklist, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
Engagement
3.1 Orientation
a) The High Fidelity Wraparound (HFW) process is fully explained to every family at the time of initial engagement and prior to or during the first Child and Family Team (CFT) meeting. The orientation includes an overview of the Wraparound principles and four phases, a review of key legal and ethical considerations such as confidentiality and mandated reporting, and a clear explanation of the roles of all team members. This includes the youth and family as central decision-makers, natural supports, formal service providers, and Tribal representatives when applicable under ICWA. See HFW Orientation Policy p. 1-2
a)The HFW Facilitator provides every youth and family with an overview of the core Wraparound principles and the four phases of the process including Engagement and Family Preparation, Planning, Implementation, and Transition at initial engagement and prior to or during the first CFT meeting. The orientation is delivered in a culturally responsive, developmentally appropriate, and linguistically accessible manner to ensure understanding. See HFW Orientation Policy p. 1-2
b) The HFW Facilitator reviews key legal and ethical considerations, including confidentiality and its limits, mandated reporting requirements, crisis response procedures, and any applicable court requirements. Families are informed of their rights and responsibilities to promote transparency and compliance. See HFW Orientation Policy p. 1-2
c) The HFW Facilitator clearly explains the roles of all team members, including the youth as the central voice, parents and caregivers, natural supports, formal service providers, and Tribal representatives when applicable under ICWA. The orientation is documented in the client’s clinical record to ensure shared understanding and adherence to High Fidelity Wraparound standards. See HFW Orientation Policy p. 1-2
3.2 Safety and Crisis stabilization
a) Safety Plan is created at onset of treatment by the HFW Clinician as a collaborative process with the client. It is individualized and collaborative, based on previous behaviors. It is updated after a crisis, easily accessed by the family, and contains the contact list. All documents are uploaded into the client’s clinical record. County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Safety Plan Policy #10 page 25.
b) The Safety Plan is an individualized and collaborative document developed at the onset of services by the HFW Clinician and further refined by the Child and Family Team (CFT) during the planning phase. It is designed to prevent crises, guide responses when crises occur, and support crisis resolution. Within High Fidelity Wraparound (HFW), the Safety Plan is proactive and comprehensive, it identifies triggers, warning signs, prevention strategies, roles of formal and informal supports, and intervention steps before, during, and after a crisis. In contrast, a Crisis Stabilization Plan is more immediate and reactive, focusing specifically on the actions taken when a crisis is actively occurring and safety has already been compromised (e.g., emergency response, psychiatric evaluation, or stabilization procedures). Therefore, while a crisis stabilization plan may inform real-time crisis response, it does not replace the broader HFW Safety Plan developed during Plan Development. The Safety Plan remains the primary, team-based document that outlines prevention, intervention, and resolution strategies and must be reviewed and updated as part of the ongoing CFT process after every crisis. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Safety Plan Policy #10 page 25.
c) The HFW team creates a brief, family-centered Safety Plan at the start of services that anticipates potential crises and outlines triggers, supports, and actions before, during, and after a crisis. The plan must honor the child and family’s voice and choice, be easily accessible, shared with the Child and Family Team, and reviewed and updated as needed, including after any crisis. The HFW Facilitator provides the client and family with the Wraparound Program After Hour Crisis Number. Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Safety Plan Policy #10 page 25.; Wraparound Program After Hour Crisis Number Flyer.
3.3 Strengths, Needs, Culture and Vision Discovery
a) The engagement and team preparation phase starts with the Enrollment meeting; the HFW Facilitator and other team members’ goal is to engage and orient the family to the HFW philosophy and approach and review each of the roles of the team members. The family’s voice and choice is supported and validated during the Enrollment meeting. The team strives for collaboration and connection to lay the groundwork for a solid partnership. Upon the family’s agreement to participate in the Masada HFW
program, they meet with the HFW therapist to start the mental health assessment. The HFW team discusses and prepares the family for the initial Child and Family Team Meeting (CFTM) to be held about 4-6 weeks from enrollment. The HFW Facilitator and team meets with the youth and family to prepare them for the CFT meeting and assists them in articulating their family story, goals and family vision (includes a planning sheet). HFW Facilitator meets with the team to conduct a case exploration. During the case exploration, the team develops hunches of underlying needs and creates a genogram, ecomap and timelines as well as identifies strengths. The HFW Facilitator utilizes the FSP-HFW Plan of Care (POC) to guide the FSP-HFW team through the creation of the Plan of Care during the CFT meeting. This is a collaborative, strength-based, individualized plan that identifies a child or youth and family’s vision and values, strengths, needs, goals, expertise, capabilities, interests, skills, trauma history, and cultural preferences. The child’s or youth’s and family’s vision is documented in the Plan of Care, which is filed in the client’s electronic health record. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures :Training Requirements For Wraparound Providers Policy 5. P.13; Child and Family Team Facilitator Guidebook “The 2 Day Child and Family Team Facilitator Training”; Case Exploration: Elicits information, creates genogram, ecomap and timeline. p.3, Staff Engagement: Explore the impact of trauma and ask for a family’s long term view. Staff Engagement worksheet. p.9, Family and Team Engagement. Preparing the Family for Teaming; prepares the family to identify goals, family story, strengths, and identify the Team list. P.15; Masada Admission Procedure-INTAKE-Wrap; Planning Sheet; Plan of Care Policy (p. 1-2); Instructions for Completing the FSP-HFW Plan of Care
b) The HFW Facilitator completes the CFT Team meeting FSP-HFW Plan of Care (POC), identifying strengths, needs, cultural preferences at a minimum of every 30 days and records the CFT FSP-HFW Plan of Care (POC) into the client’s clinical record. The HFW Facilitator updates the CFT FSP-HFW Plan of Care (POC) with each CFT team meeting and adds new strengths, needs, and cultural preferences as they are discovered. Incorporates team member changes, such as new staff. The HFW therapist completes the CANS-IP needs assessment, identifying strengths, needs, cultural preferences, collaboratively with client and caregiver/significant support persons every six months and records into the client’s clinical record. The HFW Facilitator provides the CFT FSP-HFW Plan of Care (POC) to CFT team members, including any new members, after gathering signatures and assurance of completion at the end of the CFT meeting and/or as soon as responsibly possible. New team members are oriented through team consultations and review of the clinical record. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Child and Family Team, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
3.4 Engage All Team Members
a) The HFW Facilitator develops Ecomaps during case explorations which identify natural supports. HFW Facilitator completes the Natural Supports Inventory with client and family during family engagement. A formal Child and Family Team is developed to include formal and informal supports. Informal supports are identified by the child/youth and family to help address the needs and strengths of the family and develop an individualized care plan that addresses their underlying needs. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Child and Family Team (#8, page 21); Child and Family Team Facilitator Guidebook from The 2 day Child and Family Team Facilitator Training ; it includes Ecomap, Agenda, Staff engagement, Plan of Care (POC); Natural Supports Inventory.p.17
b) All formal and informal supports elicited through the child/youth and family’s voice and choice are incorporated in the CFT, including the CSW and/or Wrap Liaison DPO. HFW Facilitator engages the identified partners in the system of care and coordinates the CFT meetings. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Child and Family Team (#8, page 21)
c) At enrollment , the HFW Facilitator explains the role of each HFW team member. The HFW Facilitator develops Ecomaps during case explorations which identify natural supports. HFW Facilitator completes the Natural Supports Inventory with client and family during family engagement. A formal Child and Family Team is developed to include formal and informal supports. Informal supports are identified by the child/youth and family to help address the needs and strengths of the family and develop an individualized care plan that addresses their underlying needs. HFW Facilitator explains the role of each CFT team member including formal and informal supports. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Child and Family Team (#8, page 21); Child and Family Team Facilitator Guidebook from The 2 day Child and Family Team Facilitator Training ; it includes Ecomap, Agenda, Staff engagement, Plan of Care (POC); Natural Supports Inventory. p.17
d) HFW Facilitator facilitates team engagement activities to promote a positive and collaborative CFT culture. HFW Facilitator outreaches and engages formal and informal supports. 1st of 4 phases of the Wrap Process: Engagement and Family Preparation. At Masada, the meeting summary is documented in the client’s clinical record as well as the CFT Plan of Care (POC), the Staff Engagement Worksheet and the Family Engagement Worksheet . See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Policy #6: (pg 15,16) Policy #7 p.18 Child and Family Team Facilitator Guidebook p.17, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
3.5 Arrange Meeting Logistics
a) The HFW team provides services three to four times per week, depending on the needs of the child or youth and family, and in a setting that is conducive to the family’s wishes. The HFW team takes into consideration the client and family schedule, transportation needs and interpretation needs. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Service Delivery #7, p. 18
b) The HFW Facilitator contacts the family via telephone within 24 hours from receiving the referral and explores the best time for enrollment and subsequent sessions and CFT meetings. During Case Exploration and Staff Engagement, the HFW Facilitator and team learn how to engage clients and family (school schedules, caregiver work schedule). See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Training Requirements for Wraparound Providers #5 p.13
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
a) The HFW team members document the strengths, team agreements, and family mission statement in the CFTM FSP-HFW Plan of Care (POC). See County of Los Angeles – Department of Mental Health Child Welfare Division, Service Delivery policy 7, p.18. CFT FSP-HFW Plan of Care (POC).
b) The HFW team members continuously assess and update the strengths of client and family in the CFTM FSP-HFW Plan of Care (POC)/CANS-IP. See County of Los Angeles – Department of Mental Health Child Welfare Division, Outcome Measures Policy 12, p. 43. CFT Plan of Care (POC), CANS-IP, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
a) The HFW Facilitator and team complete case exploration and identify underlying needs and complete staff engagement with DCFS or Probation to further explore underlying needs prior to the competition of the care plan. They complete ECOMAP, genogram, and timeline. This is documented in the client’s clinical record.
4-step CFT Sequence includes:
1. Case Exploration/Record Review & Staff Engagement” develops hunches about underlying needs”
3. CFTM-Agenda includes: “youth’s needs, family needs…”
See Masada’s Admission Procedure/Intake/Wrap (p.3) , Child and Family, Team Facilitator Guidebook (p. 3-61)
b) The HFW team collaborates with the child and family through engagement and family preparation to address immediate and long term goals. HFW clinician utilizes the outcome measures (i.e., CANS-IP) to identify, prioritize and track goals and projected outcomes. HFW clinician will develop strength based measurable goals utilizing SMART method. See County of Los Angeles – Department of Mental Health Child Welfare Division, Wraparound Staffing policy 6, p16, Service Delivery Policy 7, p.18.
c) During the CFT meeting, topics discussed include “the care plan that is created to meet those needs” and “specific action steps taken” to assist in implementing the care plan that was created and agreed upon by all members of the CFT.” This is done collaboratively with the client and family. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Child and Family Team Policy 8, p.21, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care.
d) During the Child and Family Team meeting, the HFW team brainstorms individualized strategies, utilizing a large notepad, and documents the strategies in the CFT FSP-HFW Plan of Care (POC) documenting specific actions steps and who is responsible to complete tasks to help achieve collaborative SMART goals. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Child and Family Team Policy 8, p.21, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
e) List of DMH Required Trainings include for Fac:
1) ICPM Training
2) Overview: Preparing for Child and Family Teaming
3) 2-Day CFT Facilitator Training
The HFW Facilitators are trained to lead teams in identifying, prioritizing, and selecting strategies and developing action items. They complete a 2 Day Facilitator training that includes these strategies and utilize the Child and Family Team Facilitator Guidebook. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Training Requirements for Wrap Providers (#5) p.13, Child and Family, Team Facilitator Guidebook (p. 3-61)
f) The FSP-HFW Plan of Care (POC): an individualized document is created by the CFT members during CFT meetings where discussion topics including family goal and the care plan. These are transcribed onto the CFT FSP-HFW Plan of Care (POC). During CFT meetings, it is important to document in the CFT FSP-HFW Plan of Care (POC)specific actions steps and who is responsible to complete tasks to help achieve goals. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures. Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
4.3 Develop an Individualized Child or Youth and Family Plan
a) HFW Supervisor monitors ongoing training and coaching workflow for HFW Facilitators to engage in the treatment planning process that elicits multiple perspectives, builds trust and shared vision, and demonstrates the HFW principles. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Training Requirements for Wraparound Providers Policy 5, p.13.
b) CFT FSP-HFW Plan of Care (POC) is created by CFT members during CFT meetings where goals and objectives are identified. Client’s system of care participants collaborate on establishing client’s goals during the CFT meetings and identify specific next steps and who will be doing what by when. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
c) The FSP-HFW Plan of Care (POC) are distributed to all team members, and meet the following 6 HFW criteria:
1) Fx/Team Mission based on youth/Fx’s strengths/needs/culture
2) Addresses needs across multiple life domains and CFT Members as identified by CFT.
3) Strategies and Action items and who is responsible including due dates, include CFT Members
4) Includes and array of services/supports by CFT member following ICPM principles
5) Uses natural support and comm resources to also include them for transition from Program
6) Transition Plans at family’s own pace:
See County of Los Angeles – Department of Mental Health Child Welfare Division Polices and Procedures Service Delivery policy #7 p.18. ; Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care.
d) The HFW supervisor utilizes the Quality of Care tool to provide continuous feedback to HFW staff for training and coaching purposes. See County of Los Angeles – Department of Mental Health Child Welfare Division, policy #6, Wraparound Staffing p.18. Quality of Care Tool.
4.4 Develop a Crisis and Safety Plan
a) The HFW team maintains 24/7 crisis coverage year-round, with a HFW supervisor determining the appropriate in-person response based on the child or family’s needs and ensuring follow-up and documentation aligned with the safety plan.The HFW team keeps LACDMH updated with current crisis contact information and follows specific protocols for psychiatric evaluations and holds. The HFW team remains engaged with the child, youth, and family throughout the crisis until stabilization and a safety plan are in place. Each HFW team member participates in the 24-hour/day, 7-day/week on-call crisis response system, ensuring safety of clients and providing direct crisis intervention and therapeutic guidance as needed. See Policy County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Policy #22-24/7 Crisis Coverage, Masada Crisis Intervention Policy and Procedure.
b) The HFW team creates a safety plan in the initial CFTM meeting with the child/youth and family, using their own words, to prepare for and respond to crises. It identifies triggers, supports, and clear steps before, during, and after a crisis, is accessible to the family, shared with the CFT, and updated as needed. ALL team members engage in the safety planning process with the client and caregiver. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Policy #10-Safety Plan.
c) The HFW team creates a Safety Plan at the start of HFW services with the child/youth and family, using cultural relevance as needed, to prepare for and respond to crises. The Safety Plan identifies the client’s triggers, including natural supports, and clear steps on how to manage the crisis before, during, and after a crisis. The Safety Plan is accessible to the family, shared within CFTM, and updated as needed. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Policy #10-Safety Plan.
Implementation
5.1 Implement The Plan of Care
a) The HFW facilitator develops the CFT meeting agenda and completes the CFT FSP-HFW Plan of Care (POC)which is considered to be meeting minutes. During the CFTM, specific action steps are documented, and the responsible team members for each action item are clearly identified, and the HFW facilitator follows up with each member. All participants in the CFT FSP-HFW Plan of Care (POC). All CFT team members receive a copy of the CFT FSP-HFW Plan of Care (POC). See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures,Wraparound Staffing pg 15, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
b) Within one year of hire, all HFW staff must complete the required training (14 training listed). Among the required trainings, Wraparound 101 covers reviewing the Wraparound principles, including the FSP-HFW Plan of Care. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Training Requirements for Wraparound Providers 5, pg 1, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
5.2 Review and Update The Plan of Care
a) The HFW Facilitator is responsible for managing the logistics of the CFTM process and ensuring that the HFW process is followed with fidelity. The HFW team meets with the family to develop strategies, progress and action steps that are documented in the CFT FSP-HFW Plan of Care (POC). See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Policy #8, Child and Family Team section, paragraph 5.
b) The HFW Facilitator ensures the team meetings are individualized, culturally respectful, guided by outcomes and abide by the integrated Core Practice Model. The HFW Facilitator documents all the changes and plans in the CFT FSP-HFW Plan of Care (POC) and treatment plan. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
c) During the CFTM, the HFW Facilitator documents team attendance, discussion items, assigned action steps, use of formal and natural supports and updates to the care plan. These items are captured in real time and transcribed into the CFT Planning FSP-HFW Plan of Care (POC), including task assignments and follow-up responsibilities. Completion of tasks, new assignments, and plan updates are communicated to all team members through team meeting minutes. All team members review and sign the FSP-HFW Plan of Care (POC), and copies are provided to the family and shared with the assigned CSW/DPO. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Policy #8 p.21, Child and Family Team section, paragraph 5, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
d) The HFW Facilitator completes the CFT Team meeting FSP-HFW Plan of Care (POC), identifying strengths, needs, cultural preferences at a minimum of every 30 days and records the CFT FSP-HFW Plan of Care (POC) into the client’s clinical record. The HFW Facilitator updates the CFT FSP-HFW Plan of Care (POC) with each CFT team meeting and adds new strengths, needs, and cultural preferences as they are discovered. Incorporates team member changes, such as new staff.
The HFW therapist completes the CANS-IP needs assessment, identifying strengths, needs, cultural preferences, collaboratively with client and caregiver/significant support persons every six months and records into the client’s clinical record.
The HFW Facilitator provides the CFT FSP-HFW Plan of Care (POC) to CFT team members, including any new members, after gathering signatures and assurance of completion at the end of the CFT meeting and/or as soon as responsibly possible. New team members are oriented through team consultations and review of the clinical record. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Policy #9 Wraparound Staffing, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
a) The HFW Team actively promotes a positive, respectful, and collaborative Child and Family Team (CFT) culture to support team cohesiveness, trust, and shared commitment throughout service delivery. The HFW Facilitator continually assesses team functioning, engagement, and collaboration during ongoing service coordination and weekly case consultations. Team agreements are developed collaboratively with the child or youth, family, natural supports, and formal providers; reviewed regularly; documented within the child’s or youth’s and family’s Plan of Care (POC); and presented during each CFT meeting to ensure accountability, follow-through, and shared understanding of next steps. The HFW Team utilizes the Quality of Care Tool and Quality Service Review (QSR) framework to identify strengths, monitor collaboration, address barriers, and support continuous improvement in team functioning and engagement. During Child and Family Engagement and Team Preparation activities, the HFW Facilitator prepares and orients family members and team participants by explaining the HFW and CFT process, reviewing the CFTM agenda, clarifying roles and expectations, and reinforcing family voice and choice. The HFW Team identifies, engages, and develops natural supports whenever appropriate and ensures that new team members are welcomed, oriented, and integrated into the team process in a manner that maintains trust, continuity, cultural responsiveness, and effective collaboration. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Wraparound Staffing pg 15 and Masada Admission Procedure – INTAKE; Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care; Quality of Care Tool
b) Within a year of hire, all HFW staff must complete the required training (14 training). Ongoing training (recommended training) are also available to further enhance their skills. HFW Supervisors provide ongoing support and coaching to HFW Facilitator, weekly individual and group supervision to ensure the HFW Facilitators are building, engaging, and maintaining effective teams. Coaching for HFW facilitators from LACDMH is also available as a provider request through the Coaching Division as needed. Masada JD – Team supervisor indicates providing ongoing support. Follow up Child and Family Teaming Process (Technical Assistance) Flyer
c) The HFW Facilitator completes the Natural Supports Inventory with the client and family. Natural Supports (informal supports) are individuals that are identified by the child or youth and family as members of their circle of support and will be included in the treatment plan. Use of natural supports are monitored over time and updated in the CFT FSP-HFW Plan of Care (POC) HFW Facilitator monitors natural supports throughout the treatment. HFW Team Supervisor ensures that the client’s plan is effectively and comprehensively assessed, coordinated, delivered, transitioned, and reassessed in a way that is consistent with the intent of the Shared Core Practice Model. Reviews client outcomes and use of natural supports. HFW Team Supervisor utilizes the Quality of Care tool to provide feedback to the HFW team on use of natural supports. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care and Masada JD for Team Supervisor p.21,22, 24 , the Quality of Care Tool
d) The HFW Supervisor provides guidance on how to best introduce a new team member and coordinates upcoming case consults and warm hand off with the existing team members. The HFW Facilitator outreaches and engages formal and informal supports. The HFW Facilitator orients all CFT members (including new members) to the process of HFW, including reviewing current plans and strategies, and engaging in team building exercises. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Wraparound Staffing #6 pg15; HFW Orientation Policy.
Transition
6.1 Develop a Transition Plan
a) Service delivery acknowledges the four (4) phases of the Wraparound process (Engagement, Planning, Implementation and Transition). The HFW Facilitator leads the CFT team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process. The HFW Facilitator monitors the progress and identifies the need to revisit different phases of the process to meet the evolving needs of the family. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Service Delivery pg18
b) During the CFTM, the HFW Facilitator documents discussion items, assigned action steps, and updates to the care plan. These items are captured in real time and transcribed into the FSP-HFW Plan of Care (POC), including task assignments and follow-up responsibilities. Completion of tasks, new assignments, and plan updates are communicated to all team members through team meeting minutes. The CFT FSP-HFW Plan of Care (POC) is uploaded into the client’s clinical record. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
c) The development of the individualized transition plan occurs in a team based, collaborative environment and HFW Facilitators receive training through CFTM and coaching to this process within a year of hire, all HFW staff must complete the required training (14 training). On going training (recommended training) are also available to further enhance their skills. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Training Requirements for Wraparound Providers and Service Delivery, Child and Family Team pg 13, 18 and 24, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
d) HFW Team prepares the family for transition, identifies natural and formal supports that are in place and will be available during the transition process and thereafter. Transition: Preparing the child or youth and family for the conclusion of HFW services by creating an individualized transition plan, and a celebration of the family’s success to support the child or youth and family’s continued stability. PAS service is available and the DMH Wraparound liaison is responsible for communicating with the DCFS PAS unit on the status of the referral, Wraparound provider for the case assignment. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Service Delivery #7p.18 , Policy #3 p.10,11
6.2 Develop a Post-Transition Safety Plan
a) The plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies that maximize use of natural support and that are chosen by the family. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Safety Plan #10, p.25
b) The HFW Facilitator and team review the most recent safety plan with the client and family. The plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies that maximize use of natural support and that are chosen by the family. The development of the crisis and safety transition plan occurs in a team based, collaborative environment and HFW Facilitators receive training and coaching to this process. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and ProceduresSafety Plan #10, p.25
c) HFW Facilitators receive ongoing training and coaching in leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences. HFW Facilitators must complete required training, and receive ongoing coaching from the supervisor (supervisor identifies ongoing training needs). See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Training Requirements (#5) Wraparound Staffing (6) p.13, 14, 17
6.3 Create a Commencement and Celebrate Success
a) The preparation of the child and family for the conclusion of HFW services include creating an individualized transition plan that includes a celebration of the family’s success that supports the child and family’s continued stability. The HFW Team plans the client’s graduation with the client and family. Masada’s HFW team collaborates with LACDMH Wraparound to approve graduation and then client’s exit from the program. Client’s celebration is planned with client and family based on client’s cultural considerations (this could include food, activities and transitional items). This is documented during the last CFT meeting and in the client’s clinical record. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Service Delivery #7 p.18
b) The HFW Team incorporates community resources and partnerships and utilizes flex funds to support celebrations (adoptions, graduations). The HFW team invites community partners to CFT meetings for planning and exploration of celebratory activities for HFW clients/families, and is documented in the CFT FSP-HFW Plan of Care (POC) in the client’s clinical record. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Policy #9, p.24, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
a) Mechanisms are in place to ensure families participate in decisions regarding local High Fidelity Wraparound (HFW) implementation. Families provide input through Child and Family Team (CFT) meetings, where youth and caregivers actively participate in service planning and implementation. Additional mechanisms include Caregiver and Child or Youth Satisfaction Surveys conducted by Parent Advocates within the Service Areas and client satisfaction surveys administered by Masada’s Quality Assurance and Quality Improvement (QA/QI) department under the Consumer Satisfaction Survey (CSS) Protocol. In addition, the Los Angeles County Department of Mental Health (LACDMH) routinely invites consumers and family members to participate in planning and advisory committees that inform behavioral health program implementation. Most recently, consumers and family representatives were invited to participate in the BHSA Planning Committee working on the Behavioral Health Services Act (BHSA) Integrated Plan. These mechanisms ensure families have multiple opportunities to provide input into both service delivery and broader program planning. Parent Advocates within the eight (8) Service Areas routinely conduct telephone surveys of active Wraparound program participants, including biological parents, caregivers, and the child or youth. Participation is voluntary and informed consent is obtained from each participant.
The surveys are brief and include questions that are aimed at measuring fidelity to the Integrated Core Practice Model and Wraparound Principles, participant satisfaction with the services provided by the Wraparound Teams, and some outcome indicators like client well-being, school functioning, and frequency of hospitalization. The resulting data is analyzed, and data trends are shared countywide with Wraparound Providers, as available. At the discretion of Wraparound Administration, other program monitoring tools may be utilized. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Program Monitoring #20 p.42
b)
Family feedback collected through CFT meetings, satisfaction surveys, Parent Advocate outreach, and participation in planning committees is documented and reviewed by program leadership and QA/QI staff. The information gathered is analyzed to identify trends, strengths, and areas for improvement and is used to inform decision-making related to service planning and implementation, policy and procedure development, workforce development, and continuous quality improvement of the High Fidelity Wraparound model. Parent Advocates within the eight (8) Service Areas routinely conduct telephone surveys of active Wraparound program participants, including biological parents, caregivers, and the child or youth. Participation is voluntary and informed consent is obtained from each participant.
The surveys are brief and include questions that are aimed at measuring fidelity to the Integrated Core Practice Model and Wraparound Principles, participant satisfaction with the services provided by the Wraparound Teams, and some outcome indicators like client well-being, school functioning, and frequency of hospitalization. The resulting data is analyzed, and data trends are shared countywide with Wraparound Providers, as available. At the discretion of Wraparound Administration, other program monitoring tools may be utilized. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures Program Monitoring #20 p.42
7.2 Community Leadership Team
a) The HFW Program Director serves as the identified representative for the agency. The HFW Program Director represents the agency to referring bodies through written communication and regular in-person visits. The HFW Program Director facilitates, assists with, and/or attends Wraparound Program meetings, trainings, and conferences as scheduled. Through this participation, the HFW Program Director actively engages in Community Leadership Team activities in accordance with Wraparound policies and procedures. See Masada Job Description WRAPAROUND/INTENSIVE FIELD CAPABLE CLINICAL SERVICES (IFCCS) PROGRAM DIRECTOR, #6
7.3 Eligibility and Equal Access
a) Youth that meet established eligibility criteria are able to receive services and are not excluded based on the severity or nature of their needs. Eligibility for Children/Youth FSP-HFW Services will be determined by the LAC-DMH Service Area (SA) Navigators and the LAC-DMH Countywide FSP-HFW Administration, in consultation with the Contractor’s Children/Youth FSP-HFW Teams. FSP-HFW Teams must utilize the CANS or LOCUS based Decision Support Criteria (DSC) to authorize an eligible children/youth for HFW. In conjunction the DSC and clinical judgement will inform the client’s eligibility for HFW. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Criteria and Target Population pg5 , Children & Youth Full-Service Partnership High Fidelity Wraparound Program Service Exhibit #1700 p.4-5
b) Masada will utilize a structured and data-informed case assignment, staffing, and oversight process designed to support fidelity to the High Fidelity Wraparound model, continuity of care, and timely response to youth and family needs. Program leadership, including the Program Manager, FSP-HFW Supervisors, Clinical Supervisors, Licensed Clinicians, and designated leadership staff, will conduct regular multidisciplinary staffing meetings to review referrals, caseload distribution, acuity levels, crisis activity, staffing capacity, and operational needs. Case assignments will be determined using a standardized review process that considers clinical complexity, safety concerns, hospitalization history, child welfare and probation involvement, geographic and field-based service demands, cultural and linguistic needs, staff experience, and overall workload balance to ensure equitable and clinically appropriate assignments.
Masada will utilize available data from measurement-based care, outcome measures, fidelity indicators, and operational dashboards to support ongoing monitoring and decision-making related to case assignment and staff capacity. This may include review of therapeutic alliance measures, engagement indicators, hospitalization data, crisis episodes, emergency room utilization, placement disruptions, safety concerns, and other clinical or operational outcome measures. Dashboard alerts and ticklers may be used to proactively identify youth and families experiencing increased clinical risk, frequent crises, missed contacts, hospitalization trends, or other indicators requiring enhanced intervention, reassignment consideration, or increased clinical oversight. Data-informed reviews will support early identification of service gaps, elevated acuity, and staffing pressures to promote timely intervention and continuity of care.
Masada will maintain the required staff-to-client ratios and monitor staffing capacity on an ongoing basis through review of staffing rosters, program census, and Network Adequacy Provider and Practitioner Administration (NAPPA) data. Leadership will regularly review staff language capacity and multilingual client census data to ensure that each monolingual client is assigned at least one culturally and linguistically competent staff member in the client’s primary language. Masada will also monitor Department of Mental Health (DMH) slot allocation reports to ensure that at least 75% of FSP-HFW slot allocations are filled for each FSP-HFW team and to support proactive staffing and operational planning. Masada will maintain ongoing capacity monitoring processes to evaluate staff-to-client ratios, crisis response frequency, documentation timeliness, after-hours demands, staff wellness indicators, and fidelity expectations. Supervisors will have the authority to adjust caseloads, implement temporary assignment freezes, redistribute cases, or increase clinical and supervisory support when staff are managing high-acuity cases, vacancies occur, or operational demands significantly increase. Masada will also maintain formalized 24/7/365 coverage procedures, including rotating on-call schedules, supervisory escalation pathways, clinical consultation availability, and weekend and holiday coverage to ensure continuity of care and timely crisis response. At all times, Masada will ensure access to appropriately trained and designated staff, including personnel cleared for juvenile halls/camps and county jail access, as well as LPS-designated staff capable of conducting 5150/5585 evaluations as required.
Operational oversight will additionally include routine supervision, fidelity monitoring, training compliance reviews, utilization management activities, and quality improvement processes to ensure services remain aligned with DHCS, Medi-Cal, and LACDMH FSP-HFW requirements. Masada will document assignment decisions, significant reassignment actions, staffing adjustments, and identified risk indicators as part of ongoing program monitoring and continuous quality improvement efforts.
See Children & Youth Full-Service Partnership High Fidelity Wraparound Program Service Exhibit #1700 (p. 20-27); FSP Child and Youth High Fidelity WRAP Case Assignment and 24/7 Coverage Policy
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
a) Per LACDMH Program Service Exhibit – FSP-HFW Core Group of Services require the following:
DHCS will identify a core group of Medi-Cal services that all Medi-Cal-enrolled children and youth will receive under the Medi-Cal payment model. In accordance with Assembly Bill 161, DHCS will implement a case rate or other alternative reimbursement methodology for FSP-HFW as a Medi-Cal SMHS for Medi-Cal members under 21 years of age. Consistent with the HFW model, other formal support must be available to the child(ren), youth and caregivers based on the children’s/youth’s and family’s individualized needs. LAC-DMH will require that the children/youth receive any Medi-Cal service determined clinically appropriate and necessary including, but not limited to, the core group of services, as well as any other family or community support that the FSP-HFW Team deems necessary for the children’s/youth’s success. The following activities comprise the HFW core group of services for FSP-HFW: FSP-HFW services must include, at a minimum, the following:
The core group of Medi-Cal services is defined by the Department of Health Care Services (DHCS) as the Medi-Cal HFW core group of services (e.g., HFW Facilitation and Coordination; Child Adolescent Needs and Strengths (CANS) assessment; Level of Care Utilization System (LOCUS) assessment; Individualized Care Planning, including Safety and Crisis Planning; and Caregiver Peer Support). Deliver comprehensive, intensive, community-based care aligned with each client’s demonstrated clinical needs and individualized goals, as defined by the CFT.
See Children and Youth Full-Service Partnership High Fidelity Wraparound Program Service Exhibit #1700 p.14; p.2
b) Per LACDMH Program Service Exhibit – FSP-HFW Team Structure requires the following:
FSP-HFW Team Structure
FSP-HFW staffing model has five different roles for team members. To receive reimbursement for FSP-HFW, each staff member must be a qualified SMHS practitioner type (with the possible exception of the Community Developer role, as described in the table below).
According to national and State best practices, an FSP-HFW team consists of the children/youth and family/caregiver, natural supports, FSP-HFW Facilitator and other paid FSP-HFW staff.
Medi-Cal FSP-HFW Staff: Each children/youth receiving FSP-HFW has paid supports alongside natural supports, with the children/youth and their caregiver(s)/family/Tribe (in the case of an Indian client) sitting at the head of this team. The Medi-Cal FSP-HFW staff consists of the paid support staffed by the FSP-HFW provider to provide the HFW core services to the children/youth. The Medi-Cal FSP-HFW staff are described in more detail in the table below and consist of the following:
FSP-HFW Facilitator;
Caregiver Peer Partner;
FSP-HFW Supervisor;
Licensed Clinician; and
Community Developer.
The FSP-HFW Teams must meet the following requirements:
Provide FSP-HFW Services that are culturally and linguistically appropriate to the clients served with regard to ethnicity, race, language, age, country of origin, level of acculturation, gender, gender identity, socioeconomic class, disabilities, religious/spiritual beliefs, and/or sexual orientation. Contractor must ensure that each monolingual client is assigned at least one staff member who is culturally and linguistically competent in the client’s primary language.
Demonstrate knowledge of, and the ability to effectively coordinate with, the Los Angeles County School District; Probation Department (including Parole Officers); the Office of Diversion and Reentry (ODR); the DCFS; Mental Health Court and other courts within the criminal justice system; and the Office of the Public Guardian.
Have at least two team members that are cleared to enter Juvenile Camps and Halls and County Jails at all times; and
Include at least two team members who are LPS-designated to place a client on a mental health hold pursuant to California Welfare and Institutions Code Sections 5585 and 5150. See Children and Youth Full-Service Partnership High Fidelity Wraparound Program Service Exhibit #1700 p.20
c) The Technical Review monitors implementation of the California Wraparound Standards, the Integrated Core Practice Model (ICPM), and the appropriate use of Medi-Cal and Case Rate Supports and Services (CRSS), including ICC and IHBS documentation. Reviews are conducted by an appointed Technical Review Team and include administrative and clinical chart reviews, interviews with Wraparound staff, and interviews with the child or youth, family, and supports. Reviews occur throughout the year at the discretion of DMH Wraparound Administration. Program chart reviews are conducted monthly, and peer chart reviews quarterly.
Satisfaction Surveys
Parent Advocates conduct voluntary telephone satisfaction surveys with active Wraparound participants across eight (8) Service Areas. Surveys assess fidelity to the ICPM and Wraparound Principles, participant satisfaction, and selected outcomes such as well-being, school functioning, and hospitalization. Data are analyzed and shared countywide as available. The QI Department also conducts an annual satisfaction survey.
See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Program Monitoring pg 42, Audit Tool, Satisfaction Survey
During the CFTM, discussion items are documented in a visible and accessible format (e.g., flipchart paper or poster boards), with methods adapted as needed based on the meeting setting (in-person or telehealth). This shared documentation allows all CFT members to actively follow, contribute to, and confirm the topics being discussed, including team member names, family goals, ground rules, non-negotiables, strengths, worries, underlying and selected needs, and the resulting care plan.
As the meeting progresses, discussion points are transcribed into the FSP-HFW Plan of Care (POC) to reflect the team’s shared understanding in real time. Every effort is made to ensure the FSP-HFW Plan of Care (POC) accurately reflects what is discussed and agreed upon during the meeting, promoting transparency, collaboration, and open communication. Providers must use the most current DMH-issued FSP-HFW Plan of Care (POC) and may contact their designated DMH SA Wraparound Liaison for the most updated version.
In addition, weekly team meetings are held to provide a structured forum for team members to present case reviews, share updates, and collaboratively problem-solve. These meetings encourage open communication, peer support, and coordinated decision-making, allowing team members to work together to strengthen services and better support children, youth, and families.
See See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
Masada’s HFW team adheres to all county and state mandated data collection requirements. Masada collects, manages, and submits data and reports as directed by the DMH to demonstrate, profile, track, and document the effectiveness of services delivered, performance outcomes, and quality improvement interventions, including pertinent demographic information of individuals receiving services. Masada utilizes its Electronic Health Record, CareLogic, to collect, manage and submit data. FSP-HFW Teams collects all data elements as required by LACDMH including: (1) Outcome Baseline Assessment; (2) Three Month Quarterly Assessments (3M); (3) KECs; and (4) Pediatric Symptom Checklist (PSC-35).
California Department of Health Care Services (DHCS) Population-Level Behavioral Health Measures
Masada is responsible for collecting, monitoring, and reporting the following priority goals required by DHCS. Upon County’s request the Contractor must submit these measures within 10 business days via email to the County Program Manager III and DMH Quality Assurance. Increasing access to care, including timeliness and availability.
Reducing Homelessness by 65%.
Reducing Institutionalization.
Reducing Justice-Involvement.
Reducing Removal of Children from Home
Reducing Untreated Behavioral Health Conditions
Increasing Engagement in School
See Children and Youth Full-Service Partnership High Fidelity Wraparound Program Service Exhibit #1700 p.18 & 19
8.2 Equitable Funding Across System Partners
8.3 Cost Savings are Reinvested
a) HFW team members will document, identify, and communicate HFW savings to its stakeholders and the community. Masada is committed to implementing High Fidelity Wraparound (HFW) with integrity and transparency. In alignment with Standard 8.3, Masada documents the process for identifying HFW-related cost savings and ensures that any realized savings are reinvested to strengthen Wraparound services and community-based supports. See detailed procedure: High Fidelity Wraparound (HFW) Savings and Reinvestment Procedure.
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
a) Any youth or family enrolled in HFW has access to funds that support their housing, personal, vocational, occupational, socialization goals that can’t be obtained with their own financial resources, community, or supplemental income. HFW staff completes a budget form with the family before identifying resources and accessing CRSS funds. All CRSS funds are documented thoroughly in the CFTM FSP-HFW Plan of Care (POC). (See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Policy #27-Case Rate Services and Supports). Flex Funds Request. Flex Funds App
b) HFW team requests CRSS funds based client/family need to be submitted with the original invoices and receipts in a timely manner with the Supplemental Information Request Form (SIF). The HFW team will evaluate the request to ensure it meets criteria. All CRSS are to be submitted within 30 calendar days of receipt. HFW Supervisor or Program Manager emails wts@dmhlacounty.gov. HFW teams identify rejected invoices and reasons for rejection with client/family in order to resubmit completed CRSS invoices per the above timeframes. HFW teams submit any edits of documentation on SIF requests within 48 hours. (County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Policy #27-Case Rate Services and Supports), Flex Funds App.
8.5 Collaborative Oversight of Flex Funds
a) HFW facilitator documents the Flex fund use, availability and boundaries in the CFTM. The HFW facilitator provides the flex fund requested need with the amount, copies of receipts, and the purpose of the purchase (Refer to County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures; policy #27-Case Rate Services and Supports, page 55). Flex Funds Request.
b) All HFW clients have access to funds while they are enrolled in HFW. When a need is presented to the HFW team by the client/caregiver, the HFW team collaborates to develop a budget and assess need for flex funds (Refer to County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures; policy #27-Case Rate Services and Supports, page 52). Flex Funds Request.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
a) HFW flex funds and resources are provided by System of Care funding to ensure availability for all clients and families enrolled in HFW. (Refer to County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, policy #27 Case Rate Services and Support, p.52-57), Flex Fund App.
b)The HFW team explores alternate funding options (CalWorks, low-cost community resources, SSI) to fill gaps when funding limitations exist to maintain availability of funding for all HFW clients. (Refer to County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, policy #27 Case Rate Services and Support, p.52-57), Flex Fund App.
c) The HFW team ensures that access to funding is not withheld from clients and families regardless of funding requirements established by any one funding source (Refer to County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, policy #27 Case Rate Services and Support, p.52-57), Flex Fund App.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
a) HFW team members utilizes SOGI data, OMA, and mental health assessments to monitor the demographics of the client and recruitment that reflects those served. See Wraparound Staffing Policy 6, p. 15, Outcome Measures Policy 21, p.43. SOGI, OMA, HR Recruiter.
b) When recruitment/staffing is not available to reflect the demographics served, HFW staff utilizes the client’s natural and formal support (coach, clergy, mentor) to meet the cultural, linguistic, and racial needs. (See Wraparound Staffing Policy 6, p. 15, Ten Principles of the Wraparound Process: principle #6.
c) HFW team members utilizes Boost Lingo and/or appropriate natural and formal support persons to assist with a family’s language and translator needs. (See Wraparound Staffing Policy 6, p. 15, Boost Lingo Translation Services)
9.2 Tribally Responsive Workforce
a) HFW team receives training on tribal sovereignty, traditions and values to ensure communication, advocacy, and effective collaboration. HFW team will utilize UC Davis HFW 101 training and Relias trainings to access current training materials when appropriate (see County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Policy #6 Wraparound staffing pp 15-20), Relias-Improving Behavioral Health Equity in individuals with Tribal, Indigenous, or Native Identities; UC Davis HFW 101 Training Module).
b) HFW teams identifies and engages tribal representatives to participate in services that provide support to the child/family through sharing tribal traditions and celebrations (i.e in CFT meetings, community outings).See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Policy #6 Wraparound staffing pp 15-20; DHCS-Office of Tribal Affairs
9.3 Flexible and Creative Work Environment
The High Fidelity Wraparound (HFW) program maintains organizational structures and leadership practices that promote collective responsibility for program quality and improvement, staff cohesion, open communication, and adherence to the HFW philosophy, including Wraparound principles, values, phases, and activities.
a) Masada HFW Leadership promotes program quality and continuous improvement through structured monitoring, fidelity review, and quality assurance processes. The LACDMH Technical Review Process monitors implementation of the California Wraparound Standards, the Integrated Core Practice Model (ICPM), and the appropriate use of Medi-Cal and Case Rate Supports and Services (CRSS), including documentation for Intensive Care Coordination (ICC) and Intensive Home-Based Services (IHBS). Reviews are conducted by an appointed Technical Review Team and may include administrative and clinical chart reviews, interviews with Wraparound staff, and interviews with youth, families, and natural supports. Reviews occur throughout the year at the discretion of DMH Wraparound Administration. In addition, internal program chart reviews are conducted monthly and peer chart reviews quarterly to support continuous quality improvement.
See County of Los Angeles Department of Mental Health Child Welfare Division Wraparound Program Policies and Procedures, Program Monitoring (p.42).
Participant feedback also informs program quality improvement. Parent Advocates conduct voluntary telephone satisfaction surveys with active Wraparound participants across the eight Service Areas. Surveys assess fidelity to the Integrated Core Practice Model and Wraparound principles, participant satisfaction with services, and selected outcomes such as youth well-being, school functioning, and hospitalization. Data trends are analyzed and shared countywide as available. Masada’s Quality Assurance/Quality Improvement (QA/QI) Department also conducts annual Consumer Satisfaction Surveys in accordance with the Consumer Satisfaction Survey (CSS) Protocol.
b) The HFW program promotes staff cohesion through a collaborative team structure and regular interdisciplinary meetings. HFW Team composition and utilization of staff expertise are based on the individual needs of the child or youth and family. HFW Team members meet regularly to assess progress, coordinate services, and adapt interventions as needed, including monitoring responses to treatment and psychotropic medications. Weekly team meetings provide a structured forum for case presentations, shared problem-solving, and peer consultation. These meetings promote teamwork, shared accountability, and mutual support among staff members.
See County of Los Angeles Department of Mental Health Child Welfare Division Wraparound Program Policies and Procedures, Wraparound Staffing (p.15).
c) Open communication is supported through regular Child and Family Team Meetings (CFTMs) and team collaboration processes. During CFT meetings, discussion items are documented in a visible and accessible format, such as flipchart paper or shared documentation tools, with adaptations made for telehealth meetings when necessary. This approach allows all team members to actively participate in discussions regarding strengths, concerns, needs, goals, and service planning.
Discussion points are documented in real time in the FSP-HFW Plan of Care (POC) to reflect the team’s shared understanding and decisions. Providers are required to use the most current DMH-issued FSP-HFW Plan of Care (POC) and may contact the designated DMH Service Area Wraparound Liaison for updates.
See County of Los Angeles Department of Mental Health Child Welfare Division Wraparound Program Policies and Procedures – Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
d) HFW Leadership reinforces a clear mission and commitment to the High Fidelity Wraparound model by ensuring staff consistently apply Wraparound principles, values, phases, and activities during service planning and implementation. During the planning phase of the CFT meeting, specific action steps are documented in the FSP-HFW Plan of Care (POC), including the team member responsible for each action. This ensures accountability and coordinated implementation of the care plan.At the conclusion of the meeting, all CFT members review and sign the FSP-HFW Plan of Care (POC) to confirm agreement with the plan of care. Whenever possible, the child and family receive a copy of the plan on the same day, and copies are provided to the assigned Children’s Social Worker (CSW) and/or Deputy Probation Officer (DPO). These practices reinforce transparency, shared decision-making, and fidelity to the Wraparound model. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures – Plan of Care Policy p.1-2, FSP-HFW Plan of Care, Instructions for Completing the FSP-HFW Plan of Care
9.4 Hiring, Performance Evaluation, and Job Descriptions
a) HFW team members (Facilitator, Caregiver Peer Partner, Youth Partner, Community Developer/Case Manager, Licensed Clinician, HFW Supervisor/Program Manager, Psychiatrist, Nurse, COD) roles and job descriptions are clearly defined with job duties, responsibilities and qualifications (Refer to County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures- policy #6 pp 15-17; Masada Job Description; Children and Youth Full-Service Partnership High Fidelity Wraparound Program Service Exhibit #1700 p.18).
b) The HFW team includes the Facilitator, Caregiver Peer Partner, Youth Partner, Community Developer/Case Manager, Licensed Clinician, HFW Supervisor/Program Manager, Psychiatrist, Nurse, COD).The description and responsibilities of each role minimally includes the role purpose, functions and qualities (including skills, competencies and attributes) specific to each role or function. Role descriptions can be found in the Wraparound Standards Toolkit and the Masada Job Description (Refer to County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures- policy #6 pp 15-17; Masada Job Description, Wraparound Standards Toolkit; Children and Youth Full-Service Partnership High Fidelity Wraparound Program Service Exhibit #1700 p.18).
c) Masada job description and evaluation details staff job descriptions, roles, and spell out qualities and experience required to be successful as part of the HFW team.(Refer to County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures- policy #6 pp 15-17; Masada Job Description and Evaluation tool; Children and Youth Full-Service Partnership High Fidelity Wraparound Program Service Exhibit #1700 p.18).
d) Masada’s hiring process allows HFW team candidates to demonstrate specific attitudes and skills essential to the position (i.e. Interview Questionnaire, Case Vignette, Phone Screening) (Refer to County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures- policy #6 pp 15-17; Masada Job Description).
e) Masada’s job description and performance evaluation guidelines provide clear expectations about job performance and provide frequent feedback and coaching to support the success of HFW team members provided by HFW Clinical Supervisor (Refer to County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures- policy #6 pp 15-17; Masada Job Description and Evaluation; Children and Youth Full-Service Partnership High Fidelity Wraparound Program Service Exhibit #1700 p.21).
9.5 Workforce Stability
a) Masada HR ensures that wages for HFW team members match the cost of living of the location where services are being provided. Masada HR and CEO collaborate with legal counsel to determine fair wages for all roles at Masada including HFW team. They utilize available data from ACHSA and DMH administration.
b) Masada assigns adequate staffing that aligns with the specific HFW role requirements, to ensure appropriate HFW level of care. The HFW Director and Supervisor collaborate to ensure ongoing coverage and when staff is on leave. (See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Policy #6-Wraparound Staffing pp 15-17; Children and Youth Full-Service Partnership High Fidelity Wraparound Program Service Exhibit #1700 p.24)
c) Masada is an equal opportunity employer. Masada HR clearly communicates promotion and advancement structures for all HFW team members including those with lived experience. All job opportunities are clearly posted internally and externally. Masada’s job requirements are documented in job descriptions. See Masada Employee Handbook Wages and Salary pp 7-19, Job Performance p18.
d) HFW Director and Supervisor identify leadership opportunities for the various HFW roles that do not require a position change (i.e. Parent Partner Lead). Masada Executive team creates leadership opportunities (departmental preceptor, peer lead, mentor) and wage increases to all HFW team members that is messaged to all staff at time of performance evaluation and when appropriate (see Masada Employee Handbook: Wages and Salary pp 7-19, Job Performance p18).
9.6 High Fidelity Training Plan
a) HFW staff are trained externally by attending the Statewide Standardized Foundational HFW training through the UC Davis RCFFP. HFW team members are provided with ongoing training, shadowing, supervision (individual and group), booster training, and oversight to ensure fidelity to HFW standards specific to their role. HFW Facilitators participate in a 2 day training for HFW Facilitators. Masada has a robust HFW onboarding process including individualized training based on staff’s role; for speciality interventions, we utilize Relias. Masada’s QA/QI department provides training specific to LACDMH contractual requirements. See County of Los Angeles – Department of Mental Health Child Welfare Division, policy #5-Training Requirements for Wraparound Providers pp 13-14) See Children and Youth Full-Service Partnership High Fidelity Wraparound Program Service Exhibit #1700 p.28 Masada’s HFW Training Schedule
b) HFW team members have opportunities to request coaching, peer shadowing as part of initial training with intensive field experience. Masada offers ongoing training. To ensure compliance, Masada’s QA/QI department tracks HFW team members training, training completion, certificates and frequency of training. HFW Supervisor identifies any additional training needs for each HFW team member. See County of Los Angeles – Department of Mental Health Child Welfare Division, policy #5 Training Requirements for Wraparound Providers pp 13-14) Masada’s HFW Training Tracker
c). All Masada HFW team members will receive booster training (both general and role specific). Masada offers ongoing training. To ensure compliance, Masada’s QA/QI department tracks HFW team members training, training completion, certificates and frequency of training. HFW Supervisor identifies any additional training needs for each HFW team member. See County of Los Angeles – Department of Mental Health Child Welfare Division, policy #5-Training Requirements for Wraparound Providers pp 13-14) Masada’s HFW Tracking Protocol
d) Masada HFW team members will identify specific population needs and appropriate training will be provided, including tribal sovereignty according to the ICWA. Masada’s QA/QI department monitors statewide available training opportunities and notify the HFW Supervisor and Program Manager of all available training including UC Davis available training. See UC Davis ECHO Series, DHCS Indian Health Path Collaborative meeting, LACDMH Events Hub, Relias training
9.7 Community-based Training Program
a) HFW team members will incorporate youth, family, and peer partners in the delivery of Wraparound training. HFW staff are trained externally by attending the Statewide Standardized Foundational HFW training through the UC Davis RCFFP. UC Davis utilizes trainers with lived experience. See County of Los Angeles – Department of Mental Health Child Welfare Division, Training Requirements for Wraparound Providers Policy 5, p.13.
b) HFW team members will invite formal/natural support (community partners) to wraparound training to strengthen the fidelity of HFW. HFW staff are trained externally by attending the Statewide Standardized Foundational HFW training through the UC Davis RCFFP. UC Davis includes community partners. Masada engaged a community partner STARS and had their trainer Lorne Woods present his experience with Wraparound services when he was a child to our HFW team. This was part of Masada’s HFW team retreat. See County of Los Angeles – Department of Mental Health Child Welfare Division, Training Requirements for Wraparound Providers Policy 5, p.13. TIP Model Toolkit – Lorne Wood Peer Training Specialist & Consultant
9.8 Coaching and Supervision
a) HFW Clinical Supervisor is responsible for orientation, training and ongoing coaching and support of the HFW team. HFW team members will be onboarded utilizing training, shadowing, phases of wraparound, and guided facilitation of services that covers core values, skills and knowledge of HFW. HFW team members are trained in utilization of flex funds (training video and Masada’s internal FlexFund app. Clinical Supervisor is responsible for (1) monitoring team functions to ensure that operational targets (e.g., weekly client visits, field-based services) are met; (2) facilitating team meetings to discuss the status of each client; (3) monitoring the size and relative level of acuity of FSP-HFW Clinical team caseloads; (4) allocating the work of the FSP-HFW Clinical Team to meet each client’s needs; organizing meetings with the FSP-HFW Clinical service team at least once per month to review and identify clients who may require a transition to a different level of care; (5) distributing FSP-HFW Clinical Team members into pairs or team to conduct outreach and engagement and deliver ongoing services; serving as the point of contact for the FSP-HFW Clinical Team throughout the day to address emergency needs; and (6) ensuring that necessary program monitoring data is submitted in a timely manner and charts entries are up to date. See County of Los Angeles – Department of Mental Health Child Welfare Division, Wraparound Staffing Policy 6, p.15.Policy 27, p.52 Masada Onboarding checklist, CRSS Training Video, Masada Flex Fund App. Masada JD Clinical Supervisor, Children and Youth Full-Service Partnership High Fidelity Wraparound Program Service Exhibit #1700 p.23
b) Masada will provide HFW team members support and coaching 24/7 for Intensive programs, wraparound supervisor decides if in person or what type of intervention is needed. (See County of Los Angeles – Department of Mental Health Child Welfare Division, Policy #22 24/7 Crisis Coverage) Masada JD Clinical Supervisor
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
a) Masada will utilize data analysis (Greenspace, Quality of Care Tool, therapeutic alliance measures) to provide staff with timely feedback for staff to improve practice and identify training needs. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, #21-Outcome Measures pg 43, Greenspace Summary, Quality of Care Tool, Greenspace Therapeutic Alliance Measure Summary.
b) The DMH Wraparound Outcome Measures and Program Monitoring policies align with HFW Policy 10.2 by requiring the collection, review, and reporting of standardized outcome data to assess service effectiveness and inform program-level improvements (PSC, CANS- IP, OMA is a DMH system used specifically for tracking outcomes (e.g., baseline, key event change, and 3-month measures) for youth). HFW Supervisor utilizes the Quality of Care Tool to assess program needs and communicates with staff, Program Manager and Director. Together they collaborate on strategies to improve the HFW program. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, #21-Outcome Measures pg 43. PSC, CANS – IP, OMA, Quality of Care Tool.
c) Data collected through standardized outcome measures, including the PSC, CANS- IP, and OMA, are routinely reviewed to monitor service effectiveness and fidelity to High Fidelity Wraparound. OMA data captured at baseline, key events, and three-month intervals are analyzed to identify trends, gaps in services, and system-level barriers impacting youth and families. These findings are summarized and communicated to the Community Leadership Team to inform cross-system problem solving, guide decision-making, and support continuous quality improvement efforts that strengthen High Fidelity Wraparound (HFW) implementation. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, #21-Outcome Measures pg 43, PSC, CANS-IP, OMA.
Fidelity Indicators
1.1 Timely Engagement and Planning
1.1 a (See Handbook Section 3.3; page 20)
Aspiranet’s practice prioritizes timely, family-centered engagement consistent with California High-Fidelity Wraparound principles. Upon receipt of a referral, the HFW staff initiates contact as soon as possible (normally within 48 business hours), but no later than 10 days to welcome them into the program, explain the purpose and values of Wraparound, and begin building a trusting partnership.
1.1 b (See Handbook section 3.15; page 36)
All clients and families enrolled in Wraparound receive a comprehensive, individualized Plan of Care within thirty (30) calendar days of service initiation, consistent with California High-Fidelity Wraparound standards. The Plan of Care is family-driven and team-based, informed by the IP-CANS assessment and input from the Child and Family Team (CFT). The plan is developed in close collaboration with the Facilitator, the client and family, and the referring party, and reflects the family’s identified strengths, values, culture, and priorities.
1.1 c (Handbook- Section 3.15; page 36)
Aspiranet’s practice is to review each youth’s progress and Plan of Care during Child and Family Team (CFT) meetings at least every thirty (30) to forty-five (45) calendar days, consistent with California High-Fidelity Wraparound standards. These meetings are family-driven and team-based, providing an ongoing forum for shared decision-making and problem-solving. The Facilitator invites participation from the client and family, Wraparound team members, referring party, professional supports, and natural supports identified by the client and family. The Plan of Care is updated collaboratively to remain responsive, individualized, and culturally relevant.
1.1 d (Handbook Section 3.15; page 36)
Aspiranet’s practice is to review and update the Plan of Care at least every ninety (90) calendar days, or more frequently as needed, in alignment with California High-Fidelity Wraparound standards and family-identified needs. The updated Plan of Care is documented in the youth’s file and shared with all CFT members, supporting transparency, coordination, and continued alignment with the youth and family’s goals.
1.1 e (Handbook Section 3.20 pp. 42-43; Section 5.8 pp. 66-67; Section 5.9 pp. 67-68; Section 8.4 pg. 85; Section 10.1 pg. 97; Section 11.4 pp. 103-104; Section 13.6 pp. 115-116; Section 14.1 page 118)
Staff and their supervisors are provided with feedback on their ability to meet timelines for Continuous Quality Improvement purposes. Program outcomes and fidelity indicators are monitored on a weekly basis during staff supervision, with an emphasis on engagement, planning, and review timelines. CQI feedback is used to inform coaching, identify training needs, and guide practice improvement efforts, strengthening staff capacity and enhancing service delivery.
1.1 f (Handbook 3.21 pg. 43)
Aspiranet staff are trained in timely, family-centered engagement strategies that emphasize flexibility, creativity, and persistence when initial or ongoing contact with a family is challenging. Staff are encouraged to use alternative and individualized outreach approaches that respect family preferences, culture, and circumstances while maintaining a welcoming and non-intrusive stance. Fidelity coaching, ongoing training, program supervision, and clinical supervision are integrated to strengthen engagement practices and support reflective learning.
1.2 Led by Youth and Families
1.2 a (See Handbook sections 2.2 pp. 14-15; 3.13 pp. 33-35; 4.3 page 52; 4.9 page 55; 4.11 page 56)
Aspiranet actively elicits and centers the youth and family’s perspectives, and when applicable, tribal representation, to collaboratively develop and document the family’s vision, culture, values, and goals within the Plan of Care, Family Vision, and Team Mission statements. This process honors family voice and choice and planning reflects what is most meaningful to the family. When serving youth who are eligible under the Indian Child Welfare Act (ICWA), Aspiranet engages the family’s tribe as a full and equal partner in the Child and Family Team (CFT) process.
1.2 b (Handbook section 2.1 page 13; Section 2.2 pp. 14-15; 3.7 pp. 26-28; 3.12 pg. 33; 5.3 pp. 60-61)
Aspiranet’s Wraparound team actively elicits and documents each family’s unique values, strengths, culture, lived expertise, capabilities, interests, and skills. This information is captured in the youth’s Plan of Care and Wrap Action Plan, forming the foundation for individualized, strengths-based service planning and coordination. Facilitators engage youth, families, natural supports, and tribes when applicable, early in the Wraparound process through collaborative and respectful conversations to explore family-driven goals and develop a shared Family Vision. This early engagement supports trust-building and meaningful participation across the team. Aspiranet staff are trained that each youth’s Plan of Care clearly reflects the family’s perspective, culture, and values, promoting sustained engagement.
1.2 c (Handbook Section 9.8 pp. 94-95; 10.1 page 97; 10.2 page 96; 10.5 page 97; Section 11.1 page 102; 11.3 page 103; 12.1 page 108)
Aspiranet’s Supervisors and Coaches routinely observe High-Fidelity Wraparound (HFW) team meetings and review documentation to gather information and provide constructive, strengths-based feedback to staff. This feedback is used to reinforce practice expectations, build skills, increase staff confidence, and support professional development. Feedback is provided through program supervision, clinical supervision, and fidelity coaching, and is focused on promoting ongoing skill-building and consistent adherence to California High-Fidelity Wraparound fidelity standards.
1.2 d (Handbook section 9.8 pp. 94-95; 10.1 page 97; 10.5 page 97; 11.2 page 102; 11.3 page 103; 12.2 pp. 108-109)
Aspiranet routinely elicits feedback from youth and families to inform service quality, fidelity, and continuous improvement. Feedback is gathered through Satisfaction Surveys, the Wraparound Fidelity Index (WFI-EZ), the Team Observation Measure (TOM 2.0), and quality assurance phone calls conducted by HFW Supervisors. These methods allow youth and family voices to remain central to evaluating the Wraparound process. Aspiranet uses this feedback to identify trends, celebrate strengths, and address opportunities for improvement at the individual, team, and program levels. Findings are incorporated into ongoing coaching, training, and quality improvement efforts.
1.3 Strength-Based
1.3 a (Handbook 3.5, page 22)
Aspiranet maintains a strengths inventory for every youth, family, and Child and Family Team (CFT) member as an integral part of the collaborative Wraparound planning process. The strengths inventory identifies functional strengths, skills, resources, relationships, and community connections that can be leveraged to support progress, resilience, and effective problem-solving. Facilitators guide youth, families, and CFT members in identifying individual and collective strengths through the structured, strengths-focused team discussions and must include the strengths identified in the IP-CANS.
1.3b (Handbook 3.5 pp. 24-26)
Aspiranet trains staff that individualized strengths of each youth and family include, but are not limited to, those identified through the Integrated Practice – Child and Adolescent Needs and Strengths (IP-CANS). Strengths are identified through a combination of formal assessment and collaborative, strengths-focused conversations with the youth, family, and team members. The IP-CANS serves as a foundational tool for strengths identification, offering a comprehensive understanding of the youth’s functional abilities, natural supports, and progress over time. This information informs ongoing planning and helps guide individualized interventions throughout the Wraparound process.
1.3c (Handbook 2.1 page 13-14; 2.2 page 14, 3.3 page 20; 3.16 pp. 37-38; 4.1 page 51; 5.1 pg. 59; 5.4 pp. 61-62; 5.8 page 66-67; 5.9 page 67; 9.7 pg. 94; 10.1 page 97; 10.2 page 97; 10.5 pp. 98; 11.3 pg. 103)
Aspiranet staff receive ongoing coaching and supervision to strengthen skills in strengths identification and to support consistent implementation of High-Fidelity Wraparound (HFW) practices. Staff participate in regular training focused on delivering strengths-based, solution-focused services that center family voice and choice and promote meaningful engagement. Coaching, program supervision, and clinical supervision are used to reinforce HFW principles, build staff confidence, and support fidelity to strengths-based practice, supporting high-quality, individualized service delivery for youth and families.
1.3 d (Handbook section 10.1 page 97; 10.5 page 98; 11.2 pp. 95-96; 11.3 pp. 102-103; 11.5 page 104; 12.2 pp. 108-109)
Aspiranet routinely elicits feedback from families regarding their experience of strengths-based services through multiple methods, including satisfaction surveys, the Wraparound Fidelity Index (WFI-EZ), Team Observation Measure (TOM 2.0) observations, and quality assurance phone calls. These feedback mechanisms support family voice and choice remain central to evaluating the quality and fidelity of Wraparound services. Family feedback is systematically reviewed and used as part of Aspiranet’s Continuous Quality Improvement (CQI) process. Findings inform HFW coaching, training, and supervision by providing timely feedback to staff and supervisors.
1.4 Needs Driven
1.4 a (Handbook 3.6 pp. 25-26)
Aspiranet’s Wraparound team shall identify and prioritize the underlying needs of the youth and family prior to the development of goals and strategies, consistent with High-Fidelity Wraparound practice. Needs identification shall be informed by the Integrated Practice – Child and Adolescent Needs and Strengths (IP-CANS) assessment and collaborative, family-driven discussions conducted during Child and Family Team (CFT) meetings and early engagement activities. Prioritized needs shall guide the development of the Wrap Action Plan (WAP).
1.4 b (Handbook 3.6 pp. 25-26; 3.13 pp. 33-35; 3.15 pp. 37-38; 3.16 pp.37-38)
Aspiranet staff receive ongoing High-Fidelity Wraparound (HFW) coaching and training focused on identifying and prioritizing underlying needs, developing clear, needs-based statements that reflect the root causes of challenging situations or behaviors, and implementing needs-focused planning rather than behavior-focused planning. Training and supervision emphasize the ability to distinguish underlying needs from observable behaviors, and to use the Integrated Practice – Child and Adolescent Needs and Strengths (IP-CANS) assessment and the Wrap Action Plan (WAP) to guide needs-driven planning and intervention development. Supervisors and HFW Coaches reinforce these competencies through regular case reviews, documentation review, observation, and structured feedback, supporting skill development, fidelity to HFW standards, and consistent implementation of family-centered, strengths-based planning practices.
1.4 c (Handbook 3.6 pp. 25-26)
The identification of individualized needs shall include, but not be limited to, the needs identified through the Integrated Practice – Child and Adolescent Needs and Strengths (IP-CANS) assessment. The Wraparound team shall utilize the IP-CANS as a foundational tool for understanding functional needs, while also incorporating information gathered through collaborative conversations with the youth, family, natural supports, and the Child and Family Team (CFT). This integrated approach emphasizes that needs identification is comprehensive, family-driven, culturally responsive, and reflective of the youth and family’s lived experience.
1.4 d (Handbook 5.10 pp. 68)
Transition planning occurs when the Child and Family Team (CFT) determine that the youth and family have made significant progress toward their goals and have the capacity to sustain gains through adequate formal and informal supports. Transition decisions are family-driven and team-based, reflecting shared agreement that Wraparound services are no longer required at the current level of intensity. The Child and Family Team collaboratively develop a written Transition Plan designed to focus on ensuring continuity, stability, and ongoing support following the conclusion of Wraparound services. The Transition Plan identifies ongoing formal services, natural and community supports, strategies for maintaining progress, and steps for re-engagement if needed.
1.5 Individualized
1.5 a (Handbook 3.22 pp. 43-44; 5.3 pp. 60-61; 5.4 pp. 61-62; 5.5 pp. 62-63; 5.10 pg. 68)
Aspiranet shall utilize High-Fidelity Wraparound (HFW) documentation tools, including the Wrap Action Plan (WAP), Safety Plan, and other approved Wraparound forms, to capture each youth and family’s unique needs, strengths, culture, values, and priorities. These tools support a family-driven and strengths-based planning process while maintaining consistency with HFW standards. The use of these forms allows for flexibility and individualization, and plans are tailored to the specific circumstances of each youth and family rather than applying standardized or prescriptive approaches.
1.5 b (Handbook 3.6 pp. 25-26; 3.13 pp 33-35; 3.14 pp. 35-36; 3.15 pp. 36-37; 3.16 pp. 37-38; 3.17 pp. 38-40; 3.21 pp. 41-42; 6.7 pp. 74-76)
Aspiranet staff receive ongoing High-Fidelity Wraparound (HFW) training and coaching to support the delivery of flexible, creative, and highly individualized services and strategies. Training and supervision emphasize tailoring supports to each youth and family’s unique needs, culture, values, strengths, and goals, consistent with family voice and choice. The Wraparound team utilizes flexible and innovative strategies that build upon identified natural supports and community-based resources, reducing reliance on formal services whenever appropriate. Through supportive supervision, HFW coaching, and structured case reviews, staff are guided to develop and implement strategies that are individualized, adaptable, and meaningful to families.
1.5 c (Handbook 3.5 pp. 24-25; 3.10 pg. 31-33; 3.12 pg. 33; 3.13 pp. 33-35; 3.20 pg. 40; 4.3 pg. 52)
Aspiranet Facilitators receive ongoing training and High-Fidelity Wraparound (HFW) coaching to effectively lead the Wraparound team in implementing the HFW process. Facilitators are trained to utilize the youth and family’s individual needs, strengths, values, culture, and preferences to guide the development of a unique, individualized Plan of Care that is tailored to the youth and family. Through continued training, coaching, and supervision, Facilitators are supported in maintaining fidelity to HFW standards, promoting family voice and choice, and that planning remains strengths-based, culturally responsive, and outcome-focused.
1.5 d (Handbook 3.15 pp. 36-37; 3.18 pp. 40-41; 3.19 pg. 40; 3.23 pp. 44-45; 4.2 pg. 52; 4.3 pg. 52; 5.3 pp. 60-61; 8.4 pg. 85; 10.1 pg. 97; 10.3 pp. 97-98; 10.5 pg. 98-99)
The High-Fidelity Wraparound (HFW) Plan of Care is routinely reviewed with the youth and family and through management oversight and strengths are individualized, needs and strengths are accurately identified through the Integrated Practice – Child and Adolescent Needs and Strengths (IP-CANS), and that the Child and Family Team (CFT) is actively utilizing the family’s natural and community supports to build upon identified strengths. The Wrap Action Plan (WAP) is developed and implemented within CFT meetings and is used to monitor progress on action steps, track achievements toward goals, and guide ongoing team decision-making. This process supports continuous alignment with family voice and choice, and strengths-based planning.
1.5 e (Handbook section 10.1 page 97; 10.5 page 98-99; 11.2 pp. 102-103; 11.3 page 103; 11.5 page 104; 12.2 page 108-109)
Aspiranet recognizes the importance of actively soliciting feedback from youth and families to understand their experience of the Wraparound process and supports services remain family-driven and strengths-based. Feedback is gathered through multiple methods, including satisfaction surveys, the Wraparound Fidelity Index (WFI), Team Observation Measure (TOM 2.0) observations, and quality assurance calls conducted by management. These feedback mechanisms elevate youth and family voice, support fidelity to High-Fidelity Wraparound standards, and inform ongoing quality assurance (QA) and Continuous Quality Improvement (CQI) efforts. Aggregate results are reviewed and shared with staff and management to guide targeted training, High-Fidelity Wraparound coaching, and program-level improvements.
1.6 Use of Natural and Community Based Supports
1.6 a (Handbook 5.7 pp. 64-65)
A natural and community supports inventory is developed and regularly updated for every youth and family as part of the High-Fidelity Wraparound process. The Wraparound team ensures that identified natural and community supports are actively engaged, invited, and integrated into the Child and Family Team (CFT) to support collaborative planning and shared responsibility. The Wraparound team assists the youth and family in identifying and engaging natural supports, cultural representatives, and Tribal representation when applicable, so that planning reflects the family’s culture, values, and community connections. This practice supports family voice and choice, cultural responsiveness, and team-based planning, and strengthens the sustainability of outcomes beyond formal services.
1.6 b (Handbook 3.9 pp. 29-31; 3.10 pp. 31-33; 3.12 pg. 33; 3.13 pp. 33-35; 3.15 pp. 36-37; 3.16 pg. 37-38; 3.18 pg. 40-41; 3.20 pg. 42; 3.21 pp. 42-43; 3.23 pp. 44-45; 3.24 pp. 45-46; 3.26 pp. 46-47; 3.27 pg. 48; 3.28 pp. 48-49; 4.1 pg. 51; 4.7 pg. 54; 5.3 pg. 60-61; 5.4 pp. 61-62; 5.5 pp. 62-64; 5.7 pp. 64-66)
Aspiranet staff receive ongoing training and High-Fidelity Wraparound (HFW) coaching focused on identifying, engaging, and integrating natural supports throughout all phases of planning and shared responsibility within the Wraparound process. Training and coaching emphasize culturally responsive engagement strategies and relationship-building skills to support effective collaboration with youth and families. Staff are trained to work alongside youth and families to identify and strengthen informal community networks, including extended family, neighbors, faith-based supports, and other community connections, with the goal of reducing reliance on formal services as the youth and family make progress toward their Plan of Care goals and prepare for transition.
1.6 c (Handbook 5.3 pp. 60-61; 5.7 pp. 64-65)
High-Fidelity Wraparound (HFW) Plans of Care are routinely reviewed and assessed to ensure the identification and meaningful inclusion of natural supports. Community supports, cultural connections, and other natural supports identified by the youth and family are actively utilized in the assignment of strategies and action items within the Plan of Care and Wrap Action Plan. Clinical supervision and case reviews provide structured opportunities for the Wraparound team to strengthen engagement of identified natural supports and to expand their role in planning and service delivery. HFW Coaches utilize the Team Observation Measure (TOM 2.0) to observe Child and Family Team meetings and provide targeted feedback on increasing the engagement and integration of natural supports, with the goal of reducing reliance on formal services as the youth and family progress through the phases of Wraparound and prepare for transition.
1.6 d (Handbook section 10.1 page 97; 10.5 page 98-99; 11.2 pp. 102-103; 11.3 page 103; 11.5 page 104; 12.2 pp. 108-109)
Aspiranet routinely gathers youth and family feedback regarding their experience with the integration of natural supports within the Wraparound process. Feedback is collected through satisfaction surveys, the Wraparound Fidelity Index (WFI), the Team Observation Measure (TOM 2.0), and quality assurance phone calls conducted by supervisory or management staff. This information is systematically reviewed and utilized as part of Aspiranet’s Continuous Quality Improvement (CQI) process. Findings are used to provide feedback to direct staff and supervisors, inform additional training and High-Fidelity Wraparound coaching, and strengthen practice related to engaging and sustaining natural supports.
1.7 Culturally Respectful and Relevant
1.7a (Handbook 3.5 page 24-25; 3.6 pp. 25-26; 3.7 pp. 26-28)
The Aspiranet Wraparound team are trained that a strengths, needs, and cultural discovery process is completed prior to the development and documentation of the Plan of Care. This discovery process informs the prioritization of underlying needs and guides the development of family-driven goals and strategies within both the Plan of Care and the Wraparound Action Plan (WAP). During early engagement with all youth and families, the Wraparound team actively explores and discusses the family’s culture, values, beliefs, traditions, and lived experience. This information is intentionally used to highlight and integrate individualized strengths and needs into planning.
1.7 b (Handbook 2.2 pp. 14-15; 3.1 pg. 17-18; 3.3 pp. 20-22; 3.7 pp. 26-28; 3.12 pg. 33; 3.14 pg. 35-36; 3.18 page 40-41; 3.23 pp. 44-45; 3.26 pp. 46-47; 5.2 pp. 59-60; 6.6 pg. 73-74; 8.4 pg. 85)
Aspiranet staff receive ongoing High-Fidelity Wraparound (HFW) coaching, training, and supervision focused on the elicitation, understanding, and integration of family culture into planning and service delivery. Staff are trained to utilize culturally respectful and responsive strategies that honor each family’s traditions, values, heritage, beliefs, and lived experiences. This approach is focused on services that are family-driven, culturally responsive, and strengths-based.
1.7 c (Handbook section 10.1 pg. 97; 10.5 pg. 98-99; 11.2 pp. 102-103; 11.3 page 103; 11.5 page 104; 12.2 page 108-109)
Aspiranet staff receive ongoing High-Fidelity Wraparound (HFW) training, coaching, and supervision to support the elicitation of feedback from youth and families regarding their experience of culturally relevant and respectful services and strategies. Feedback is collected on a consistent and ongoing basis through satisfaction surveys, the Wraparound Fidelity Index (WFI), the Team Observation Measure (TOM 2.0), and quality assurance phone calls conducted by management. This feedback is used to inform supervision, coaching, and training, and to support quality assurance and Continuous Quality Improvement (CQI) efforts, so that services remain culturally responsive, and family-driven.
1.8 High-Quality Team Planning and Problem Solving
1.8a (Handbook 4.10 pg. 56)
Aspiranet’s Wraparound team establishes a Team Agreement and Team Mission early in the engagement process to guide the Child and Family Team (CFT), including the youth and family, natural supports, formal service partners, and Tribes when applicable. The Team Agreement and Mission are developed collaboratively and reflect family voice and choice, setting shared expectations for communication, participation, decision-making, and problem-solving, and is clearly documented in the youth’s file. These foundational elements promote clarity, collaboration, mutual respect, and accountability among team members and support consistent, strengths-based, and culturally responsive planning.
1.8 b (Handbook 3.19 pg. 41; 3.23 pp. 44-45; 3.24 pp. 45-46; 5.4 pp. 61-62; 6.7 pp. 74-76)
Aspiranet staff receive ongoing High-Fidelity Wraparound (HFW) training, coaching, and supervision to support the elicitation and meaningful use of feedback from youth, families, and HFW team members regarding their experience of team engagement and collaboration. Feedback is collected on a consistent and ongoing basis through satisfaction surveys, the Wraparound Fidelity Index (WFI), the Team Observation Measure (TOM 2.0), and quality assurance phone calls conducted by management. Collected feedback is reviewed with staff, supervisors, and management and is actively incorporated into service planning and Child and Family Team (CFT) decision-making. Feedback informs adjustments to goals, strategies, roles, and supports within the Plan of Care and Wrap Action Plan, and guides supervision, coaching, training, and Continuous Quality Improvement (CQI) efforts to strengthen collaboration, engagement, and fidelity to California High-Fidelity Wraparound standards.
1.8 c (Handbook 9.7 pg. 94; 9.8 pg. 94-95; 10.1 page 97; 10.2 pg. 97; 10.5 pp. 98-99)
Aspiranet acknowledges that youth and family feedback is a critical component of fidelity to the California High-Fidelity Wraparound standards. Consistent and ongoing feedback is gathered through satisfaction surveys, the Wraparound Fidelity Index (WFI), the Team Observation Measure (TOM 2.0), and quality assurance phone calls conducted by management. This feedback is systematically reviewed and incorporated into Aspiranet’s Continuous Quality Improvement (CQI) process, including the provision of targeted training, HFW coaching, and supervision. The use of youth and family feedback supports ongoing improvements in practice, strengthens fidelity to HFW standards, and supports services remain family-driven, strengths-based, and culturally responsive.
1.8d (Handbook 3.15 pp. 36-37; 3.20 pp. 42)
Aspiranet routinely reviews and assesses High-Fidelity Wraparound (HFW) Plans of Care and Child and Family Team (CFT) meeting minutes to ensure shared ownership, accountability, and follow-through on identified strategies and action items. The team routinely and consistently reviews the Wraparound Plan of Action and the Plan of Care to update strategies and adjust goals as needed to reflect current needs, strengths, and circumstances. Any changes to goals, strategies, roles, or action items are clearly documented and communicated to all CFT members to support alignment, follow-through, and shared responsibility.
1.9 Outcomes Based Process
1.9a (Handbook 3.15 pp. 36-37)
The Aspiranet Wraparound team is trained to develop High-Fidelity Wraparound (HFW) Plan of Care and the Wraparound Action Plan (WAP) to include specific, measurable strategies and action items with clearly defined timeframes. Tasks are assigned to identified Child and Family Team (CFT) members with mutually agreed-upon timelines to support accountability and follow-through. This information is documented in the youth’s file and used to guide CFT collaboration, monitor progress, and support timely adjustments to strategies. This practice supports the youth and family’s identified needs and goals, promotes shared responsibility, and maintains fidelity to California High-Fidelity Wraparound standards.
1.9b (Handbook 3.15 pp. 36-37)
Aspiranet’s Facilitators track completion of action items associated with the youth’s High-Fidelity Wraparound (HFW) Plan of Care and update the Wraparound Action Plan (WAP) as needed during HFW Child and Family Team (CFT) meetings. During each CFT meeting, the team reviews progress, confirms follow-through on as-signed tasks, and collaboratively identifies and addresses barriers by adjusting strategies as needed.
1.9c (Handbook 3.15 pp. 36-37)
Aspiranet staff are trained that all changes to the Plan of Care and the Wraparound Action Plan (WAP) are clearly documented, communicated, and shared with all members of the Child and Family Team (CFT). Wraparound forms and processes are designed to allow timely adjustment of strategies and action items in response to changing needs, progress, or identified barriers. Any updates to the youth and family’s Plan of Care or Wraparound Action Plan are documented promptly, distributed to the CFT team, and maintained in the youth’s file to support shared understanding, accountability, and follow-through
1.9 d (Handbook 3.13 pp. 33-35)
Aspiranet shall designate the Facilitator or Clinician to complete or update the Integrated Practice – Child and Adolescent Needs and Strengths (IP-CANS) assessment when it has not been completed or updated by the county funder at the time of referral. The Child and Family Team (CFT), including the youth, family, and identified natural supports, plays a central role in informing the IP-CANS, ensuring that the assessment accurately reflects the youth’s functioning, strengths, needs, and progress. Completed IP-CANS assessments are shared with all CFT members to promote transparency and shared understanding. IP-CANS results are used to inform service planning, adjust strategies, monitor progress, and drive the ongoing development and refinement of the individualized Plan of Care and Wraparound Action Plan.
1.9 e (Handbook 3.13 pp. 33-35)
While IP-CANS assessment data is utilized for outcome tracking and reassessment, the Child and Family Team (CFT) primarily use the Plan of Care and the Wraparound Action Plan (WAP) to track goal completion, progress toward identified needs, and the use of strengths as identified by the youth, family, community members, and natural supports. The Plan of Care and Wraparound Action Plan serve as the central tools guiding ongoing planning, shared decision-making, and team discussions, and are used to support the youth and family’s progression through the phases of Wraparound. This approach demonstrates planning that remains family-driven, strengths-based, needs-focused, and responsive to change.
1.10 Persistence
1.10 a (Handbook 3.20 pg. 42)
The Aspiranet Wraparound team demonstrates persistence and continued engagement with youth and families, including during periods of challenge, crisis, or setback. The Child and Family Team (CFT) maintains active collaboration with the youth, family, and identified natural supports to reassess needs, adjust strategies, and modify the Plan of Care and Wraparound Action Plan as necessary to support continued progress through the phases of Wraparound. Wraparound services continue until the Child and Family Team reaches consensus, with primary emphasis on family voice and choice, that the youth and family’s identified needs have been sufficiently addressed and that it is appropriate to transition from Wraparound services.
1.10 b (Handbook 3.20 pg. 42; 7.1 pg. 77; 7.2 pg. 77)
The Aspiranet Wraparound team has ongoing access to High-Fidelity Wraparound (HFW) coaching and training whenever additional support is needed to address challenges or complex situations. Aspiranet’s Clinical Supervisor is available for consultation and collaborates with management and the Program Director to provide guidance, problem-solving support, and clinical oversight to the Wraparound team. Flexible funding is discussed collaboratively with the Child and Family Team (CFT), including the youth, family, and natural supports, as a resource to provide financial assistance when necessary to support identified needs, stabilization efforts, or Plan of Care goals. All Aspiranet Wraparound team members receive training on flexible funding policies, procedures, and access, including how requests are made, approved, and tied directly to the youth and family’s individualized Plan of Care.
1.10 c (Handbook 3.22 pp. 43-44; 8.4 pg. 85)
Aspiranet Facilitators and all Wraparound team members receive ongoing High-Fidelity Wraparound (HFW) coaching and training in post-crisis safety planning and conflict resolution to effectively support youth and families during periods of crisis or heightened challenge. Facilitators receive targeted training to strengthen their ability to lead the Child and Family Team (CFT) in reassessing underlying needs, brainstorming solutions, refining strategies, and revising the Plan of Care and Wraparound Action Plan as needed. This approach supports timely stabilization, promotes collaborative problem-solving, and continued progress through the phases of Wraparound while maintaining fidelity to California High-Fidelity Wraparound standards.
1.11 Transitions as a part of the Fourth Phase of HFW
1.11 a (Handbook 3.24 pp. 45-46)
The Aspiranet Wraparound team begins preparing for transition from the point of program introduction, engaging the youth, family, community partners, and natural supports early to support long-term sustainability. Transition planning is family-driven and needs-based and occurs only when the youth and family’s prioritized needs have been sufficiently addressed, as determined collaboratively by the Child and Family Team (CFT). Preparation for transition includes ongoing review of progress toward identified needs, goals, and action items, and regular CFT discussions regarding the natural and formal supports necessary to maintain stability and progress after Wraparound services conclude. Aspiranet does not discontinue Wraparound services due to adverse events, crises, or administrative factors. Instead, the Wraparound team receives ongoing coaching, supervision, and training to revise the Plan of Care and Wraparound Action Plan, strengthen natural and community supports, reassess needs, and adjust strategies as necessary to support continued engagement and a successful, planned transition consistent with California High-Fidelity Wraparound standards.
1.11 b (Handbook 3.28 pg. 48-49)
Aspiranet celebrates transitions out of High-Fidelity Wraparound (HFW) in ways that honor the youth and family’s culture, values, preferences, and traditions. Wraparound teams may utilize flexible spending funds, as appropriate, to support a meaningful and family-centered celebration that recognizes successes achieved, goals reached, community partnerships established, natural supports identified, and relationships strengthened throughout the Wraparound process. Members of the Aspiranet Wraparound team attend the transition celebration and intentionally highlight the youth and family’s accomplishments, resilience, and strengths that will continue to support stability and progress after Wraparound services conclude.
Expected Outcomes
2.1 Youth and Family Satisfaction
2.1 (Handbook 12.2 pp. 108-109)
Aspiranet Wraparound programs evaluate youth and family satisfaction with their High-Fidelity Wraparound (HFW) experience by administering the Aspiranet Satisfaction Survey at discharge. Aggregate satisfaction data are reviewed and shared with Wraparound staff, program management, and Division leadership as part of Aspiranet’s quality assurance and Continuous Quality Improvement (CQI) processes. Results are used to inform High-Fidelity Wraparound coaching, training, and program improvement efforts, supporting ongoing fidelity to HFW standards and enhancement of family-centered service delivery.
2.2 Improved School Functioning
2.2 (Handbook 14.1 page 118; 14.2 pp. 118-119)
The Aspiranet Wraparound team routinely and consistently evaluates school attendance and academic performance as part of required program outcomes and Continuous Quality Improvement (CQI) efforts. Data is collected through the Integrated Practice – Child and Adolescent Needs and Strengths (IP-CANS), school report cards, and attendance records. Collected data is entered and maintained in Aspiranet’s Options database, where reports are generated to monitor trends, inform coaching, supervision, and training, and guide targeted interventions. As a result of their involvement in High-Fidelity Wraparound (HFW), youth demonstrate improved educational functioning. As youth progress through the phases of Wraparound, they experience more consistent school attendance and show improved academic performance, working toward achieving grade-level performance or higher, as appropriate to and consistent with their individualized educational plan.
2.3 Improved Functioning in the Community
2.3 (Handbook 14.6 pg. 121)
The Aspiranet Wraparound team documents community involvement and supports, as well as any involvement with the justice system, including citations, arrests, probation involvement, and juvenile justice detention or incarceration, as applicable in Aspiranet’s Options database. This information is used to inform service planning, strategy adjustments, and outcome tracking, and is reviewed as part of Aspiranet’s outcome-based practice and Continuous Quality Improvement (CQI) efforts.
2.4 Improved Interpersonal Functioning
2.4 (Handbook 14.5 pp. 120-121)
result of involvement in High-Fidelity Wraparound (HFW), youth and their families demonstrate improved interpersonal functioning, including strengthened family relationships and positive peer connections. The Child and Family Team (CFT) engages in ongoing discussions to assess whether the youth is building and maintaining healthy family relationships and friendships. Progress in interpersonal functioning is tracked through the Integrated Practice – Child and Adolescent Needs and Strengths (IP-CANS) assessments and documented in CFT meeting notes and the youth’s file.
2.5 Increased Caregiver Confidence
2.5 (Handbook 14.7 pg. 122)
As a result of involvement in High-Fidelity Wraparound (HFW), caregivers demonstrate increased confidence resulting from access to effective, needed services and supports. Caregivers report greater confidence in their ability to manage future challenges, navigate and access services, and respond effectively to crises. Aspiranet assesses caregiver confidence through satisfaction surveys, feedback gathered during Child and Family Team (CFT) meetings, and quality assurance phone calls.
2.6 Stable and Least Restrictive Living Environment
2.6 (Handbook- 14.3 pg. 119)
Aspiranet measures placement stability and least restrictive living environment as part of required program outcomes. This information is reviewed and discussed during Child and Family Team (CFT) meetings and is documented in CFT notes, HFW Plan of Care, and in Aspiranet’s Options database.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
2.7 (Handbook 14.3 pg. 119; ORG-23a)
Aspiranet monitors reductions in inpatient psychiatric admissions, emergency department utilization, and behavioral health related hospital visits as part of ongoing program outcome measurement. Aspiranet tracks all behavioral health related crises through the completion of Incident Reports, which are reviewed by program management and Division leadership. Incident data is entered and maintained in Aspiranet’s Options database and is aggregated and reported on a quarterly basis as an agency. This data informs High-Fidelity Wraparound coaching, supervision, and training, and supports Continuous Quality Improvement efforts to strengthen crisis prevention, response, and overall service effectiveness.
2.8 Reduction in Crisis Visits
2.8 (Handbook 14.4 pp. 119-120;ORG-23a)
Aspiranet monitors reductions in inpatient psychiatric admissions, emergency department utilization, and behavioral health–related hospital visits as part of ongoing program outcome measurement. Aspiranet tracks all behavioral health–related crises through the completion of Incident Reports, which are reviewed by program management and Division leadership. Incident data are entered and maintained in Aspiranet’s Options database and are aggregated and reviewed on a quarterly basis.
2.9 Positive Exit from HFW
2.9 (Handbook 14.8 pp. 122-123)
The Child and Family Team (CFT) continues to assess and acknowledge when the youth and family are prepared to transition to the next phase of Wraparound. Upon a CFT recommendation for graduation from the Wraparound program, Aspiranet ensures that program exit is based on demonstrated stabilization and adequate progress toward meeting the youth and family’s identified needs, consistent with family-driven decision-making. Youth and families are not discharged from Wraparound due to adverse events, crises, or setbacks. Instead, services continue until transition criteria are met through collaborative CFT consensus, with preference given to family voice and choice. Aspiranet administers a satisfaction survey at the time of discharge to gather youth and family feedback regarding their experience in the Wraparound program and their perception of progress achieved.
Engagement
3.1 Orientation
3.1a (Handbook 3.4 pp 22-24)
The Aspiranet Wraparound team schedules an orientation with each youth and family to introduce the High-Fidelity Wraparound (HFW) principles and phases, review legal and ethical considerations, and explain the roles and responsibilities of all team members, including natural and community supports and Tribal representation when serving an Indian child. The orientation includes a clear explanation of expectations for participation across the four phases of Wraparound and emphasizes the family-driven, team-based approach that identifies underlying needs and strengths to develop goals that guide services and supports. Families are encouraged to ask questions and seek clarification, and information is delivered in a manner that is understandable, culturally responsive, and provided in the family’s language of choice. This orientation process supports informed participation and shared decision-making.
3.1b (Handbook 3.4, pp. 22-24)
The Aspiranet Wraparound team schedules an orientation immediately following referral to provide the youth and family with a clear explanation of expectations for participation across the four phases of Wraparound—Engagement, Planning, Implementation, and Transition. The orientation emphasizes the family-driven, strengths-based, team-based, culturally and linguistically responsive, and outcomes-focused approach that guides Wraparound practice.
3.1c (Handbook 3.4 pp.22-24)
During orientation, the Aspiranet Facilitator explains the role and responsibilities of each Wraparound team member, and describes how the youth and family, along with community and natural supports and Tribal representatives when applicable, collaborate within the Child and Family Team (CFT) to address identified needs and achieve shared goals. Natural supports, including extended family members, neighbors, mentors, and religious or spiritual guides, are recognized and emphasized as key participants in the Wraparound process. When serving Indian children, the Wraparound team includes Tribal representation or designated liaisons, as appropriate, so cultural values, traditions, and Tribal resources are fully integrated into planning and decision-making, and that services are delivered in a manner that honors Tribal sovereignty and supports culturally responsive outcomes.
3.2 Safety and Crisis stabilization
3.2a (Handbook 3.4 pp. 22-24)
The Aspiranet Wraparound team addresses crisis and safety concerns during orientation at the first point of engagement. Current safety risks or behavioral concerns that may interfere with stabilization are discussed with the youth and family, documented, and used to develop an initial, collaborative Crisis Safety Plan. The Crisis Safety Plan identifies early warning signs and escalating behaviors, outlines de-escalation strategies, and specifies crisis resources, as well as natural and community supports to be contacted. A copy of the Crisis Safety Plan is provided to the youth and family, and a copy is maintained in the youth’s file.
3.2b (Handbook 3.8 pp. 28-29)
The initial crisis safety plan developed during orientation and at the first point of engagement is used to support immediate stabilization and safety during the Engagement phase of Wraparound. This initial plan is intended to inform—but not replace—the formal High-Fidelity Wraparound (HFW) Safety Plan developed during the Plan Development phase. Information gathered through the initial crisis safety planning process is incorporated into the development of the formal HFW Safety Plan, which is created collaboratively with the youth, family, and Child and Family Team (CFT). The HFW Safety Plan integrates the family’s strengths, natural and community supports, and Tribal resources when applicable, and is designed to support long-term prevention, sustained safety, and shared responsibility across the phases of Wraparound.
3.2c (Handbook 3.4 pp. 22-24; 3.8 pp. 28-29; ORG-55)
At the first point of contact, the Aspiranet Wraparound team provides the youth and family with clear and accessible information on how to access Aspiranet’s Wraparound 24/7 after-hours crisis response line, community mobile crisis teams, and emergency supports. This includes Tribal-based crisis and support resources for Indian children, when applicable. This information is provided so youth and families know who to contact for support outside of regular business hours, including evenings, weekends, and holidays, and to support timely crisis response, safety, and stabilization.
3.3 Strengths, Needs, Culture and Vision Discovery
3.3a (Handbook 5.1 pg. 59)
The Aspiranet Wraparound team assists each youth and family in developing a Family Vision during the Engagement phase so family priorities, cultural values, and long-term hopes remain central to all decision-making and planning throughout the phases of Wraparound. When serving Indian children, the Family Vision is developed with consultation from Tribal liaisons or representatives, as appropriate, to ensure cultural values, traditions, and Tribal perspectives are fully integrated. The Family Vision reflects the youth and family’s long-term hopes for stability, strengthened relationships with natural supports, progress toward educational goals, and increased community involvement in activities that support strengths-based outcomes. The Family Vision serves as a guiding foundation for the Plan of Care, Wraparound Action Plan, and Child and Family Team (CFT) decision-making.
3.3b (Handbook 5.2, pp. 59-60)
The Aspiranet Wraparound team initiates a Strengths, Needs, and Cultural Discovery document with each youth and family during the Engagement phase, which is maintained in the youth’s chart. This document is reviewed and updated at least every ninety (90) days, or more frequently as needed when new strengths, needs, or cultural considerations are identified. The Strengths, Needs, and Cultural Discovery document captures the youth and family’s unique story, including their values, lived experience, culture, and priorities, and serves as a foundational tool to inform the development and ongoing refinement of the individualized Plan of Care and Wraparound Action Plan. The document is shared with all members of the Child and Family Team (CFT) and provided to new team members as they join, to establish a shared understanding of the youth and family’s story, priorities, and goals. This practice supports family voice and choice, continuity of care, and team-based collaboration.
3.4 Engage All Team Members
3.4a (Handbook 5.7 pp. 64-65)
The Aspiranet Wraparound team initiates a Natural Supports Inventory with each youth and family during the Engagement phase, which is maintained in the youth’s chart. During the early stages of services, this inventory is reviewed and updated throughout the Wraparound process to support the development of a strong, supportive team around the youth and family. Reviewing the Natural Supports Inventory with the youth and family helps identify extended family members, friends, neighbors, community mentors and leaders, faith-based representatives, and Tribal liaisons, as applicable, who play meaningful and supportive roles in the youth’s life. The Facilitator and Parent Partner each actively explore the youth and family’s informal support system and document all identified natural supports in the youth’s file and Aspiranet’s Options database. With the youth and family’s permission, identified natural supports are invited to participate in the Child and Family Team (CFT) to promote shared responsibility and to create sustainable supports beyond formal services throughout the phases of Wraparound and following transition. This practice supports family voice and choice, team-based planning, natural supports, and long-term stability.
3.4b (Handbook 3.3 pp. 20-22; 3.28 pp. 48-49; 4.8 pp. 54-55; 9.1 pg. 88; 13.1 pg. 113)
The Aspiranet Wraparound team identifies and engages Children’s System of Care (CSOC) partners during the Engagement phase, including but not limited to Behavioral Health, Child Welfare social workers, Probation, Education representatives, and relevant community-based organizations that are directly involved with the youth and family. Coordination with CSOC partners, Probation, and Tribal partners when applicable ensures that the Child and Family Team (CFT) reflect all relevant systems involved with the youth. This collaborative approach promotes unified, coordinated, and non-duplicative service planning, and supports shared accountability.
3.4c (Handbook 2.1 pp. 13-14; 2.2 pp. 14-15; 3.1 pp. 17-18; 3.3 pp. 20-22; 3.4 pp. 22-24; 3.9 pp. 29-31; 3.10 pp. 31-33; 3.20 pg. 42; 3.26 pp. 46-47)
The Aspiranet High-Fidelity Wraparound (HFW) team engages the youth and family to identify potential Child and Family Team (CFT) members, including formal service providers, community partners, natural supports, and Tribal representatives when serving an identified Indian child.
The Facilitator clearly explains the roles and responsibilities of each team member so youth and family understand how each role contributes to planning and supports progress toward identified needs and goals. The Aspiranet HFW team documents in CFT meeting notes how each team member will support the Plan of Care, assume shared ownership of strategies and action items, and promote shared responsibility. This approach strengthens sustainable supports beyond formal services throughout the phases of Wraparound and following transition.
3.4d (Handbook 4.12 pg. 57)
The Aspiranet High-Fidelity Wraparound (HFW) team promotes ongoing engagement and team-building activities throughout all phases of Wraparound so voices are heard in a safe, respectful, and inclusive environment. These activities support the identification of additional strengths, strengthen relationships among team members, and facilitate the development of shared goals. Engagement and team-building activities are documented in the youth’s file, including Child and Family Team (CFT) meeting minutes and/or case notes, to support transparency, and continuity of care.
3.5 Arrange Meeting Logistics
3.5a (Handbook 3.3 pp. 20-22)
Aspiranet staff demonstrate flexibility in work hours and scheduling to arrange Child and Family Team (CFT) meetings at times and in locations that are convenient and accessible for all team members, with priority given to the youth and family’s needs, preferences, and voice and choice.
The Aspiranet High-Fidelity Wraparound (HFW) team plans and coordinates meeting logistics, including transportation assistance, interpretation and translation services, and telehealth options for those team members who are unable to attend in person meetings.
3.5b (Handbook 3.3 pp. 20-22)
The Aspiranet High-Fidelity Wraparound (HFW) team is trained to work collaboratively with youth, families, and other Child and Family Team (CFT) members to schedule meetings that align with the youth and family’s needs, preferences, and availability. The Aspiranet HFW team proactively coordinates CFT meeting logistics to encourage full participation by all identified team members. Facilitators arrange transportation assistance when needed, secure interpretation or translation services, and provide telehealth options for CFT members whose participation may be limited by travel or other barriers. When applicable, Tribal representatives are consulted to ensure that meeting times, locations, and formats align with Tribal protocols and cultural preferences, supporting respectful collaboration, inclusiveness, and accessibility.
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
4.1a (Handbook 3.5 pp. 24-25; 3.12 pg. 33; 4.10 pg. 57)
The Aspiranet High-Fidelity Wraparound (HFW) team collaboratively develops a Team Mission Statement that aligns with the youth and family’s vision, crisis/safety plan, team agreements, and team strengths inventory prior to the development of the HFW Plan of Care. This supports a shared purpose and common direction for all planning and decision-making. The Child and Family Team (CFT) establish and adopts formal agreements regarding decision-making processes, roles, and shared accountability. The CFT then identifies and prioritizes the youth and family’s underlying needs, assigns roles and responsibilities through the Wraparound Action Plan, and develops measurable, needs-driven goals that form the foundation of the Plan of Care. This structured, collaborative approach supports family voice and choice, team-based planning, and shared responsibility.
4.1b (Handbook 3.5 pp. 24-25)
The Aspiranet High-Fidelity Wraparound (HFW) team identifies and documents the youth and family’s strengths during the Engagement phase of Wraparound. The HFW team reviews the most current Integrated Practice – Child and Adolescent Needs and Strengths (IP-CANS) assessment and updates it as necessary throughout the phases of Wraparound to reflect changes in functioning, needs, and strengths. Identified needs and strengths directly drive the development and ongoing refinement of the Plan of Care. The process of identifying strengths and assessing needs is ongoing and reviewed at least monthly to inform shared decision-making and service planning. Updates are documented in the Plan of Care, Child and Family Team (CFT) meeting notes, and the Wraparound Action Plan (WAP).
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
4.2a (Handbook 3.6 pp. 25-26)
Underlying needs are identified and prioritized for each youth and family prior to the development of the HFW Plan of Care, and that these needs are clearly documented in the youth’s file. The Plan of Care is developed collaboratively with the youth and family, aligning with the Family Vision and addressing prioritized needs across relevant life domains. Updates support strategies and action steps remain culturally responsive, strengths-based, and relevant to the family’s values, traditions, and preferences, supporting effective intervention, shared responsibility, and sustained safety throughout the phases of Wraparound.
4.2b (Handbook 2.2 pp. 14-15; 3.6 pp 25-26; 3.14 pp. 35-36; 5.3 pg. 60-61)
Measurable goals are developed directly from the youth’s identified underlying needs and are specific, measurable, relevant, and time-bound. Goals are needs-driven rather than behavior- or deficit-focused. Developed goals are reviewed at each High-Fidelity Wraparound (HFW) Child and Family Team (CFT) meeting to assess progress, identify barriers, and make collaborative adjustments to strategies or timelines as needed. This ongoing review process supports outcome-based decision-making.
4.2c (Handbook 3.14 pp. 35-36; 3.15 pp. 36-37; 5.3 pp. 60-61)
Measurable goals are developed directly from the youth’s identified underlying needs and are specific, measurable, relevant, and time-bound. Goals are needs-driven rather than behavior- or deficit-focused, ensuring alignment with High-Fidelity Wraparound principles and family-centered planning.
Goals are developed collaboratively with the youth, family, and High-Fidelity Wraparound (HFW) team, including natural and community supports and Tribal liaisons when applicable. The Aspiranet Facilitator documents and reviews goals regularly, updating them as needed based on progress, family feedback, and Child and Family Team (CFT) decision-making.
4.2d (Handbook 3.23 pp. 44-45; 3.13 pp. 33-35; 3.14 pp. 35-36; 3.15 pp. 36-37; 3.16 pp. 37-38)
Multiple individualized, collaboratively brainstormed strategies are documented in the youth’s file to support needs-driven planning and shared decision-making. Strategies developed through the Child and Family Team (CFT) process are reflected across documentation sources, including CFT meeting minutes, Aspiranet Wraparound team progress notes, the Wraparound Action Plan (WAP), and other relevant planning documents.
These records are used to capture, refine, and revisit brainstorming efforts as needed.
4.2e (Handbook 3.20 pg. 42; 4.3 pg. 52; 7.1 pg. 77)
Aspiranet Facilitators are trained and coached to effectively lead High-Fidelity Wraparound (HFW) teams in identifying and prioritizing strategies, selecting appropriate interventions, and developing clear action items to support needs-driven planning. All new Facilitators receive Foundational Wraparound training upon hire and participate in annual refresher training. Facilitators also receive ongoing monthly coaching and supervision to strengthen leadership skills, and support fidelity to HFW standards.
4.2f (Handbook 3.20 pg. 42; 3.23 pp 44-45; 4.1 pg. 51; 5.3 pp. 60-61)
Structured steps for identifying, prioritizing, and selecting strategies, and for developing Child and Family Team (CFT) action items, are consistently utilized within a team-based, collaborative environment to develop the individualized High-Fidelity Wraparound (HFW) Plan of Care.
This process supports strategies and action items are needs-driven, strengths-based, and informed by family voice and choice, and that responsibilities are clearly defined and shared among CFT members. The collaborative approach supports effective implementation and accountability.
4.3 Develop an Individualized Child or Youth and Family Plan
4.3a (Handbook 3.5 pp. 24-25; 3.20 pg. 42; 3.21 pg. 42-43; 3.23 pp. 44-45; 4.3 pg. 52; 9.1 pg. 88)
Aspiranet Wraparound Facilitators complete Foundational Wraparound training and receive annual refresher training, along with ongoing coaching and supervision, to effectively engage the High-Fidelity Wraparound (HFW) team in a collaborative planning process that elicits multiple perspectives from all Child and Family Team (CFT) members. The Aspiranet Wraparound Facilitator leads team-building activities that promote trust, shared understanding, and a unified vision, and ensures that planning and decision-making consistently adhere to High-Fidelity Wraparound principles, including family voice and choice, strengths-based practice, collaboration, and cultural responsiveness.
4.3b (Handbook 4.8 pp. 54-55)
The Plan of Care comprehensively integrates goals and objectives identified collaboratively by all High-Fidelity Wraparound (HFW) Child and Family Team (CFT) members, including the youth and family, natural and community supports, Tribal liaisons when applicable, and Children’s System of Care partners involved with the youth. This inclusive, team-based approach supports coordinated planning, shared ownership, and alignment across systems.
4.3c (Handbook 5.3 pp. 60-61)
The Plan of Care is documented in the youth’s file and distributed to all members of the Child and Family Team (CFT). The Plan of Care includes identified CFT members, including natural supports, community resources and supports, and Tribal liaisons when applicable, supporting comprehensive and coordinated planning. The Plan of Care is also shared with all new members of the High-Fidelity Wraparound (HFW) CFT as they join the team to ensure a clear and consistent understanding of the youth and family’s goals, strategies, and shared responsibilities, supporting continuity and accountability.
4.3d (Handbook 5.3 pp. 60-61)
Clinical supervision and case reviews are conducted on a consistent and regular basis to review the Plan of Care, assess fidelity to High-Fidelity Wraparound standards, and support Continuous Quality Improvement (CQI). These reviews are used to identify training and coaching opportunities and to provide structured feedback to staff, supervisors, and HFW coaches to strengthen practice and skill development.
4.4 Develop a Crisis and Safety Plan
4.4a (Handbook 3.22 pp. 43-44; Crisis/Safety Plan Attachment)
Upon referral to the Aspiranet Wraparound program, immediate needs and safety concerns are promptly identified, discussed with the High-Fidelity Wraparound (HFW) team, including the youth and family, natural and community supports, Tribal liaisons when applicable, and Children’s System of Care partners, and documented in the youth’s file. A plan is developed to address potential safety, high-risk, and crisis situations, incorporating reactive crisis management strategies identified by the family and clearly outlining who should be contacted for support on a 24/7 basis. The roles and responsibilities of each team member are clearly defined to ensure coordinated response. A written Safety Plan is collaboratively developed that identifies safety needs and potential risks, includes both proactive and reactive strategies, ensures cultural relevance, and incorporates natural supports and community resources to promote and maintain a safe environment in the family’s home. This process supports early stabilization and shared accountability.
4.4b (Handbook 3.22 pp. 43-44)
The Aspiranet High-Fidelity Wraparound (HFW) Facilitator ensures that the development of the Plan of Care actively involves all Child and Family Team (CFT) members within a collaborative, strengths-based environment that centers family voice and choice. The Facilitator and Aspiranet CFT members complete Foundational Wraparound training and participate in annual refresher training, as well as monthly coaching and supervision focused on effective Plan of Care development and needs-driven planning.
4.4c (Handbook 3.22 pp. 43-44)
Crisis and Safety Plans are reviewed by supervisors, HFW coaches, and clinical supervisors so strategies are individualized, include a progression of proactive and reactive responses, and are culturally responsive, including Tribal representation when applicable. Reviews also confirm that plans are inclusive of identified natural and community supports. Findings from these reviews are used for Continuous Quality Improvement (CQI) and to identify training and coaching opportunities that strengthen safety planning, crisis response, and overall program quality.
Implementation
5.1 Implement The Plan of Care
5.1a (Handbook 4.1 pg. 51; 4.3 pg. 52)
The Aspiranet Facilitator leads the High-Fidelity Wraparound (HFW) team in reviewing strategies and action items at each Child and Family Team (CFT) meeting to confirm completion of assigned tasks, monitor timelines, and identify and address any barriers to implementation. The Facilitator utilizes CFT agendas, CFT meeting minutes, the Wraparound Action Plan (WAP), and Safety Plans to guide structured check-ins with the team and ensure accountability for agreed-upon deliverables. Strategies and action items are adjusted as needed, based on team input and progress, and all updates are clearly documented in the youth’s file.
5.1b (Handbook 3.28 pg. 46; 5.3 pp. 60-61)
The Facilitator and Aspiranet Child and Family Team (CFT) members complete Foundational Wraparound training and participate in annual refresher training, along with monthly coaching and supervision focused on effective Plan of Care development, needs-driven planning, and fidelity to High-Fidelity Wraparound standards. The Aspiranet Wraparound team may utilize Wraparound flexible funding, as appropriate, to celebrate successes with the youth and family as they occur, reinforcing progress and strengthening the youth and family’s sense of achievement and motivation. Celebrations may include verbal recognition during CFT meetings or family-identified, meaningful activities, consistent with family voice and choice. Progress and accomplishments are documented in Aspiranet progress notes and reflected in updates to the Plan of Care and Safety Plan, ensuring accurate tracking of achievements and continued alignment with the youth and family’s goals.
5.2 Review and Update The Plan of Care
5.2a (Handbook 5.3 pp. 60-61)
The Aspiranet Wraparound Facilitator leads the Child and Family Team (CFT) in reviewing strategies, progress, and assigned action items during each High-Fidelity Wraparound (HFW) team meeting. Reviews focus on how effectively strategies are addressing the youth and family’s identified needs and whether adjustments are needed to achieve desired outcomes and goals agreed upon by the CFT team. Documentation from each HFW team meeting includes identified barriers and plans to move forward, highlights what is working well, and confirms next steps and responsibilities in the Wraparound Action Plan (WAP). This structured approach supports shared accountability, timely follow-through, and continuous improvement.
5.2b (Handbook 3.15 pp. 36-37; 5.3 pp. 60-61)
The Aspiranet Facilitator leads the Child and Family Team (CFT) in ongoing discussions to adjust the Plan of Care when successes are achieved, new needs are identified, or new strategies are implemented, with corresponding updates to action items in the Wraparound Action Plan (WAP).
5.2c (Handbook 5.8 pp. 66-67)
The Aspiranet Facilitator documents CFT activity and progress in Child and Family Team (CFT) meeting notes, Wraparound Action Plans (WAP), progress notes, and the Plan of Care. Documentation includes completion of tasks assigned to CFT members, team attendance, invitation and participation of formal and natural supports, use of flexible funds, and any updates to the Plan of Care. All updates are communicated to and shared with CFT members to promote transparency, shared accountability, and follow-through.
5.2d (Handbook 3.15 pp. 36; 5.3 pp. 60-61)
Aspiranet Wraparound forms and tools are flexible and adaptable, allowing for updates that reflect the individualized and evolving needs of the youth, family, and Child and Family Team (CFT) throughout the phases of Wraparound.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
5.3a (Handbook 4.10 pg. 56)
Team Agreements are presented and reviewed at all High-Fidelity Wraparound (HFW) team meetings, so they are regularly revisited and actively used to guide planning and collaboration. Team Agreements are updated as needed to reflect changes in team membership, the youth and family’s preferences, and shared expectations of all HFW team members.
5.3b (Handbook 3.4 page 22-24; 4.3 page 52)
Aspiranet Facilitators receive ongoing training, coaching, and clinical supervision focused on building, engaging, and sustaining cohesive Child and Family Teams (CFTs) that work collaboratively in the best interest of the youth and family. Ongoing training emphasizes trust-building, effective team engagement, and meaningful collaboration with natural supports and Tribal representation when applicable.
5.3c (Handbook 5.7 pp. 64-65)
The use and engagement of natural supports are actively monitored by Aspiranet High-Fidelity Wraparound (HFW) team members and documented in the youth’s file and in Aspiranet’s Options database. Documentation reflects the identification, involvement, and ongoing role of natural and community supports in planning and service delivery. Ongoing coaching and supervision reinforce the importance of meaningful inclusion of natural supports in decision-making and care planning, supporting shared responsibility and long-term stability.
5.3d (Handbook 3.4 pp. 22-24)
The Aspiranet Wraparound Facilitator orients all new Child and Family Team (CFT) members—including formal service providers, natural supports, and Tribal representation when applicable to the team. Orientation includes a review of the current Plan of Care, strategies for achieving identified goals, each team member’s role and responsibilities, the family’s vision, the Safety Plan, and expectations for CFT participation and collaboration. New CFT members are provided with copies of all relevant documentation to support a clear and shared understanding of the youth and family’s goals, strategies, and agreed-upon roles. The Aspiranet Facilitator also leads team-building activities with new CFT members to promote trust, mutual respect, and shared understanding, and to foster a collaborative, inclusive, and welcoming team environment.
Transition
6.1 Develop a Transition Plan
6.1a (Handbook 3.24 pp. 45-46)
The Aspiranet Facilitator leads the High-Fidelity Wraparound (HFW) team in identifying when the youth and family are ready for transition, based on benchmarks monitored throughout the phases of Wraparound. Benchmarks include stability in the home, consistent progress toward established goals, and strengthened natural and community supports that reduce reliance on formal services.
6.1b (Handbook 3.25 pp. 46)
The Aspiranet Facilitator is responsible for guiding the High-Fidelity Wraparound (HFW) team in the development of an individualized Transition Plan once the team reaches agreement that transition from Wraparound services is appropriate. The Transition Plan identifies ongoing needs that will continue beyond formal Wraparound services, outlines formal services that will remain involved, specifies natural and community supports that will continue to support the youth and family, and documents strategies necessary to maintain the progress and stability achieved. The Transition Plan is documented in the youth’s file and distributed to all Child and Family Team (CFT) members.
6.1c (Handbook 3.24 pp. 45-46; 3.25 pp. 46)
The Aspiranet Facilitator is responsible for guiding the High-Fidelity Wraparound (HFW) team in the development of an individualized Transition Plan once the team reaches agreement that transition from Wraparound services is appropriate. The Transition Plan identifies ongoing needs that will continue beyond formal Wraparound services, outlines formal services that will remain involved, specifies natural and community supports that will continue to support the youth and family, and documents strategies necessary to maintain the progress and stability achieved. Facilitators receive training and support in determining readiness for transition.
6.1d (Handbook 3.25 pp. 46)
The Aspiranet Child and Family Team (CFT) members verify that the services and supports identified in the Transition Plan will continue and remain accessible after High-Fidelity Wraparound (HFW) services conclude. The Aspiranet Facilitator ensures that the youth and family have current contact information for community supports, Children’s System of Care partners, Tribal programs and resources when applicable, and all natural supports who supported the family throughout the Wraparound process.
6.2 Develop a Post-Transition Safety Plan
6.2a (Handbook 3.27 pg. 48)
The Aspiranet Facilitator is responsible to update Crisis and Safety Plan that is individualized and reflects transition, or that a Transition Crisis and Safety Plan is developed, completed, and documented in the youth’s file prior to the conclusion of High-Fidelity Wraparound (HFW) services. The Transition Crisis and Safety Plan identifies potential post-transition crisis situations and outlines proactive and reactive strategies the youth and family can use to maintain safety and stability following transition. The Aspiranet Facilitator includes strategies in the Crisis and Safety Plan that are selected by the family, are culturally relevant, and maximize the use of natural supports and community resources, including Tribal resources when applicable, particularly where formal supports were previously utilized. This approach supports sustainability, and family confidence.
6.2b (Handbook 3.22 pp. 43-44)
Crisis and Safety Transition Plan occurs within a collaborative High-Fidelity Wraparound (HFW) team setting. The Facilitator leads the youth, caregiver, natural supports, Children’s System of Care partners, and Tribal liaisons when applicable in identifying potential post-transition risks and crisis situations. Together, the team outlines proactive and reactive strategies that align with the family’s long-term goals, strengths, values, and culture, supporting sustained safety and stability following transition.
6.2c (Handbook 3.24 pp. 45-46)
Aspiranet supervisors and High-Fidelity Wraparound (HFW) coaches review Crisis and Safety Plans on a consistent basis to ensure that plans include individualized, needs-driven strategies, with clearly defined proactive and reactive responses that are culturally relevant, incorporate natural and community supports, and reflect the family’s chosen approaches. These reviews support Continuous Quality Improvement (CQI) by identifying training needs, informing targeted coaching opportunities, and strengthening Facilitators’ skills in safety planning and crisis response.
6.3 Create a Commencement and Celebrate Success
6.3a (Handbook 3.28 pg. 46)
Transitions out of the Wraparound process is celebrated according to the family’s values, culture, traditions, and preferences.
6.3b (Handbook 3.28 pp. 48-49)
The Aspiranet High-Fidelity Wraparound (HFW) team supports staff to have the resources, time, and flexibility to facilitate transition celebrations for youth and families. The HFW team has access to Wraparound flexible funds, as appropriate, to support meaningful celebrations of this milestone without creating financial burden for the family. The Aspiranet HFW team collaborate with the family to develop a list of individuals they wish to invite to the celebration, consistent with family voice and choice. During the celebration, the HFW team plan for dedicated time for community resourcing, acknowledge community partnerships, and highlight the contributions of natural and formal supports. Aspiranet Wraparound CFT members make themselves available to attend the celebration to recognize, honor, and affirm the youth and family’s progress and achievements.
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
7.1a (Handbook 12.2 pp. 108-109; 13.4 pg. 114)
Aspiranet has multiple mechanisms in place for youth and families to provide feedback on policies, procedures, and system-level improvements related to local High-Fidelity Wraparound (HFW) implementation. Aspiranet routinely gathers feedback from youth ages twelve (12) and older and caregivers through the Aspiranet Satisfaction Survey, and family experiences are used to inform program adjustments and system-level improvements. In addition, Aspiranet provides quarterly opportunities at Wraparound Advisory Board Meetings for caregivers, youth, community partners, and Tribal representatives when applicable to share feedback, identify barriers, and offer recommendations to improve service delivery. T
7.1b (Handbook 12.2 pp. 108-109; 13.4 pg. 114)
Feedback is consistently gathered through multiple avenues, including Aspiranet Satisfaction Surveys, the Aspiranet Wraparound Advisory Board, and structured reporting from Aspiranet team members. This feedback is actively utilized in decision-making related to service planning and implementation, policy and procedure development or revision, workforce development, and Continuous Quality Improvement (CQI) efforts. The youth and family’s lived experience remains central to all decision-making processes, supporting a family-driven, strengths-based, and culturally responsive High-Fidelity Wraparound implementation.
7.2 Community Leadership Team
7.2a (Handbook 13.3 pg. 114)
Aspiranet leadership participates in the Community Leadership Team by contributing data, feedback, and program insights, support the team’s ability to monitor performance, identify trends, and address service delivery.
7.3 Eligibility and Equal Access
7.3a (Handbook 3.2 pp. 18-20)
In the counties with which Aspiranet contracts, Child Welfare establishes minimum service eligibility criteria in accordance with state law. These criteria are clearly defined and consistently applied, ensuring equitable access to services regardless of system involvement, placement setting, or level of care and does not exclude services based on the severity or nature of a referred youth’s needs. This approach supports fairness and transparency.
7.3b (Handbook 7.2 pg. 77; 8.5 pg. 85)
Caseload assignments are regularly reviewed that support the intensity and frequency of services necessary to meet families’ complex needs; staff (including supervisors) are available 24/7 for any crisis need.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
8.1a (Handbook 7.1 pg. 77)
Program budgets for each Aspiranet HFW program are structured to prioritize the majority of funding toward direct service delivery, ensuring that sufficient staffing, service intensity, and resources are available to meet the individualized and complex needs of youth and families. This allocation supports the delivery of timely, responsive, and high-quality services in alignment with Wraparound principles. In addition, flexible funding is available to address immediate and individualized needs identified through the Wraparound process. These funds are used to remove barriers, support stabilization, enhance engagement, and promote progress toward goals identified in the Plan of Care and Wraparound Action Plan (WAP).
8.1b (Handbook 7.2 pg. 77)
Aspiranet’s High-Fidelity Wraparound (HFW) rates reflect the required staffing roles and qualifications outlined in Workforce Development Standard 9.3, ensuring that programs are appropriately staffed to deliver High-Fidelity Wraparound services with fidelity. Staffing structures support effective engagement, facilitation, care coordination, coaching, supervision, and clinical oversight necessary to meet the complex needs of youth and families and to maintain adherence to California High-Fidelity Wraparound standards.
8.1c (Handbook 7.3 pp. 77-78)
Aspiranet’s High-Fidelity Wraparound (HFW) rates reflect the inclusion of required data collection and/or data management systems.
8.2 Equitable Funding Across System Partners
N/A
8.3 Cost Savings are Reinvested
N/A
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
8.4a (Handbook 7.1 page 77; 7.2, pg. 77)
Flexible funds are a supportive resource used to address individualized, needs-driven barriers that cannot be met through traditional funding sources, with the purpose of supporting engagement, stability and successful implementation of the Plan of Care and Wraparound Action Plan. Flex Funds are part of the overall funding plan for High Fidelity Wrap.
8.4b (Handbook 7.2 pg. 77; 7.5 pg. 79)
Aspiranet has established a clear, consistent, and documented process for requesting, approving, and tracking the use of flexible funds, ensuring timely access for families when urgent needs are identified and the appropriate, accountable, and needs-driven use of these resources.
The approval process includes clearly defined evaluation criteria (Items 1–7) to guide decision-making and ensure alignment with the youth and family’s Plan of Care and California High-Fidelity Wraparound standards. Aspiranet also maintains a transparent process for communicating funding decisions, including written notification of denied requests, the rationale for denial, and a formal appeal process for families or team members to request reconsideration. This structure supports equitable access, fiscal accountability, transparency, and family-centered decision-making in the use of flexible funds.
8.5 Collaborative Oversight of Flex Funds
8.5a (Handbook 7.1 pg. 77; 7.2 pg. 77; 7.3 pp. 77-78)
Flexible fund use and availability are documented and transparently communicated to contracted counties and relevant providers. Documentation includes the amount of the purchase, the purpose and justification for the expenditure, receipts, and the High-Fidelity Wraparound (HFW) team’s recommendation supporting the request. This documentation process ensures fiscal accountability, transparency, and alignment with the youth and family’s Plan of Care and supports county oversight and monitoring requirements.
8.5b (Handbook 7.1 pg. 77; 7.2 pg. 77)
Flexible funds are intended to meet the needs of all families served through Aspiranet High-Fidelity Wraparound (HFW) programs. Flexible funding is utilized to address individualized and urgent needs in support of the youth and family’s Plan of Care, while remaining responsive to varying levels of need across all families participating in Wraparound services.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
N/A
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
9.1a (Handbook 9.1 pg. 88)
Aspiranet High-Fidelity Wraparound (HFW) programs routinely monitor the demographic composition of the populations served in each county and use this information to inform recruitment and hiring practices. Aspiranet actively seeks to hire and retain staff whose cultural backgrounds, lived experiences, and linguistic capabilities reflect the communities served, including meeting identified language access needs.
9.1b (Handbook 9.1 pg. 88)
When Aspiranet is unable to recruit or hire staff who fully reflect the cultural, racial, or linguistic needs of the families served, alternative strategies are implemented to ensure culturally responsive practice. These strategies include engaging identified natural supports, community leaders or cultural brokers, and formal service providers who can offer relevant cultural and linguistic representation as part of the High-Fidelity Wraparound (HFW) Child and Family Team (CFT).
9.1c (Handbook 9.1 pg. 88)
When an Aspiranet High-Fidelity Wraparound (HFW) program is unable to provide a staff member who can deliver services in the family’s preferred language, Aspiranet ensures access to qualified interpretation or translation services, or—with the family’s consent—identified natural supports who can assist with communication.
9.2 Tribally Responsive Workforce
9.2a (Handbook 4.9 pg. 55; 6.3 pg. 72; 6.4 pp. 72-73; 6.5 pg. 73)
Aspiranet Wraparound staff receive training on Tribal sovereignty, Tribal traditions, and cultural values, including guidance on respectful communication, collaboration, and advocacy when working with American Indian/Alaska Native youth, families, and Tribal partners.
9.2b (Handbook 3.7 pp. 26-28; 6.3 pg. 72; 6.4 pp. 72-73; 6.5 pg. 73)
When serving an Indian child, Aspiranet High-Fidelity Wraparound (HFW) teams actively build partnerships with Tribal representatives, engaging Tribes at the very beginning of services. Tribal representatives are invited to participate in Child and Family Team (CFT) meetings and are included in the development and ongoing review of the Plan of Care. Aspiranet HFW teams encourage meaningful participation in Tribal traditions and ceremonies, as appropriate, and recognize the value of Tribal services, resources, and supports available to the youth and family.
9.3 Flexible and Creative Work Environment
9.3a (Handbook 9.1 pg. 88; 9.2 pp. 88-90)
Aspiranet shall obtain and maintain certification by the State of California as an authorized Wraparound provider and shall certify compliance with all applicable High-Fidelity Wraparound (HFW) standards, including fidelity requirements, practice guidelines, and quality assurance protocols established by the State of California. Aspiranet provides ongoing training to staff and supervisors on the use of fidelity and quality monitoring tools, including the Wraparound Fidelity Index (WFI), Team Observation Measure (TOM 2.0), Document Assessment Review Tool (DART), and Aspiranet Satisfaction Surveys. Aspiranet supervisors and HFW coaches routinely review documentation, observe Child and Family Team (CFT) meetings, and provide structured feedback to staff to support ongoing skill development, fidelity to the Wraparound model, and continuous quality improvement standards.
9.3b (Handbook 4.3 pg. 52; 9.2 pp. 88-90)
Aspiranet Wraparound programs shall intentionally promote and maintain team cohesion and foster a positive, collaborative team environment across all High-Fidelity Wraparound (HFW) activities. This includes orienting new Child and Family Team (CFT) members and adding additional natural and formal supports as needed to ensure the team remains responsive to the youth and family’s evolving needs. These practices support respectful communication, shared decision-making, mutual accountability, and trust among CFT members.
9.3c (Handbook 2.1 pp. 13-14; 3.20 pg. 42; 4.12 pg. 57; 9.2 pp. 88-90)
Aspiranet High-Fidelity Wraparound (HFW) teams shall practice open, respectful, and transparent communication with all Child and Family Team (CFT) members, including natural supports, community resources, Children’s System of Care partners, and Tribes when applicable. Open communication supports shared understanding, collaboration, and informed decision-making, ensuring that all voices are heard and that planning remains family-driven, and culturally responsive.
9.3d (Handbook 9.2 pp. 88-90)
Aspiranet High-Fidelity Wraparound (HFW) programs shall establish and maintain Child and Family Team (CFT) agreements and team mission statements to support ongoing compliance with High-Fidelity Wraparound principles, values, phases, and core activities. Team agreements and mission statements guide communication, collaboration, decision-making, and shared accountability, and are reviewed and updated as needed to reflect family voice and choice, cultural considerations, and the evolving needs of the youth and family, consistent with California High-Fidelity Wraparound standards.
9.4 Hiring, Performance Evaluation, and Job Descriptions
9.4a (Handbook 9.1 pg.88)
Aspiranet High-Fidelity Wraparound (HFW) programs maintain the roles or functions of the following positions, either through distinct positions or through combined roles with clearly defined role descriptions and responsibilities: Youth Partner, Parent Partner, HFW Facilitator, Family Specialist, Fidelity Coach, Clinical Supervisor (licensed), and HFW Supervisor/Manager (license not required). This staffing structure supports the core functions required to implement High-Fidelity Wraparound with fidelity—including engagement, facilitation, peer support, clinical oversight, fidelity monitoring, supervision, and program management.
9.4b (Handbook 9.1 pg. 88)
Aspiranet High-Fidelity Wraparound (HFW) staff fulfill the roles or functions of a Youth Partner, Parent Partner, HFW Facilitator, Family Specialist, Fidelity Coach, Clinical Supervisor, and HFW Supervisor/Manager. These roles may be filled through distinct positions or combined roles with clearly defined responsibilities.
9.4c (Job descriptions)
Aspiranet supports workforce development practices, including recruitment, hiring, training, supervision, and coaching, are consistent with the California High-Fidelity Wraparound Standards and Toolkit, including standards related to Wraparound staffing. Job descriptions for all required positions are specific to High-Fidelity Wraparound (HFW) and clearly reflect the attitudes, skills, knowledge, and lived or professional experience necessary for successful performance in each role.
9.4d (Handbook 9.2 pp. 88-90)
Aspiranet High-Fidelity Wraparound (HFW) programs hiring process includes opportunities for candidates to demonstrate the specific attitudes and skills essential to each position. Hiring practices may include behavioral interviews, scenario-based questions, role plays, or other practical exercises designed to assess candidates’ ability to engage families, collaborate with teams, practice strengths-based and culturally responsive approaches, and uphold High-Fidelity Wraparound principles and values.
9.4e (Handbook 9.4 pg. 91; 9.5 pp. 91-93; 9.6 pg. 93-94; 9.7 pg. 94)
Aspiranet High-Fidelity Wraparound (HFW) programs ensure that employees are provided clear performance expectations and receive frequent, strengths-based feedback and coaching to support their success. Staff receive ongoing feedback during regular supervision with their supervisor, which focuses on case progress, skill development, problem-solving, and fidelity to High-Fidelity Wraparound principles. Aspiranet also conducts annual performance evaluations to provide formal feedback, recognize strengths, and establish professional development goals for the next evaluation period. In addition, Wraparound staff receive feedback following each internal Continuous Quality Improvement (CQI) audit of case files, supporting ongoing learning, accountability, and continuous improvement.
9.5 Workforce Stability
9.5a (Handbook 9.1 pg. 88)
Aspiranet periodically adjust salary ranges based on industry standards.
9.5b (Handbook 7.2 pg. 76)
Workload expectations are monitored and adjusted as needed to promote effective engagement, timely documentation, meaningful team participation, and sustainable staff performance, in alignment with California High-Fidelity Wraparound standards.
9.5c (Handbook 9.9 pp. 87-88)
Aspiranet High-Fidelity Wraparound (HFW) programs maintain clearly communicated and accessible promotion and advancement opportunities that are equitable and not prohibitive for staff with lived experience. Aspiranet offers ongoing training and coaching to support advancement opportunities, helping prepare staff to grow into expanded roles and leadership positions.
9.5d (Handbook 9.9 pg. 95)
Aspiranet periodically adjust salary ranges based on industry standards. Aspiranet encourages staff to pursue advanced training, certifications, and leadership development opportunities that do not require a position change to achieve.
9.6 High Fidelity Training Plan
9.6a (Handbook 9.3 pp. 90-91)
Aspiranet utilizes both internal trainers and UC Davis Resource Center for Family-Focused Practice (RCFFP) trainers to train High-Fidelity Wraparound (HFW) staff using the Statewide Standardized Foundational HFW Wraparound curriculum. Aspiranet HFW trainers have completed the Foundations for Fidelity training through UC Davis, including the trainer-specific Foundations for Fidelity curriculum, ensuring trainers are qualified to deliver model-consistent instruction. Aspiranet utilizes the Foundations for Fidelity curriculum for all initial training of HFW staff and provides annual booster trainings to reinforce skills, fidelity, and best practices.
9.6b (Handbook 9.3 pp. 90-91; 9.5 pp. 91-93; 9.6 pp. 93-94)
Aspiranet maintains a comprehensive training plan that ensures all new High-Fidelity Wraparound (HFW) staff receive the Statewide Standardized Foundational High-Fidelity Wraparound curriculum training upon hire, followed by an annual refresher or booster training at a minimum. In addition, HFW staff receive role-specific training through a combination of formal trainings provided by Aspiranet’s training department, contracted external trainers, and county-offered trainings, as applicable.
9.6c (Handbook 9.3, pp. 90-92)
Aspiranet maintains a comprehensive training plan that ensures all High-Fidelity Wraparound (HFW) staff have an individualized HFW training plan that is monitored by their supervisor. This plan incorporates annual booster training on the Statewide Standardized Foundational HFW curriculum, as well as role-specific training aligned with each staff member’s responsibilities. This structured training approach supports ongoing skill development, fidelity to the Wraparound model, and high-quality service delivery in alignment with California High-Fidelity Wraparound standards.
9.6d (Handbook 9.3, pp. 90-92)
Aspiranet clinical supervisors, High-Fidelity Wraparound (HFW) supervisors, and program managers complete initial training in the Statewide Standardized Foundational HFW curriculum and participate in ongoing training related to the HFW model. In addition, supervisors and managers receive role-specific booster trainings focused on leadership, supervision, fidelity oversight, coaching, and workforce development, ensuring effective guidance and support of HFW staff in alignment with California High-Fidelity Wraparound standards.
9.6e (Handbook 9.3 pg. 90-92)
Under Aspiranet’s High-Fidelity Wraparound (HFW) training plan, all staff receive training on the Indian Child Welfare Act (ICWA) and Tribal sovereignty prior to working with any Indian child and their family. Aspiranet also promotes and provides specialized training to support populations with specific and unique needs through Aspiranet’s Social Justice Department, contracted external trainers, and county-provided trainings, as applicable. In addition, Aspiranet’s HFW training plan includes instruction on integrating family culture, traditions, values, and lived experience into planning and service delivery. Aspiranet Facilitators are trained to center the youth and family’s strengths, underlying needs, values, and culture in all aspects of the Wraparound process.
9.7 Community-based Training Program
9.7a (Handbook 9.5 pp. 91-93)
Under Aspiranet’s High-Fidelity Wraparound (HFW) training plan, youth, families, and peer partners with prior Wraparound or lived experience are actively incorporated into the delivery of required Wraparound trainings. This approach elevates lived experience as expertise, strengthens family-driven and youth-guided practice, and enhances staff understanding of authentic engagement, cultural responsiveness, and fidelity to the Wraparound model in alignment with California High-Fidelity Wraparound standards.
9.7b (Handbook 9.5 pp. 91-93)
Aspiranet invites community partners to participate in Wraparound trainings to strengthen their effective participation on High-Fidelity Wraparound (HFW) teams and to enhance their role in supporting Wraparound implementation within the Children’s System of Care. This collaborative training approach promotes shared understanding of the Wraparound model, improves cross-system coordination, and supports consistent, high-fidelity practice across partners in alignment with California High-Fidelity Wraparound standards.
9.8 Coaching and Supervision
9.8a (Handbook 9.5 pp. 91-93)
Under Aspiranet’s High-Fidelity Wraparound (HFW) training plan, new staff participate in an initial apprenticeship that builds core values, skills, and knowledge related to HFW principles, phases, and activities, including the appropriate and effective use of flexible funds to meet individualized family needs. New staff joining the Aspiranet HFW team receive the Statewide Standardized Foundational HFW curriculum training as part of their initial apprenticeship and comprehensive onboarding process. In addition, new staff are provided with structured shadowing opportunities to observe Child and Family Team (CFT) meetings and service delivery with families. Following initial training, staff are supported through ongoing, consistent coaching and supervision to ensure services are delivered in accordance with High-Fidelity Wraparound principles, fidelity requirements, and California HFW standards.
9.8b (Handbook 8.5 pg. 85)
Aspiranet High-Fidelity Wraparound (HFW) staff have access to supervision and coaching on a 24/7 basis as needed to support effective service delivery and crisis response.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
N/A
10.2 Evaluation Metrics & Outcomes
10.2a (Handbook 12.1 pg. 108; 12.2 pp. 108-109; 12.3 pg. 109 12.4 pp. 109-110; 12.5 pg. 110; 12.6 pp. 110-111)
Aspiranet High-Fidelity Wraparound (HFW) data is systematically collected and utilized to improve practice and deliver high-quality, family-centered care. Data provides timely feedback to staff to support continuous improvement in service provision and is consistently used to inform coaching and training needs. In addition, data trends are analyzed to guide targeted coaching efforts and to identify individual or team-level training needs.
10.2b (Handbook 12.1 pg. 108; 12.2 pp. 108-109; 12.3 pg. 109 12.4 pp. 109-110; 12.5 pg. 110; 12.6 pp. 110-111)
Aspiranet utilizes High-Fidelity Wraparound (HFW) data to identify and address program-level needs in order to better serve youth and families and improve overall program effectiveness. Data is used to adjust program workflows, strengthen supervision and coaching practices, and implement targeted improvement strategies.
10.2c (Handbook 13.3 pg. 114)
Aspiranet High-Fidelity Wraparound (HFW) programs recognize that data is used to identify and communicate system-level barriers across the Children’s System of Care, including Child Welfare, Probation, Education, Behavioral Health, and Tribal partners through Community Leadership Team structures. Data-informed communication supports collaborative problem-solving, enabling leadership and system partners to address systemic challenges, improve cross-system coordination, and strengthen the overall service environment in which High-Fidelity Wraparound is delivered, supporting effective implementation and positive outcomes for youth and families.
Fidelity Indicators
1.1 Timely Engagement and Planning
(a) Upon receipt of a referral, the Program Manager (PM) contacts caregiver and client within 24 hours and conducts outreach and engagement. This meeting is documented by completing a COS note (see document COS template) in electronic health record. An intake is scheduled within 5-7 days from the receipt of referral by Wraparound Facilitator (see Client Service workflow document)
If initial contact attempts are unsuccessful, the PM documents all attempts in the Wraparound Contact Log (see supporting doc Wraparound Turning Point Contact Log during O/E ) and consults with the referring party, DCFS CSW, and DMH liaison to implement alternative engagement strategies (e.g., contacting natural supports, varying contact times, or outreach at schools or community locations.
(b): The Wraparound Facilitator (WF) schedules an Initial Child and Family meeting within the first 30 days of enrollment with the client, family and agency partners (DCFS, DMH, Regional Center etc) and the Wraparound team to create an action plan utilizing the CFT matrix (see CFT Planning Matrix page 3). Per DMH LA County Wraparound Policy and Procedure (See WA P&P policy 9 pg 24) The CFT matrix is the document to be used to:
“to document the specific action steps that will be taken, and which team member is responsible for following up on that particular action item. This ensures that everyone on the team is clear about their identified tasks and how they will assist in implementing the care plan that was created and agreed upon by all members of the CFT. At the conclusion of the meeting, all members of the CFT are to review the CFT Planning Matrix and sign the form indicating they are in agreement with the care plan”
Please note as indicated in the LA County Wraparound Program Policies and Procedures the CFT Matrix acts as the family’s care plan.
Procedure (c) Teams review the plan within the context of a HFW team meeting at least every 30-45 calendar days
A follow up CFT meeting is scheduled within 30 days from the initial CFT meeting (WA P and P policy Child and Family Team policy number 9, page 23) and Client Service Workflow) by the WF wherein the Wraparound team reviews action plan documented on the initial CFT matrix (see Facilitation Workflow). All changes and updates on the initial plan are recorded on the follow up CFT matrix (see CFT Planning Matrix template)
(d) Teams update the plan of care, distribute to all team members, and document the updated plan in the child or youth’s file at least every 90 days and more often as needed. Monthly follow up CFT meetings are scheduled to track and updated action plan in place (see CFT meeting tracker document). All updates and changes are documented in the follow up CFT matrix (see document) and distributed to all team members. A copy of the completed follow up matrix is stored in the client’s electronic chart
(e) In order to meet meeting timelines, program uses a CFT meeting tracker(see CFT Tracker template) to monitor timeline adherence. This is reviewed during scheduled supervisions, case reviews and chart reviews.
A random technical review is also conducted by DMH Wraparound administration so that program staff and supervisors are provided feedback on their ability to meet timelines (see Wraparound Policies and Procedures Program Monitoring policy 20, page 42).
(f) Staff are trained to timely engagement strategies that include encouraging alternate strategies when contact with the family is difficult
As a part of training, client engagement using the 4 step CFT process including fundamental Wraparound trainings are incorporated in the training schedule of every Wraparound staff that joins the Wraparound team. These trainings are outlined in the Wraparound Policy and Procedure (see doc Wraparound Training Requirements for WA Providers Policy 5 page 13) Additionally, a program training is conducted by the Wraparound Program Manager, Wraparound Program Coordinator and Clinical Team Lead within the first two months of starting in the wraparound Program. A training schedule/checklist (see supporting doc Wraparound IFCCS Training Schedule) is utilized to ensure timely training on engagement.
A monthly meeting with DMH WA Liaison for coaching, support and consultation on challenging cases is an important part of our program coaching and development (see consultation worksheet template). This document is then stored in the client’s electronic health record
1.2 Led by Youth and Families
(a) During family engagement meeting, the Wraparound Facilitator along with Wraparound team members- Parent Partner, Clinician and Child and Child family Specialist meet with family and guides a discussion on Family Goal, wherein the client and family is encouraged to share their hopes and aspirations about their future and vision about their family in its best version. Family Vision and Team Mission statement are all rolled into the discussion of Family Goal and Long-Term view during family engagement (see family engagement planning sheet and family engagement practice guide) and initial CFT Meeting and is documented in the CFT Planning matrix (see CFT matrix page 1).
(b) Family values, culture, expertise, interests and skills are elicited using the CFT engagement process- during family engagement and documented in the family engagement planning sheet(see family engagement planning sheet and family engagement practice guide) and discussed again during CFT meeting (see supporting document and CFT matrix pages 1-2).
(c) Wraparound Supervisors- i.e. program manager or program coordinator or both attend CFT Meetings to observe WA team implementation of CFT engagement process. Supervisors utilize Fidelity Checklists (see supporting document Fidelity Checklist: CFT meeting and Facilitator Fidelity Measure ) to ensure team’s fidelity to the process. Feedback is provided during scheduled supervision and case review.
DMH Wraparound Liaison is invited to attend CFT meetings and a debrief meeting is conducted afterwards for feedback (see supporting document debrief practice guide)
(d) A yearly perception survey is conducted by administrative staff assistants of the Wraparound Program to obtain family’s satisfaction with Wrap services (see sample Client Perception Survey template). DMH Wraparound Administration also conducts random phone calls to survey families enrolled in Wraparound program (see WA Policy Program Monitoring 20 page 43)
1.3 Strength-Based
a) During the first family engagement, the Facilitator facilitates a discussion on strengths specifically functional strengths (see supporting document family engagement practice guide). The Facilitator helps define what functional strengths are and how these strengths will be used in finding solutions and meeting the needs that are identified by client and families. The Facilitator provides examples of functional strengths based on observations and previous conversations with client and family (see supporting document sample strength’s list). One way a Facilitator encourages participation in this discussion is by putting a poster board sized paper around the client’s home or place of meeting with each poster paper labeled with client, family and all meeting participants, Then, the Facilitator invites each member of the family engagement meeting, both formal and informal supports, to write at least one strength on the poster board. Upon completion of this exercise, the Facilitator invites each team member to read the strengths that were listed under their names. Feedback is obtained regarding this process from client and family to highlight a shift in perspective of focusing on gains instead of deficits. The Facilitator then notifies the family and client that these strengths will be reviewed collectively during each CFT meeting and any new strength will be added in the CFT matrix (see CFT matrix document page 2). A laminated copy of each family member and client’s strength list is provided to client and family during the initial CFT meeting.
(b) The Wraparound Clinician summarizes strengths of client and family obtained from completion of IP-CANS during the initial CFT meeting (See CANS template) and is documented in the CFT Matrix under client and caregiver’s strengths.
In order to identify client and family member’s individualized strengths, A strengths discovery discussion (see supporting document sample strengths list) is conducted by the Facilitator during the first family engagement meeting and explains the relevance of identifying what each team member’s positive attributes, hobbies, values that can support the client and the family in creating an action plan that is more in line with their natural preferences, talents and positive attributes. One way a Facilitator encourages participation in this is by putting a poster board sized paper around the client’s home or place of meeting with each poster paper labeled with client, family and all meeting participants’ name. Then, the Facilitator provides each member of the participant of the family engagement meeting-both formal and informal supports to write at least one strength on the poster board. Upon completion of this exercise, the Facilitator invites each team member to read the strengths that were listed under their names. Another way a Facilitator creatively obtains strengths from each participant is by inviting them to an exercise wherein a white 8X11 paper is taped behind each participant’s back and each meeting participant writes at least one strength for that person. Then, once everyone is done, the Facilitator asks each team member to retrieve the paper taped behind them and share to the group the strengths that were identified on their list. This strength’s discovery meeting is usually an enjoyable and uplifting meeting and a good rapport building exercise. These strengths are reviewed, shared, updated, and documented in the CFT matrix during CFT meetings.
The Wraparound Clinician summarizes underlying needs of client and family obtained from completion of IP-CANS during the initial CFT meeting ( See CANS template). The family and client prioritize which needs they want to focus on along with the needs identified during the CFT planning meeting (see CFT Planning Matrix page 3)
Additionally, individualized needs are discussed and identified during the initial staff engagement meeting with all formal supports involved in the care of the client and family. Needs are also discussed during the initial family engagement with the client and family. This is documented under “hunches about underlying needs” section of the staff engagement worksheet (see supporting document staff engagement worksheet)
Individualized needs and concept of underlying unmet needs is introduced to the family and the child during the initial family engagement meeting by the Wraparound Facilitator. Questions such as, “what might me behind client’s negative behaviors?, what might the client be communicating with these behaviors? What are their worries and concerns?” are asked to the client, family, and the participants to help identify unmet needs. This discussion is documented using the family engagement worksheet (see supporting document family engagement worksheet)
The Facilitator then lets the family and client know that the identified needs will be reviewed and further discussed during the Child and Family Team meeting along with creating an action plan to meet identified needs.
During the CFT meeting, the Wraparound Facilitator reviews and shares unmet need “hunches” discussed from staff engagement and family engagement meetings. The Facilitator then asks the client and family to identify their top three needs they would like to work on first.
These needs are then listed and identified in the CFT matrix under need 1, need 2, need 3 etc. Each need is then discussed in a more detailed manner where in a specific action plan is collaboratively created and agreed upon by all participating natural and formal supports and the client in the CFT meeting. These needs and action plan and updates are reviewed, tracked and documented at least monthly in the CFT matrix (see supporting document CFT matrix page 3)
(c) Wraparound Supervisors- i.e. program manager or program coordinator or both attends CFT Meetings to observe WA team implementation of CFT engagement process. Supervisors utilize Fidelity Checklists (see supporting document Fidelity Checklist: CFT meeting and Facilitator Fidelity Measure ) to ensure team’s fidelity to the process. Feedback is provided during scheduled supervision and case review.
DMH Wraparound Liaison is invited to attend CFT meetings and a debrief meeting is conducted afterwards for feedback (see supporting document debrief practice guide)
(d) A yearly perception survey is conducted by administrative staff assistants of the Wraparound Program to obtain family’s satisfaction with Wrap services (see sample Client Perception Survey template). DMH Wraparound Administration also conducts random phone calls to survey families enrolled in Wraparound program (see WA Policy Program Monitoring 20 page 43)
1.4 Needs Driven
(a) During the staff engagement meeting, WF guides a discussion on underlying needs with Wrap team and agency partners (see staff engagement planning sheet). Staff engagement is scheduled prior to first family engagement. During first family engagement meeting, WF introduces what an underlying unmet need means and how this identified and utilized in creating an action plan to meet this need (see family engagement practice guide). Staff engagement and Family engagement are scheduled prior to the first Child and Family Team Planning meeting before goals and strategies are established with the family (See Facilitation Workflow)
(b) Staff receives ongoing training and coaching on underlying unmet needs and needs statement development as stated in Wraparound Program Policies and Procedure policy 6 page 15, training title: Underlying Needs: A Strengths/Needs- Based Service Crafting Approach. These trainings are both provided by La County Wraparound administration and by supervisors of the wraparound program (see IFCCS/Wraparound Training Schedule)
Underlying needs and needs statement development are reviewed during supervision and case reviews
(c) The Wraparound Clinician summarizes underlying needs of client and family obtained from completion of IP-CANS during the initial CFT meeting (See CANS template). The family and client prioritize which needs they want to focus on along with the needs identified during the CFT planning meeting (see CFT Planning Matrix page 3)
Additionally, individualized needs are discussed and identified during the initial staff engagement meeting with all formal supports involved in the care of the client and family. Needs are also discussed during the initial family engagement with the client and family. This is documented under “hunches about underlying needs” section of the staff engagement worksheet (see supporting document staff engagement worksheet)
Individualized needs and concept of underlying unmet needs is introduced to the family and the child during the initial family engagement meeting by the Wraparound Facilitator. Questions such as, “what might me behind client’s negative behaviors?, what might the client be communicating with these behaviors? What are their worries and concerns?” are asked to the client, family, and the participants to help identify unmet needs. This discussion is documented using the family engagement worksheet (see supporting document family engagement worksheet)
The Facilitator then lets the family and client know that the identified needs will be reviewed and further discussed during the Child and Family Team meeting along with creating an action plan to meet identified needs.
During the CFT meeting, the Wraparound Facilitator reviews and shares unmet need “hunches” discussed from staff engagement and family engagement meetings. The Facilitator then asks the client and family to identify their top three needs they would like to work on first.
These needs are then listed and identified in the CFT matrix under need 1, need 2, need 3 etc. Each need is then discussed in a more detailed manner where in a specific action plan is collaboratively created and agreed upon by all participating natural and formal supports and the client in the CFT meeting. These needs and action plan and updates are reviewed, tracked and documented at least monthly in the CFT matrix (see supporting document CFT matrix page 3)
(d) Wraparound Team tracks strategies discussed during follow up CFT meetings. Progress, updates, worries, concerns are all discussed and documented on the CFT Planning matrix until identified underlying need is met (See CFT Planning Matrix pages 3-5). Once all identified underlying needs have been met and criteria for transition or exit have been met, per Wraparound P and P policy #18 Exit from Wraparound Services page 39, Wraparound Providers conduct a CFT Planning meeting to finalize transition plan.
1.5 Individualized
(a) The Wraparound team along with the family meet during the CFT Meeting to collaboratively brainstorm and decided on strategies that are based on the client’s/family’s needs, which is then documented on the CFT Matrix under the section of Planning for Needs (see sample CFT Matrix doc)
(b) Staff is encouraged and requested to attend on-going trainings on trauma and specialized populations to enhance their understandings and acquire new interventions (See Training Monitor Worksheet), Along with attendance to official trainings, staff is also provided with in-house services (see WRAPAROUND IFCCS Program Training Schedule) using materials from previous trainings (reference examples engaging youth in placement and CFT Meeting Training)
(c) Our facilitators have participated in in-house services using materials from previous trainings (reference PowerPoint Facilitating Change & Identifying Underlying Needs: slide 21) and have been provided with support through weekly supervision and record reviews (see Facilitator fidelity measure/ Fidelity Checklist).
(d) CFT Matrixes are regularly checked and reviewed bi-weekly either in supervision or record review times using in-housing measures (Facilitator fidelity measure/Fidelity Checklist).
(e) Routine consumer surveys (available in Spanish and English for both youth and parent) are conducted on a regular basis to ensure quality of care (see consumer surveys)
1.6 Use of Natural and Community Based Supports
(a) Informal supports are first explored during staffing engagement meetings where the facilitator inquires about any support system the family may be involved with and further explored during family engagement. The team then continues to inquire and explore family support systems withing the in-going CFTM process. (see Sample CFT_Records review and Staff engagement training page 13; Family Engagement Training, page 10 and CFT Matrix sample page 27)
(b) In-house services and trainings are delivered to staff members using materials from previous trainings (see Sample CFT_Records review and Staff engagement training page 13; Family Engagement Training page 10 and CFT Matrix sample page 27)
(c) CFT Matrixes are regularly checked and reviewed bi-weekly either in supervision or record review times using in-housing measures (Facilitator fidelity measure/ Fidelity Checklist).
(d) Routinely consumer surveys (available in Spanish and English for both youth and parent) are conducted on a regular basis to ensure quality of care (see consumer surveys).
1.7 Culturally Respectful and Relevant
(a) During Staff Engagement, the team (clinical and referring party) initially discuss information attained from records, reports and observations pertaining to the family’s cultural considerations (refer to CFT_Records review and Staff Engagement training page 14), The team then further discusses the family’s culture within the CFTM (see Sample CFT Matrix page 1)
(b) Staff is encouraged and required to attend on-going trainings on various topics in order to enhance their understandings and acquire new interventions (See WRAPAROUND Policies and Procedures Required Trainings for Wraparound Providers policy #5 page 13-14), Along with attendance to official trainings, staff is also provided with in-house services (see WRAPAROUND IFCCS Program Training Schedule).
(c) consumer surveys (available in Spanish and English for both youth and Parent) are conducted on a regular basis to ensure quality of care (see sample Client Perception Survey template)
1.8 High-Quality Team Planning and Problem Solving
(a) Service delivery involves engagement, planning, and implementation based on family needs and strengths, along with strategies and agreements, are documented as part of the Child and Family Team Matrix (CFT Matrix). A copy of the CFT Matrix is part of the client file while a copy is shared with the family and with the referring agency (DFCS or Probation) (Wraparound Program Polices and Procedure Manual, policy 8, page 21). These, along with strategies and agreements, are documented as part of the CFT Matrix. Planning occurs with the child and family through Child and Family team meetings in addition to linkage to other services and involvement and partnering with natural supports, referring agencies, and community-based supports as outlined as part of the integrated core practice model (01 Wraparound PP Manual, policy 8, page 20). Needs identification, plans strategies, and commitments as part of the CFT Matrix (Wraparound Program Polices and Procedures Manual, policy 9, page 24). In addition, supervisors (Program manager and program coordinator), consult and communicate regularly with the DMH liaison regarding case progress, resources, and family needs.
(b) The team continuously asks the family for feedback during the CFT process, during outings, sessions, and any other interactions with the family. In addition, DMH Parent Advocates will survey families by phone regarding service delivery and satisfaction (Wraparound Program Polices and Procedures Manual, policy 20, page 18), while the DMH Liaison may attend CFTMs in order to provide support and give feedback. This helps ensure collaboration, monitoring, and quality improvement.
(c) Feedback from the Youth and Family are discussed by the team in debrief meetings and case consultations and are used to improve service quality and delivery (see document, Case Consultation Worksheet, Client Service Flow). The feedback loop is continuous and the Program manager will often arrange to discuss broader topics during staff meetings or schedule trainings to enhance service delivery and maintain fidelity to the model.
(d) The CFT Matrix, developed as part of the Child and Family Team Meeting (CFTM), is shared the family as well as with DCFS and DMH for review (Wraparound PP Manual policy 20, p42). The CFT Matrix is singed and reviewed with the family and informal supports to ensure ownership and follow through of agreements while debriefs with formal supports, such as DCFS, occur after each CFTM in order to ensure continuous collaboration and understanding (See document Client Service Flow). The CFT Matrix is reviewed internally with supervisors as well as with the DMH liaison.
1.9 Outcomes Based Process
(a) The Child and Family Team Matrix (CFT Matrix), is created by the Child and Family Team and takes the place of the Plan of Care. The CFT Matrix documents client and family needs as well as specific measurable strategies and action items as well as the time frames in which they are to be met along with commitments on who is to complete which strategy and/or action item (01 Wraparound PP Manual, policy 9, p24).
(b) Progress towards completion and completion if items are tracked by the Wraparound team during team meetings and throughout services and are documented as part of the CFT Matrix. The child and family team meets as often as needed to update and track progress (Wraparound Program Policies and Procedures Manual. policy 8, page 21).
(c) The CFT Matrix is created and updated during Child and Family Team Meetings and is used to document needs, strategies, and action items and can is updated as frequently as needed in order to meet the needs of the youth and family (01 Wraparound Program Policies and Procedures Manual. policy 8, page 21).
(d) Outcome measures including the Child Adolescent Needs and Strengths Assessment (CANS) and Pediatric Symptom Checklist (PSC-35) are administered during the assessment period and during key event changes by the Clinician (01 Wraparound Program Polices and Procedures Manual policy 21, page 43).
(e) Outcome measures including the Pediatric Symptom Checklist (PSC-35), the Child Adolescent Needs and Strength Assessment (CANS), as well as the Outcome Measure Application (OMA) are administered during partnership and at key event changes throughout the delivery of services (01 Wraparound Program Policies and Procedures Manual, policy 21, page 43). These are used in conjunction with feedback and updates during CFT Meetings and as documented in the CFT Matrix (03 CFT Documents, CFT Planning Matrix) to continually improve strategies and implementation of services.
1.10 Persistence
(a) Wraparound is committed to the child and family to successfully completing the Wraparound process without fear of ejection. The wraparound team will make adjustments to the plan, the team, and/or services to accommodate changes, crises, new circumstances, or the needs of the family (01 Wraparound PP Manual, policy 7, p18). Any adjustments or changes are done through planning with the family using the CFT process (03 CFT Documents, CFT Planning Matrix) and with consultation with DMH (01 Wraparound PP Manual, policy 18, p39).
(b) The Clinical Supervisor ( in this case, both the Program Manager and Program Coordinator) provide ongoing support and coaching when the team faces challenges. In addition, they may recommend addition trainings as necessary, as well as review and monitor use of CRSS Flexible funds (01 Wraparound PP Manual, policy 6, p 15)
(c) Facilitators are required to obtain required trainings as outlined in the manual as offered through the DMH Coaching Division (01 Wraparound PP Manual, policy 5, p 13). In addition, Facilitators receive ongoing support, training, and consultation internally from the clinical supervisors (both the program manager and program coordinator), as well as with coaching and consultation with the DMH Liaison and Parent advocates (see document Wraparound IFCCS Training Schedule).
1.11 Transitions as a part of the Fourth Phase of HFW
(a) The Wraparound provider conducts a Child and Family Team Meeting to determine the family’s readiness to exit or transition services. The CFT Matrix is used to document the child and family’s progress towards meeting goals as well as develop a plan for transition and linkage if necessary. The provider consults with DMH regarding exiting from services as well as regarding linkage of services when needed (01 Wraparound Program Policies and Procedures Manual, policy 18, page 39).
(b) Transitions from Wraparound services are planned as part of the CFT Matrix which can include the use of funds to celebrate the family’s success in a way that honors the family’s culture, values, and preferences and may include supports that the family and child may have engaged throughout the Wraparound process. Often seen as a “graduation” from services, the team will celebrate the client and family in a way of the youth or family’s choosing and inviting supports that have been part of the process or other figures that the youth or family have deemed important in their life (Wraparound PP Manual, policy 18, page 39). In some cases and when appropriate, the team may create a transitional object for the youth or the family to take with them at the conclusion of services.
Expected Outcomes
2.1 Youth and Family Satisfaction
DMH annually surveys families from different programs, including Wraparound, regarding satisfaction with services (see document Surveys – DMH, Family and Youth). In addition, DMH Parent Advocates for the eight service areas routinely conduct telephone surveys with program participants (01 Wraparound Program Policies and Procedures Manual – 20, page 43). Internally, Parent Partners utilize a survey to assess and get feedback regarding service satisfaction (see document Surveys – SAMSHA Outcome Measures Form).
2.2 Improved School Functioning
Youth’s improved school functioning is tracked and documented during the monthly CFT Planning Meeting (see CFT Planning Matrix). Progress in school functioning is also tracked through quarterly completion of OMA (see Oma template). CANS (See CANS template) and PSC 35 are also completed to monitor and track progress in school functioning. (see PSC 35 Template)
A problem list is also created upon intake along with a treatment plan to target improvements in symptoms and impairments that may include school functioning (see treatment plan template). WA P&P policy Outcome Measures policy 21 pages 43-44 points to use of OMA, PSC 35 and CANS to monitor youth’s progress in Wrap services. Additionally, Wraparound Clinician completes an initial assessment and reassessments to determine levels of functioning and life impairments (see initial assessment and reassessment templates)
2.3 Improved Functioning in the Community
Youth’s improved community functioning is tracked and documented during the monthly CFT Planning Meeting (see CFT Planning Matrix). Progress in community functioning is also tracked through quarterly completion of OMA (see OMA template). CANS (See CANS template) and PSC-35 are also completed to monitor, track progress in school functioning. (see PSC-35 Template)
A problem list is also created upon intake along with a treatment plan to target improvements in symptoms and impairments that may include community functioning (see treatment plan template). WA P&P policy Outcome Measures policy 21 pages 43- 44 points to use of OMA, PSC 35 and CANS to monitor youth’s progress in Wrap services. Additionally, Wraparound Clinician completes an initial assessment and reassessments to determine levels of functioning and life impairments (see initial assessment and reassessment templates)
2.4 Improved Interpersonal Functioning
Youth’s improved interpersonal functioning is tracked and documented during the monthly CFT Planning meeting (see CFT Planning Matrix). Progress in interpersonal functioning is also tracked through quarterly completion of OMA (see Oma template). CANS (See CANS template) and PSC 35 are also completed to monitor, track progress in interpersonal functioning every 6 months. (see PSC 35 Template)
A problem list is also created upon intake along with a treatment plan to target improvements in symptoms and impairments that may include interpersonal functioning (see treatment plan template). WA P&P policy Outcome Measures policy 21 pages 43-44 points to the use of OMA, PSC 35 and CANS to monitor youth’s progress in Wrap services. Additionally, Wraparound Clinician completes an initial assessment and reassessments to determine levels of functioning and life impairments (see initial assessment and reassessment templates)
2.5 Increased Caregiver Confidence
Increased caregiver confidence is tracked and documented during the monthly CFT Planning Meeting under the strategies noted in the action plan section of the CFT Matrix as evidenced by caregiver’s ability to meet underlying need as identified in the CFT Matrix (see CFT Planning Matrix). Increased caregiver confidence is also tracked through quarterly completion of OMA (see OMA template). CANS (See CANS template) and PSC-35 are also completed to monitor, track an increase in caregiver’s strength in meeting youth’s various needs every 6 months. (see PSC-35 Template)
A Problem List is also created upon intake along with a treatment plan to target improvements in caregiver’s capacity (see treatment plan template). WA P&P policy Outcome Measures policy 21 pages 43-44 points to the use of OMA, PSC 35 and CANS to monitor youth’s progress in the context of youth’s environment and primary relationships i.e. caregiver relationships in Wrap services. Additionally, Wraparound Clinician completes an initial assessment and reassessments to determine levels of functioning and life impairments, caregiver capacity and barriers to treatment (see initial assessment and reassessment templates)
2.6 Stable and Least Restrictive Living Environment
Outcome Measure Application (OMA) is utilized to track placement stability, especially OMA Key Event Change( see template and WA P&P policy Outcome Measures number 21 page 43-44) to track all placement changes including foster placements, psychiatric hospitalizations, treatment centers or STRTP. Less frequency in completion of OMA Key Event Changes suggests positive correlation with placement stability.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Youth’s improved behavioral functioning is tracked and documented during the monthly CFT Planning Meeting (see CFT Planning Matrix). Behavioral health is also tracked through quarterly completion of OMA (see OMA template). CANS (See CANS template) and PSC 35 are also completed to monitor, track progress in behavioral functioning every 6 months. (see PSC- 35 Template)
Less crisis response, noted by tracking crisis stabilization services provided, can be an indication of improved behavioral functioning. This is pointed out during monthly follow up CFT meetings
2.8 Reduction in Crisis Visits
During follow up monthly CFT Meetings, reduction in crisis responses are noted in the CFT Planning Matrix and documented in 6 month CANS assessments and quarterly OMA assessments (See 3 month OMA templates and CANS assessments).
Youth and Family are able to effectively demonstrate use of Family Safety and Crisis Plan (see template) and independently deescalate a crisis.
2.9 Positive Exit from HFW
The Wraparound provider conducts a Child and Family Team Meeting (CFTM) to determine the family’s readiness to exit or transition services. The CFT Matrix is used to document the child and family’s progress towards meeting goals, readiness to transition from services, as well as develop a plan for transition and linkage if necessary. The provider consults with DMH regarding exiting from services as well as regarding linkage of services when needed. DMH reviews and verifies the exit request while the team continues to provide services until an exit or transition date is provided (01 Wraparound P&P Manual, policy 18, page 39).
Engagement
3.1 Orientation
(a) The family is contacted within 24 hours of receipt of a referral and scheduled for Outreach and Engagement (O&E). During this time an overview of Wraparound services is given to the family, including an introduction to the Wraparound model, processes, service delivery, and team members, and scheduled for intake based on family voice and choice (04 Client Service Workflow, Turning Point Brochure). This process is also completed during family engagement (Wraparound IFCCS Training schedule)
(a) As part of the Outreach and Engagement and during the assessment period, the family is stabilized, engaged, and oriented to the Wraparound process as a means of meeting immediate and long term goals (01 Wraparound PP Manual, policy 7, page 18).
(b) During the assessment period, the Clinician and the Wraparound team will review legal and ethical procedures, discuss Payor Financial Information (PFI), limits of confidentiality, and system involvement. These may also be discussed and reviewed as part of the CFT throughout the course of services (Client Services Workflow, Facilitation Workflow, CFT Matrix).
(c) The individual team members as well as their roles are introduced and discussed during engagement and throughout the assessment period (Client Services Workflow, 01 Wraparound PP Manual, policy 6, page 15).
3.2 Safety and Crisis stabilization
(a) During Outreach and Engagement, the team assesses for any emergent safety and crisis issues that may be present at the time of referral. These are immediately addressed and a safety and stabilization plan is created (08 Safety and Crisis Plan LACDMH SP CDW). The family is also given resources as well as important emergency numbers, including 24/7 support provided by the provider (01 Wraparound PP Manual, policy 22, p46).
(b) A Safety and Crisis Plan is created at the onset of services. The Wraparound team continually assesses for safety needs throughout delivery of services and works with the family and referring agencies to develop and continually update Safety Plans as well as in the CFT Matrix during plan development (01 Wraparound PP Manual, policy 10, page 25).
(c) During the development of the safety and crisis plan, the family is provided and shown how to access, important emergency numbers including 24/7 support provided by the provider (01 Wraparound provider Manual, policy 22, page 45). Additional supports and numbers may be added as the family is engaged in Child and Family Team Meetings. These lead to updating of the safety plan as well as the CFT Matrix (CFT Matrix)
3.3 Strengths, Needs, Culture and Vision Discovery
(a) The Child and Family’s Strengths, Needs, Vision, Family goal, and long term view are developed with the family throughout engagement and as part of the CFT process (01 Wraparound PP Manual, policy 10, page 26). These are documented as part of the CFT Matrix and utilized when developing strategies to assist the family in meeting their goals, ensuring safety, and in moving towards independence (CFT Matrix).
(b) As the family is engaged in services and in Child and Family Team Meetings, new strengths and needs are added and documented as part of the CFT Matrix and are leveraged in the development of strategies to assist the family in meeting goals (CFT Matrix).
3.4 Engage All Team Members
(a) Upon engagement and throughout the process, the Wraparound team will assess for and reviews the composition and members of the Child and Family Team which will include natural supports, service partners, and referring agencies (Wraparound Program Policies and Procedure Manual, policy 8, p21). The Facilitator will continue to engage the child and family during CFT meetings regarding potential members as well as current supports and document this as part of the CFT Matrix (CFT Matrix).
(b) Throughout the process, the team encourages natural supports to be identified and included in the process as well as facilitates communication and participation with referring agencies including DCFS or Department of Probation. The Facilitator is responsible for engaging and coordinating with systems of care to ensure participation and feedback (Wraparound Program policies and Procedures, policy 6, p15). Members of the team, and their roles and commitments, are documented as part of the family plan in the CFT Matrix (CFT Matrix, Wraparound Program Policies and Procedures Manual, policy 7, p18).
(c) The Wraparound team will engage the family in identifying formal and informal supports at outreach and throughout services. While the Facilitator coordinates and documents these as part of CFT meetings, other members of the team will also contribute by engaging the family during outings to find and identify potential members that could be added to the team (Wraparound Program Polices and procedures, policy 6, p15). These are documented by the Facilitator as part of the CFT Matrix, and is shared with the rest of the team including systems of care partners.
(d) Needs, strengths, and strategies to help in meeting goals including activities in the community, engagement that helps support the youth and family are documented by the Facilitator during Child and Family Team Meetings as part of the CFT Matrix (see supporting document CFT Matrix, Wraparound Program polices and Procedures, Policy 9, page 24).
3.5 Arrange Meeting Logistics
(a) Services are provided three to four times a week, depending on the needs of the child and family, at a time, location, and setting that is conducive to the family’s wishes (01 Wraparound PP Manual, policy 8, p20). The Facilitator is responsible for coordinating the meeting with the family as well as with system of care providers to ensure a time and location that will best suit the family’s wishes and needs and maximize participation across agencies. The Facilitator also ensures that the plans reflect teh ongoing needs and preferences of the youth and family (Wraparound Manual PP, policy 8, page 22) .
(b) Staff work collaboratively across multiple systems to identify individualized services that will address underlying needs (Wraparound PP Manual, policy 7, page 19, policy 8. page 21) with a Child and Family Team that includes both formal and informal supports, as well as DMH, and Child Welfare agencies. Debriefs with staff and DCFS occur after each Child and Family Team Meeting to ensure collaboration and support (Debrief Meeting Practice Guide).
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
(a) The CFT Matrix, which replaces the Plan of Care in Los Angeles County is used to document and describe family and team strengths, mission, plans, agreements and commitments. (01 Wraparound PP Manual, policy 8, page20).
(b) The Facilitator facilitates a family engagement meeting (See document Agenda, family engagement worksheet) where strengths, underlying needs are defined and an introduction family goal and long term view are conducted. These are documented and shared within the Child and Family Team Matrix (Wraparound PP Manual, policy 9, p24)
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
(a) The Wraparound team crafts and delivers individualized Wraparound services based on underlying needs, goals, and strategies. Services are dynamic and evolve depending on the child and family’s needs and presenting issues (01 Wraparound PP Manual, policy 8, p20). Plans, strategies, and commitments are documented as part of the CFT Matrix (see document CFT Documents Merged, CFT Planning Matrix).
(b) The child and Family are engaged in a Child and Family Team meeting to develop goals along with measurable outcomes in order to assist in meeting underlying needs (Wraparound Manual policy 8, page 21).
(c) Needs identification and goal development and progress are developed in collaboration with the youth and family. The youth and parents play central roles in the Child and Family Team Meeting with the assistance of the facilitator (Wraparound PP Manual, policy 8, page 21)
(d) The Child and Family Team Meeting engages the youth and family in identifying strengths and underlying needs as well as in brainstorming and developing strategies that are individualized to the family and prioritizes their voice and choice (Wraparound PP Manual, policy 8, page 21)
(e) The Facilitator is responsible for managing the logistics, coordinating, and engaging the family in the Child and Family Team Meeting process, wherein needs and corresponding strategies are identified, developed, and followed through (Wraparound PP Manual, policy 8, page 22)
(f) Strengths, needs, and planning are developed as part of the Cfild and Family Team meeting and documented as part of the CFT Matrix (Wraparound Manual, policy 7, page 18)
4.3 Develop an Individualized Child or Youth and Family Plan
(a) Facilitators receive initial required trainings through DMH that outline the Wraparound model and its components, delivery of services, the use of the four step CFT process and the CFT Matrix (Wraparound Manual policy 5, page 13). In addition, Facilitators receive additional training and supervision internally to review Wraparound concepts and philosophy related to developing a youth and family plan (see WraparoundIFCSS Training worksheet) and to ensure fidelity to the model and key concepts. Training for Facilitators and all members of the team also includes the use of roleplaying CFTs and planning meetings as well as training in completing documents such as the CFT Matrix (see WraparoundIFCCS Training Worksheet). Roleplaying also contributes to team cohesion as more seasoned members of the team will play different roles and give feedback. Tools such as the Facilitator Fidelity Measure are used to track progress and give feedback (see document – Facilitator Fidelity Measure). Wraparound team crafts and delivers individualized Wraparound services based on the child and family’s underlying needs and trauma history (01 Wraparound PP Manual, policy 8, page 20). In addition to initial training, both externally with DMH and internally with supervisors, Facilitators receive ongoing weekly supervision and consults as needed to ensure continuing fidelity.
(b) The four step CFT process is used to develop and integrate goals as identified by the family and system partners. The CFT Matrix (used instead of the Plan of Care per Los Angeles County DMH) are used to document and outline plans, strategies, and commitments (see document CFT Planning Matrix). This includes identification of the family’s vision and mission statement, identification of informal and natural supports, as well as engagement of referring agencies. The
(c) The planning matrix is developed and agreed upon by each member of the team (01 Wraparound PP Manual, policy 9, page 24) and is shared with the family as well as system of care partners ( Wraparound PP Manual, policy 9, page 24)
(d) The CFT Matrix is reviewed with Clinical Supervisors on an ongoing basis to ensure fidelity and that the family’s voice and choice are honored and reflected in the plan (see document CFT Matrix, Wraparound IFCCS training Schedule)
4.4 Develop a Crisis and Safety Plan
(a) The Safety Plan is an individualized and collaboratively written document that is a culturally and linguistically accommodating document that provides strategies to the youth and family to address safety concerns. It is updated and developed further as part of ongoing Child and Family team meetings and as safety concerns arise. (Wraparound PP Manual. policy 10, page 25). Safety and Crisis needs are identified as part of the CFT Matrix (see documents: CFT_Matrix-with-instructions) and as part of the family’s Safety and Crisis Plan (See Document: Safety & Crisis Plan LACDMH SP CWD 10.25.24).
(b) Development of the Safety Plan is initially created by the Wraparound team at the onset of treatment. The facilitator assists the team, including the family and referring agencies, in identifying Safety and Crisis needs as well as strategies to meet and these needs. Safety and Crisis needs are identified and documents as part of the CFT Matrix (see documents: CFT_Matrix-with-instructions) and as part of the family’s Safety and Crisis Plan (See Document: Safety & Crisis Plan LACDMH SP CWD 10.25.24). The Facilitator and the Wraparound team, will support the family in identifying supports that could assist in the event of a crisis, proactive strategies to help prevent an crisis situation form escalating, reactive strategies for when a crisis has already occurred, as well important numbers for informal and informal supports, as well as numbers to utilize in the event of an emergency. The Crisis and Safety Plan is then constantly updated and revised during Child and Family Team Meetings or as services are provided and new needs are identified (Wraparound Policy, policy 10, page 25). In the event that safety needs and concerns may be identified as part of the referral or during initial outreach and engagement, a Safety and Crisis Plan is created with the family at that point and reviewed throughout assessment and into the first CFT meeting. Facilitators receive training in needs identification, safety planning, and in identifying strategies collaboratively with the child and family as well as with children’s system of care both externally as part of DMH trainings as well as internally (see document: WraparoundIFCCS Training Worksheet). In addition, regular supervision and consults as well as case reviews occur on a weekly basis to address safety and other issues that may arise while working with the child and family.
(c) The Safety Plan is developed with the Child and Family Team to ensure that needs and concerns as well as the corresponding strategies are completed in as strengths-based and individualized manner. and may include the participation from formal and informal supports (Wraparound policy manual, policy 10, page 25).
Implementation
5.1 Implement The Plan of Care
(a) During Child and Family Team Meetings, the Facilitator uses meeting agendas and flipcharts to document needs, strengths, strategies, and progress to allow all members of the Child and Family Team to be able to view and contribute to topics being discussed. These are then transcribed onto the CFT Matrix, which replaces the Plan of Care for Los Angeles County DMH Wraparound (Wraparound Program Polices and Procedures, policy 9, page 24). The Facilitator is responsible for ensuring that action plans and commitments are followed by members of the Child and Family team and checks to make sure that plans and strategies are met and updated as needed (Wraparound Program Policies and Procedures, policy 8, page 22).
(b) The Program Manager and Program Coordinator ensure that Wraparound staff receive initial and ongoing training and coaching regarding the Wraparound model and implementation as well as maintaining fidelity to the model (Wraparound IFCCS Training Schedule, Child and Family Team Facilitator Training).
5.2 Review and Update The Plan of Care
(a) The CFT Matrix, used as part of Los Angeles County DMH replaces the Plan of Care. The Facilitator is responsible for managing the logistics of the Child and Family Team process and coordinating the initial and revised plans that reflects the family’s needs and preferences (01 Wraparound PP Manual, policy 9, page 24). The Facilitator reviews and updates this on a regular basis with the Child and Family Team and will update strategies to reflect presenting issues or as needs are identified (01 Wraparound PP Manual, policy 8, page 20).With the use of the CFT Planning Matrix (see CFT Planning Matrix document pages 3-4) Facilitator leads a discussion during the Child and Family Team meeting in reviewing action plan agreed upon from previous meetings. Follow up CFT Meetings are scheduled once a month at a location and time most conducive to client and family.
(b) During the Child and Family Team meeting, the Wraparound Facilitator reviews each strategy under Action Plan section. If additional strategies are necessary, it is documented on the brainstorming section of the CFT matrix See CFT Planning Matrix doc pages 3-4). Progress and barriers are all noted under the Brainstorming section of the CFT Matrix. Who, what, when information is discussed and identified to have clear timelines and specific responsibilities that each team member has agreed to complete in the plan. As noted in Wraparound Policy and Procedure policy number 9 page 24, the CFT Matrix acts as the Plan of Care of care document. The CFT Planning matrix is stored in client’s electronic chart.
(c) All communication including completion of tasks, new assignments, attendees and participants including formal and informal supports, use of Flex Funds (Case Rate Support and Services is the term used in LA County per Wraparound Policies and Procedures, Policy #27, page 22) and updates, progress, barriers, successes are documented in the CFT Planning Matrix (WA Policies and Procedures, policy #9 page 24). A signed copy of the completed CFT Planning Matrix is provided to all participants after the CFT meeting.
(d) All forms are fillable and are consistently updated monthly during the CFT meeting (Wraparound Program Policies and Procedures, policy 9, The CFT Matrix, page 22). Action plan created in the CFT Matrix is based on the underlying need identified by family and client. Action steps are created in collaboration with family and client utilizing individual strengths, voice, choice, preferences enlisting natural supports.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
(a) Ground rules, Family vision/long term view are reviewed every CFT Meeting to ensure that these remain relevant and meaningful to the client and family and are documented in the CFT planning matrix (see CFT Planning Matrix document page 1). The client and family are asked every CFT meeting if there are other supports they would like to invite in their next CFT meeting (see CFT Matrix document page 5).
If the client and family identify a new team member they want included in the CFT meeting, the Wraparound Facilitator contacts and invites the identified potential team member to a family engagement meeting with the family. A family engagement is conducted monthly prior to the next scheduled CFT Meeting to help prepare the family, including new natural supports for their upcoming CFT Meeting. The facilitator utilizes Family Engagement Planning Guide to help prepare the family and orient new natural supports (see Family Engagement Planning Guide)
(b) Training for Facilitators is required as per Wraparound Policies and Procedures (see Wraparound Program Policies and Procedures policy #5 Required Trainings for Wraparound Providers, page 13). Training title “Principles of Teaming Wraparound Role Definitions and Skills specifically targets building, engaging and maintaining effective teams. Two-day Facilitator training, Integrated Core Practice Model, Cultural Humility training, Overview of Child and Family Team Meeting are a few of the required trainings identified in the Wraparound Policies and Procedures that support effective teaming skills for Facilitators.
Tracking and further building of these skills are addressed and provided during weekly supervisions.
(c) Use of natural supports are tracked and reviewed during monthly CFT meetings (see CFT Planning matrix action plan section pages 3-4 and page 5 where it asks who else should be invited) and family engagement meetings (see family engagement planning sheet)
Weekly supervision is provided to all team members for feedback and skills building and development
Wraparound supervisors observe CFT Meetings and provide feedback on fidelity to the Wrap process including use of natural supports
A debrief meeting follows every single CFT meeting wherein formal supports provide feedback on the CFT meeting that just concluded (See debrief meeting practice guide). This allows for discussions on use of natural supports, opportunities for improvement and strengths and highlights of the current process. This discussion is facilitated by the WF as outlined in the Debrief Meeting Practice Guide (see Debrief Meeting Practice Guide).
(d) If the client and family identify a new team member they would like included in the CFT Meeting, The Wraparound Facilitator contacts and invites the identified potential team member to a family engagement meeting with the family. A family engagement is conducted monthly prior to the next scheduled CFT Meeting to help prepare the family, including new natural supports for their upcoming CFT Meeting. The Facilitator utilizes Family Engagement Planning Guide to help prepare the family and orient new natural supports (see Family Engagement Planning Guide)
Transition
6.1 Develop a Transition Plan
(a) Child and Family Team Meetings are conducted to assess and determine the family’s readiness for transition of services (01 Wraparound PP Manual, policy 18, page 39). These are done in conjunction and consultation with program supervisors and the DMH liaison, keeping in mind family voice and choice (Opening and Closing Procedures for Wraparound)
(b) The Facilitator prepares the youth and family for the conclusion of wraparound services by creating an individualized transition plan and celebration of the family’s successes. This plan is documented as part of the CFT matrix and shared with the Child and Family Team (01 Wraparound PP Manual, policy 18, page 39)
(c) The transition plan is developed in collaboration with the youth and family as well as with systems of care that are involved in the youth’s life. These are done in conjunction with consultation and approval from the DMH liaison, with additional coaching and training provided as necessary (Wraparound PP Manual, policy 18, page 39)
(d) When transitioning from services, the team engages the family in a transition plan that includes linkage to continuing care, resources, and outlines supports that were created throughout the process. The team also reviews strategies and Safety Plans that have been successful in meeting the family’s needs throughout services. The team will factor the Integrated Core Practice Model when assessing the family’s progress towards desired goals (Wraparound Program Policies and Procedures, policy 18, page 39). This plan is outlined in the CFT Matrix and is shared with both the family and with the DMH Liaison for approval (See document: Facilitation Workflow).
6.2 Develop a Post-Transition Safety Plan
(a) The individualized Crisis and Safety plan is updated to reflect transition (or a new transition Crisis and Safety plan is completed) and documented in the youth’s file. The plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies that maximize use of natural support and that are chosen by the family.
An individualized Safety Plan is created for every client in Wraparound (see Wraparound P&P. policy #10 pg 25- definition section). See sample Safety Plan Template (see Family Safety and Crisis Plan document). The plan helps family determine what leads to a crisis (triggers) in various phases of treatment including during transition phase. Proactive interventions are identified under step 3, page 1 of the Safety and Crisis Plan. Reactive interventions are identified under step 4. Natural supports are identified in step 5 of the safety plan.
(b) The development of the Crisis and Safety Transition Plan occurs in a team-based, collaborative environment and facilitators receive training and coaching to this process.
Safety Planning meeting occurs during CFT Meeting involving all formal and natural supports who actively participate in client’s Wraparound services (see Wraparound P&P. policy #10 page 25- policies and procedures section).
Facilitators and all team members receive ongoing training and coaching on safety planning process as per Wraparound Policy and Procedure (see WA Policies and Procedures policy #5 Required Trainings for Wraparound Providers page 13- training entitled: “Addressing High Risk Behaviors). Another training included in Wraparound Policy #5 Required Trainings for Wraparound Providers is titled “Promoting Placement Stability Utilizing the Child and Family Team Process”.
Wraparound program provides in house Safety Planning training (See Wraparound/IFCCS Training Schedule). Safety issues and concerns along with safety planning is a regular discussion during weekly supervision and case consultations (see case consultation worksheet)
(c) Processes are in place to review Crisis and Safety Plans for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.
Safety plan is created within the first 30 days of treatment. Safety Plan is amended every time a new behavior or trigger results to a crisis response. An emergency CFT meeting is scheduled to address crisis situation and an action plan is created within the CFT meeting which involves the revision of the current safety plan (See Wraparound Policies and Procedures policy 10, page 25, last paragraph.) Additionally, Safety Plan is reviewed every 6 months and noted in the first page of the CFT Planning Matrix
The Crisis Plan and Safety encourages client and family to use natural supports and strengthen/expand network of support. Constant discussion of natural support is embedded in the CFT planning process (see CFT planning matrix document). Tracking of strategies is conducted in CFT meetings to ensure that agreed upon safety strategies continue to be relevant and effective.
Program bi weekly chart review includes review of Safety Plan for coaching and improvement
6.3 Create a Commencement and Celebrate Success
(a) At the conclusion of Wraparound services, an individualized transition plan is created with the family and a celebration of the family’s successes is conducted to support the child and family’s continued stability (Wraparound manual, policy 7, page 18)
(b) A Child and Family Team Meeting is conducted in preparation for transition in order to document successes, provide for consultation with DMH liaison, and access CRSS funds for use in graduation procedures is conducted (see document client service flow)
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
(a) These occur at a county level, however, internally, in addition to surveys used to monitor service delivery and inform decision-making, Parent Partners in the Wraparound team will survey families in order to determine satisfaction with service delivery and gather data about youth and family opinions which directly informs how services are delivered day to day (Surveys-SAMSHA Outcome Measures form). Family feedback and voice and choice is also documented as part of the CFT Matrix as part of CFT meetings (see document CFT Matrix with instructions).
(b) The County surveys families annually regarding services provided and makes decisions and gives feedback to agencies in order to inform decision making in delivery of services (see documents: 1181221_YouthEnglish, 1181236_FamilyEnglish). In addition, DMH Parent Advocates will contact families to conduct telephone surveys to collect data regarding service delivery, which is then shared countywide and used in decision making and program monitoring.
7.2 Community Leadership Team
a) In Los Angeles County Wraparound, Community Leadership Meetings are called Wraparound Provider Meetings and Roundtable Meetings instead of Community Leadership Meetings. The Program Manager and Program Coordinator attend Wraparound Provider Meetings every other month as scheduled by LACDMH Wraparound Administration. These meetings are hosted by County Program Heads. In attendance are County Wraparound Administration, Department of Children and Family Services, Department of Probation and WA Providers in all of Los Angeles County. These meetings include discussions about policies, processes, barriers, challenges surrounding Wraparound implementation and service delivery. See supporting document- Sample Provider Meeting Agenda and Wraparound Provider Meeting Schedule.
The Program Manager and Program Coordinator also attend Wraparound Roundtable meetings every other month also hosted by LACDMH Service Area 2 Wraparound Administration. Our Wraparound Program is in Service Area 2 which includes the San Fernando Valley, Burbank, Glendale and the Santa Clarita Valley. In attendance are LACDMH Wraparound Service Area 2 Liaisons and Supervisor and Service Area 2 Wraparound Providers. These meetings include a case clinical case presentation of a Wraparound Provider and a group discussion on the case including clinical brainstorming and resource suggestions. Updates on issues impacting Wraparound in service area 2 are discussed during this meeting such as but not limited to DCFS and Probation referral updates, enrollment updates, administrative information etc.
7.3 Eligibility and Equal Access
a) Referrals to Wraparound Services are reviewed, screened and assigned by LA County DMH Wraparound Administration to Wraparound Providers who have capacity or openings to receive cases in the local service area. The Wraparound DMH Liaison ensures that eligibility requirements and criteria are met before assigning cases to respective WA Providers (See supporting document Wraparound Policy and Procedure, policy #2 Referral Procedures pages 6-7).
Upon receipt of the referral which is assigned by LACDMH Wraparound administration, Wraparound Program manager reviews the referral and all documentation attached to determine which team members are best suited for the youth/client. No client is declined services regardless of the acuity of the case as long as eligibility is met (See sample referral document).
b) To ensure quality and appropriate care is provided to each client in Wraparound, Per Wraparound Policy and Procedure, policy #6 Wraparound Staffing, page 15, each assigned youth has to have one full dedicated clinical team made up of Facilitator, Clinician, Child and Family Specialist and a Parent Partner.
The staffing ratio per LACDMH Wraparound Policy and Procedure #6 , Wraparound Staffing, page 15 is an average of ten (10) children or youth to one (1) full-time Wraparound team, at any given time. Clinicians, Child and Family Specialists and Parent Partners can provide services to as few as eight (8) and as many as twelve (12) children or youth- based on acuity and staffing patterns. At the discretion of the Contractor, Facilitators can provide services to as few as ten (10) and as many as fifteen (15) children or youth, as appropriate.
Our program is funded for 30 clients. To meet this service need, our staffing is for 3 full teams- ten clients per each team. 3 Facilitators, 3 Clinicians, 3 Child and Family Specialist and 3 Parent Partners. We have one Program Coordinator who carries up to 3-4 cases. Therefore, each Clinician typically carries up to –8-9 cases. Each team member meets with the client/caregiver at least once /week for IHBS, ICC and therapy services (therapy provided by clinicians only). However, for clients who are considered high risk, team members can meet with clients at least 2x/week or more to provide needed support especially during crisis stabilization.
In the event of a crisis during office hours, the Wraparound team responds to stabilize the situation and is approved overtime if necessary (see supporting document: Company Policy Crisis Response). During after-hours crises, a crisis hotline is accessible to all clients 24/7 including an LPS response team if needed for a hold evaluation ( see supporting document LPS Crisis Response Company Policy).
In the event of a staffing shortage, i.e. lack of Clinician or any clinical team member to make up a full/complete team, which limits the program to have the capacity to serve 30 clients, this staffing issue is reported to LACDMH Wraparound Administration and the designated Wraparound Liaison assigned to our program so that appropriate case assignment is adjusted. Program Manager notifies staff assistant weekly on the number of cases program has capacity to receive. This information is noted in the LACDMH weekly roster report submitted by staff assistant weekly- (see Wraparound weekly roster report sample).
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
a) Flex funds, identified by DMH as Case Rate Services and Supports (CRSS), are an aggregate pool of funds that are allocated based on the number of children or youth and families served along with the approved County monthly dollar rate per child (Case Rate). Case Rate Services and Support (CRSS) funds are meant to assist in meeting immediate and long-term needs in the areas of housing, personal, vocational, occupational, and socialization goals that cannot be met through the youth and family’s financial resources, community resources, and/or other funding sources that are available to the families. Use of the funds are determined through the CFT Meetings and are individualized to each youth and family. These are approved through consultation with the DMH Liaison (Wraparound Program Policies and Procedures, policy 27, page 52).
b) The provider assigns full time, dedicated Wraparound team members to each youth and family team. The provider is responsible for maintaining adequate staffing which includes a Facilitator, Child and Family Specialist, Parent Partner, and Clinician, as well as a Supervisor to maintain clinical oversight, supervision, and maintain fidelity to Wraparound principles (Wraparound Program Policies and Procedures, policy 6, page 15). Members of the Wraparound team are trained both through DMH and internally by the Program Manager and Program Coordinator (Wraparound IFCCS Training Schedule). Required trainings through DMH are outlined in the Wraparound Program Polices and Procedures (policy 5, pages 13-14).
c) Wraparound programs are required to utilize the Outcome Measure Application (OMA) for collecting, tracking, and reporting data for clients. These are completed within 30 days the enrollment or partnership date and every three months thereafter or when there is a key event change throughout services (Wraparound Program Polices and Procedures, policy 21, page 43).
8.2 Equitable Funding Across System Partners
8.3 Cost Savings are Reinvested
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
(a) Flex Funds, now identified by DMH as Case Rate Services and Supports (CRSS), are allocated to the provider and are to be used as reasonably and economically as possible in order to meet the needs of the youth and family (Wraparound Program Policies and Procedure Manual, policy 27, page 52).
(b1) In the event that Funds are needed urgently, the Program Manager has the discretion to approve an expense of up to $1500 for emergencies and urgent needs, which is reimbursed later (CRSS Policy + Attachments, page 56). At a program level, a separate amount of Petty Cash, specific for use for urgent client needs for Wraparound is readily available (302 Petty Cash Handling) and is reimbursed from program funds as expenses occur. In addition, Wraparound staff have access to the use of Purchase Cards (PCards) to be used in programs that provide direct client care in the field such as Wraparound (Purchase Card Fiscal Policy, page 3). P-Cards will often come with a set amount but are easily recharged or increased with a simple call to the Center’s Fiscal Department (Purchase Card Fiscal Policy, p3). In addition, the Wraparound team will attempt to link the family to resources and donations through organizations such the Maravilla Foundation, New Economics for Women, Family Resource Center (DCFS), and Baby2Baby, to assist with any areas of shortage.
(b2) Use of CRSS funds is discussed as part of the Child and Family team meeting and is documented as part of the CFT Matrix. This needs to be approved on an individualized basis through DMH to allow for timely access to funds. It should be noted, however, that use of funds is but one of several strategies when trying to develop a plan around a youth or family’s needs. The team will explore other avenues and strategies including linkage to community resources, informal supports, donations from partnerships such as Baby2Baby, prior to utilizing funds. The team also ensures that whatever strategies are implemented are sustainable by the family should services come to a close. This has led to significant savings of county assigned funds as well as few, if any, denials that need to be approved. Flex funds are approved at a program level by the Program Manager and sent for approval to DMH by the liaison (CRSS Policy + Attachments, p55, 56). In the case of DCFS referrals, the team is also able to contact the social worker to solicit the use of Stopgap funds to fulfill any areas where CRSS funds may fall short.
(b3) The Wraparound team communicates regularly with the DMH liaison to ensure that funds are appropriate in scope and to reduce incidence of denials. Allowable and non-allowable expenditures are outlined as part of the CRSS policy (06 CRSS Policy). The wraparound team ensures that any use of CRSS funds are completed with sustainability and family independence in mind so that the family is able to continue these strategies, even after services have concluded. In the event that funds are denied, the Wraparound manager and team will communicate directly with the DMH Liaison to resolve the issue in a timely manner (CRSS Policy + Attachments, p55, 56). It should be noted, however, that because extensive planning and adherence to the Wraparound model is completed prior to CRSS funds being utilized, denials have been non-existent for the agency and there is often a surplus available for use with families.
8.5 Collaborative Oversight of Flex Funds
a) Flex Funds, identified by DMH as Case Rate Services and Supports (CRSS) are allocated to each provider’s funds based on the number of children or youths and families that are served. Access and use of these funds are outlined in the Wraparound Program Policies and Procedures Manual (policy 27, page 52) along with the different categories of funds that may be used which include client housing support, client housing operating, and client flexible expenditures. These funds are meant to assisting in meeting immediate and long-term needs in the areas of housing, personal, vocational, occupational, and socialization goals that cannot be met through the youth and family’s financial resources, community resources, and/or other funding sources that are available to the families. Use of the funds are determined through the CFT meetings and are individualized to each youth and family. These are approved with consultation with the DMH Liaison (Wraparound Program Policies and Procedures, policy 27, page 52).
b) Flex funds, identified by DMH as Case Rate Services and Supports (CRSS) are an aggregate pool of funds that are allocated based on the number of children or youths and families served along with the approved County monthly dollar rate per child (Case Rate). CRSS funds are not pooled at an agency level (Wraparound Program Polices and Procedures, policy 27, page 52).
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
a) DMH ensures the availability of Case Rate and CRSSS funds to providers for use in addressing the identified needs of youth and families as outlined the Wraparound Program Polices and Procedures Manual (policy 27, page 52). Case Rate and CRSSS funds are based on the number of youths and families served.
b) During CFT meetings, the Wraparound team explores and strategizes with the family to meet specific needs with the use of CRSS Funds being one of many possible strategies. Use of CRSS Funds are outlined during Child and Family team meetings and are outlined as part of the CFT Matrix. SFVCMHC will solicit for donations and other grants to cover gaps in budget. (see document SFVC HC Policy & Procedure page 108)
c) CFT meetings are conducted by the Wraparound team to identify needs and explores and strategizes with the family to meet specific needs with the use of CRSS Funds being one of many possible strategies. Part of strategizing with the families will involve exploring areas of additional financial support the family may be able to access, as well as budgeting, and linkage to resources to ensure strategies that are low-cost/no cost and sustainable by the family long after services have ended (CFT Planning Matrix). This does not however preclude the use of CRSS funds to assist the family in stabilization or in meeting immediate and long-term needs. Use of CRSS funds are documented in the CFT Matrix as part of the Child and Family team meeting and are approved by the Program manager and by the DMH liaison (Wraparound Program Policies and Procedures, policy 27, page 56)
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
(a) The Agency uses guidelines from the Commission on Accreditation of Rehabilitation Facilities (CARF) accreditation as a guide in workforce development and management. The Center’s workforce is composed of multicultural staff who are diverse in knowledge, skill and abilities and are sensitive to the cultural and linguistic needs of its clients and their families. Teh agency’s staff is reflective of the community and families it serves (see document Workforce Development and Management, section 1, page 5-6).
(b) The Center’s workforce is multi-cultural and multilingual, and therefore able to provide services that are culturally sensitive to the needs of its clients (Workforce Development and Management, section 1, p 5). In addition, the Wraparound team will engage informal supports that are able to provide a unique perspective and information due to their relationship with the Child and Family (Wraparound Policies and Procedures Manual, policy 8, page 22).
(c) Per DMH Contract, the Center is responsible for ensuring that consumers receive equal access to interpreter services in their primary or preferred language, including threshold and non-threshold languages. In the event that a member of the staff is unavailable, the Center is required to use other methods such as Telephonic Interpreter services and if necessary and clinically appropriate, the use of a natural support (Policy #200.03 Language Translation and Interpreter Services, page 1). The agency also has access to a Language Line to obtain translation in multiple languages when needed.
9.2 Tribally Responsive Workforce
(a) Although the Center does not typically receive referrals of this nature and youth are typically referred to a specialized DMH unit (see document American Indian Counseling Center – Department of Mental Health). In the event that a child from a tribe is referred to our agency for services, all staff receive ongoing training on cultural humility and responsiveness. Staff are encouraged to seek out consultation on the specific needs of the individual and working collaboratively with the family regarding their voice and choice. The Center promotes an environment of continuous learning and development (Workforce Development and Management, section 1, page 6)
(b) Although the agency does not typically receive referrals from tribes, there are protocols in place that would guide the treatment team to assess and engage the tribe as a natural support. In addition, engagement, of natural supports are built in as part of the Wraparound process (see supporting document CFT Matrix). In the event that our agency/program receives a referral for American Indian client and their family we would contact American Indian Counseling Center and NAMI to consult about the client’s background and specialized services that would meet the client’s cultural background needs to increase engagement and treatment effectiveness. We would establish best practices and treatment modalities that align with the client’s American Indian cultural heritage. We would develop a client specific cultural competency plan with the client and community experts in the areas of American Indian culture, language and customs. This plan will be incorporated into the client’s Treatment Plan and ongoing services provided at the program.
The SFVCMHC, Inc. Cultural Competency Policy and Procedure (201 Cultural Competence and Diversity, Service Delivery, page 3) outlines the Center’s philosophy and practice of Cultural Competency throughout the organization and service delivery models as carried out by multidisciplinary teams who provide direct care to clients and their families. It should be noted that this is currently being update in February 2026 and will include language giving guidelines specific to tribes.
9.3 Flexible and Creative Work Environment
(a) All staff are evaluated based on competencies outlined in their current Job Description. An employee is evaluated based on written performance goals, performance summary, core competencies, productivity/program compliance, strength-based summary and goals for areas of improvement. As ongoing communication is essential, all workforce members receive weekly supervision from their immediate supervisor, thus allowing employee and supervisor to continually discuss the expectations of the position (Workforce Development and Management, Section 1, page 15).
(b) Center staff are assigned to smaller cohesive teams that serve as a more “family-like” program unit where staff get individualized attention, supervision and multiple training opportunities for professional growth (Workforce Development and Management, section 1, page 7).
(c) Great emphasis is placed on the values of Transparency and effective and open Communication throughout the Center. The Center maintains an open door policy throughout the organization. In addition, All Workforce Meetings are held regularly since 2020 to communicate and get feedback from the staff (Workforce and Development, Section 1, page 17).
(d) Program Manager and coordinator review the core Wraparound principles (ICPM, Cultural Humility, team roles, family voice and choice) and integrate these into everyday practice, supervision, and team activities, to maintain fidelity and adherence to the model. These principles reflected in all aspects of the Center, including the manner in which weekly staff meetings and clinical supervision are conducted even in how weekly staff meetings and supervision are conducted. (See Document Staff Meeting Agenda).
9.4 Hiring, Performance Evaluation, and Job Descriptions
a) Per the DMH Wraparound Guidelines, the provider is to assign full time dedicated team members to each Child or youth and family enrolled in the program at a ratio of 1 team per 10 clients. The team is to include the following: Facilitator, Clinician, Child and Family Specialist, Parent Partner, and Clinical Supervisor. Their roles and job descriptions are outlined in Section (c) below (Wraparound Program Policies and Procedures, policy 6, p15) and while varying slightly from HFW staffing patterns, they are consistent with the roles outlined in the Wraparound model and meet the different roles of High Fidelity Wraparound as well as contract requirements.
b) Although staffing patterns vary due to present contract requirements, each of the High Fidelity Wraparound roles and functions are met by the team roles in the contract and based on the model practiced by the agency as follows:
1. Youth Partner – While not presently a required role per DMH contract, this role is met currently by the Child and Family Specialist. While having lived experience is not required under DMH contract, the Child and Family specialist engages the child or youth by providing empathy, mentorship, guidance, and advocacy. The CFS is often the voice of the child or youth during meetings with the team or with systems of care while simultaneously modeling and assisting the child to find their own “voice” that can carry on long after services have ended.
2. Parent Partner – this role is met by the Parent Partner role in the DMH Contract. The Parent Partner comes with lived experience that allows them to develop a unique and specialized relationship with parents and caregivers, providing empathy, support, mentorship, and advocacy, as well as assisting the parents and caregivers in having a voice and perspective in team meetings both with the team and in other systems of care meetings.
3. HFW Facilitator – This role is presently filled by the Facilitator of the Wraparound team. The Facilitator coordinates, organizes, and engages the youth and family as well as different systems of care that are involved in the family’s life. The Facilitator is key in identifying family strengths and needs as well as in supporting the Child and Family Team in developing strategies to meet those needs both in the immediate and long term.
4. Family Specialist – This role is presently filed by the Child and Family Specialist. As aforementioned, the Child and Family Specialist serves as a mentor and guide for the youth. In addition, the Child and Family Specialist works closely with the clinician or therapist and will support the client by providing an avenue to model and practice behavioral as well as other skills in the community through outings. Additionally, the Child and Family Specialist assists with linkage to resources. When needed, and clinically appropriate, the program manager may assign a second CFS in cases where a separation of roles or when a sibling may be involved, to provide additional support to the Child and Family team.
5. Fidelity Coach – This role is performed by the Clinical Supervisor as outlined below in section (c). In the case of the agency, the Clinical Supervisor role is held by both the Program Manager and the Program Coordinator. In the case of our Wraparound program, both the Program Coordinator have been in Wraparound since starting with the agency and have been part of early efforts to pilot the Wraparound model in the County. Both roles monitor and support the teams, ensuring fidelity to Wraparound Model both during onboarding and ongoing. The Program manager and Program Coordinator monitor participation of Wraparound staff in required DMH trainings. In addition, Wraparound staff attend trainings on concepts such as needs and strengths identification, as well as how to conduct CFT meetings and engage with families and system of care, determining the use of flex funds. These trainings take place internally on an ongoing basis through supervisions, staff meetings, team meetings, as well as in weekly check ins with the different teams (see IFCCS Wraparound Training Schedule).
6. Clinical Supervisor – This role is fulfilled by the Clinical Supervisor, outlined below in section (c). As aforementioned, within the current program, the Clinical Supervisor role is performed by both the Program Manager and Program Coordinator. They provide clinical oversight to the teams as well as provide supervision and mentoring to clinicians. They also oversee and ensure that the program administratively meets DMH guidelines and standards while ensuring that clinical work is also done with a “Wraparound lens” when formulating case conceptualization and treatment goals.
7. HFW Supervisor/Manager – This role is performed by the Program Manager, with the assistance of the Program Coordinator. Both ensure that the program meets DMH contract standards as well as agency expectations and requirements. Teh management team ensures that the Wraparound Program is able to function as a team, both in service of the youth and families as well as in how the program functions administratively and overall. They are responsible for hiring and onboarding new staff, interfacing with DMH Liaisons on to ensure program compliance with regulations, and delivering feedback to the team.
c) DMH Wraparound guidelines outline the roles and competencies of required team members. The Job Description and roles of each are outlined in Wraparound Program Policies and Procedures, policy 6, page 15. These are blended with agency Job Descriptions that outline both general agency expectations as well as Wraparound specific job duties (see supporting documents: 2 Program manager TP, Program Coordinator, 4 Mental Health Clinician, 5 Mental Health Counselor II – Facilitator, 6 Mental health Counselor II – CFS, 7 Parent Partner). These Job Descriptions are reviewed regularly and will be updated in the upcoming fiscal year to better align with High Fidelity Wraparound standards and as new contract requirements arise.
d) The Center’s Human Resources Department posts all Wraparound openings on the agency website as well as on local career job posting sites such as Indeed, Career Builder etc. The postings clearly communicate job duties for the position- see sample job posting for a Parent Partner position. This ensures that applicants have a good overview if what each position entails. All qualifying candidates who apply for the position are forwarded to the Wraparound Program Manager who then screens the applicants and schedules the interviews with the prospective candidates together with the Program Coordinator. During the interview, the Program Manager provides an overview of the Wraparound Program, the agency and the general culture of the program. The Candidates are asked a series of standard questions (see supporting document-interview questions standard- therapist) so that they can demonstrate specific attitudes, skills essential to the position. Additionally, all candidates are asked to share their “why” for doing this work – their life purpose that drives them to be a part of the Wraparound mental health team. Asking candidates about their “why” provides the interviewers with insight into the passion and purpose that drive their commitment to the core of their work.
A clinical vignette is also presented to the candidate to allow candidates to demonstrate clinical acumen and competence.
For bilingual candidates, specifically in Spanish, a portion of the interview is conducted in Spanish to determine proficiency
e) From onboarding on, the Program Manager and Coordinator provide training and ongoing coaching regarding key Wraparound concepts and processes to different members of the team (IFCCS Wraparound Training Schedule) including reviews of goals that meet both expected outcomes for Wraparound and agency expectations. Once a month, a performance report is provided to each Wraparound clinical team member that summarizes amount of service provided as well as documentation compliance. For Wraparound team members who are not meeting performance expectations based on their monthly performance report, a collaborative discussion is conducted to create a plan of action and deadline to meet expectations- see supporting document sample Monthly Performance Report
Supervisors review caseload reports with each staff regularly. These meetings also include the opportunity to highlight areas of strength and areas of growth for each staff. (see supporting document Supervisee Case Load Report).
Performance Appraisals are completed across the agency on an annual basis at the end of each fiscal year by Program Managers and Coordinators (see supporting document sample performance appraisal). This tool is used to provide constructive feedback that recognizes strengths, clarifies expectations, and identifies opportunities for growth. It supports professional development by aligning individual contributions with organizational goals while fostering open communication, accountability and continuous improvement- see supporting document performance evaluation. Each team member’s Job Description is also reviewed during their annual performance evaluation.
9.5 Workforce Stability
Our organization has implemented a comprehensive set of human resources strategies that have significantly strengthened workforce stability since 2021. By focusing on competitive compensation, manageable workloads, professional growth, and a supportive organizational culture, we have meaningfully reduced turnover and improved staff satisfaction.
a) We regularly review compensation using cost of living benchmarks and industry specific salary surveys, including those from CASRA and ACHSA. These data sources help us ensure that our wages remain competitive within our region and aligned with the economic realities of the communities we serve (see document Strategic Plan,2025-2027, Strategic Plan status and goals 2019, page 20).
b) We actively monitor caseloads and staffing ratios to maintain reasonable, sustainable workloads. Supervisors use regular check ins, workload reviews. Our hybrid and flexible scheduling model has also contributed to improved work–life balance, supporting both retention and overall staff wellbeing (see document Strategic Plan,2025-2027, Strategic Plan status and goals 2019, page 20).
c) The organization maintains transparent, accessible advancement pathways. We promote both personal and professional development through recognition programs, wellness initiatives, and ongoing training opportunities. Our commitment to Trauma Informed Care, community driven practices, and ACEs training has also strengthened staff engagement and created meaningful avenues for growth (see document Strategic Plan 2025-2027, pages 7-8).
d) We offer multiple opportunities for staff to grow without needing to change roles. These include skill-based pay increases, leadership assignments, Evidence Based Practice lead roles, and participation in a large array of organizational committees. Additionally, our sign on bonuses have supported recruitment efforts, contributing to the overall stability of our workforce (see document Strategic Plan 2025-2027, pages 7-8).
9.6 High Fidelity Training Plan
a) All Wraparound staff are required to attend mandatory training with DMH as outlined by the DMH Contract within the first year of employment (Wraparound Program Policies and Poocedure, policy 5, page 13). Required DMH Trainings are as follows:
California Wraparound Standards
Cultural Competency Training
Documenting and Claiming for Intensive Care Coordination
Fetal Alcohol Spectrum Disorders
Individuals with Intellectual Disabilities
Integrated Core Practice Model Foundational Training
Overview: Preparing for Child and Family Team Meetings
Principles of Teaming Wraparound Role Definitions and Skills
Promoting Placement Stability Utilizing the Child and Family Team Process
Addressing High Risk Behaviors
The 2-Day Child and Family Team Facilitator Meeting
Trauma Informed Training
Underlying Needs: A Strengths/Needs Based Service Crafting Approach
Wraparound 101
In addition, internally, the Wraparound Program Manager and Program Coordinator provide additional and ongoing training, coaching, modeling and support to new hires which includes shadowing outings and CFT meetings, roleplaying CFT Meetings other team members (IFCCS Wraparound Training Schedule). Historically, all Wraparound Trainings are provided by DMH Wraparound Program Policies and Procedures, policy 5, p13). Moving forward, in the new fiscal year, all staff will be registered to complete HFW training through UC Davis RCFFP and other trainings required by DMH.
b) As part of the onboarding process for all new Wraparound team members, a program training is conducted by the Wraparound Program Manager, Wraparound Program Coordinator and Clinical Team Lead within the first two months of beginning employment. A training schedule/checklist (see supporting document Wraparound IFCCS Training Schedule) is utilized to ensure timely training on the Wraparound process. With client and family permission, new team members shadow services being provided in order to expand their learning and further exposure to Wraparound principles and interventions. New team members are assigned to a supervisor who connects them with an experienced team member in the same role. New staff then shadow this person, especially during individual sessions and team meetings. The Supervisor also connects new team members with a Facilitator who invites them to all CFT related engagement meetings. The onboarding/ training period is about two months before a new team member starts building their own caseload. The WA Supervisor also connects this new team member with a Facilitator who invites this new team member to all CFT related engagement meetings. This onboarding/ training period is about two months before a new team member starts building their own caseload.
LACDMH Wraparound Administration provides ongoing trainings to Wraparound Providers and their staff as per Wraparound Policy and Procedures, policy #5 Wraparound Trainings for Providers. (See supporting document Wraparound Policies and Procedures #5 page 13). All staff must complete required trainings as well as attend recommended trainings as a part of ongoing training and development as identified in Wraparound Program Policies and Procedures policy number 5 page 14. All Parent Partners are sent to Parent Partner Training Academy, a 12-week training series per Wraparound Program Policies and Procedure #5 page 14.
A monthly meeting with DMH Wraparound Liaison for coaching, support and consultation on challenging cases.
c) For on going support Program Manager provides weekly supervision to all Clinicians, Office Manager, Program Coordinator and Team Lead; Program Coordinator provides weekly supervision to all Facilitators and Parent Partners; Clinical Team Lead provides supervision to all Child and Family Specialists.
All Wraparound Team members are offered booster trainings in general Wraparound concepts and roles. These booster trainings are offered throughout the year by the LACDMH Wraparound Training Department (See sample DMH training opportunities calendar.) Additionally, Wraparound core concepts including CFT matrix, Safety Planning, Flexible Spending (CRSS), underlying unmet need are reviewed during scheduled weekly program staff meetings (see supporting document sample staff meeting agenda) by the Program Manager or Program Coordinator.
(d) Clinical Supervisors and HFW Supervisors/Managers attend general Wraparound training as well as receive initial, ongoing, and booster trainings specific to their leadership/supervisory role.
All Wraparound Team members are offered booster trainings in general Wraparound concepts and roles. These booster trainings are offered throughout the year by LACDMH Wraparound training department (see sample DMH Training Opportunities calendar.) Additionally, Wraparound core concepts including CFT Matrix, Safety Planning, Flexible Spending (CRSS), underlying unmet need are reviewed regularly during scheduled weekly program staff meetings (see supporting document sample staff meeting agenda) by the Program Manager or Program Coordinator.
(e) All Wraparound Team members are required to complete Integrated Core Practice Model Training per Wraparound Policies and Procedures, policy #5 Training Requirements for Providers, page 13. This training includes ho to engage youth who are ICWA members (see supporting document California Child Welfare Core Practice Model: The Activation of CA’s Integrated Core Practice Model in Child Welfare training brochure, pages 2, 8, 10, 12).
As per WA Policies and Procedures #2 Referrals page 6 (see supporting document), Wraparound DMH Liaison screens and assigns all Wraparound referrals received before assigning to a specific provider. When a provider is assigned a youth who is an ICWA member, the Wraparound program manager coordinates and connects immediately with DCFS- Dept of Child and Family Services ICWA social worker to ensure that appropriate permissions and communications are obtained from the youth’s Tribe.
However, if a youth in Wraparound has tribal roots and was discovered during the regular assessment phase or any phase of treatment (i.e. during needs and strengths and cultural considerations interview throughout the CFT engagement process, during family engagement or during a CFT meeting) the youth and family are supported in exploring ways to connect to their roots and support in honoring their tradition and connecting them to appropriate resources that can help in expressing and enhancing their tribal identity. If it is determined that a youth is a member of a tribe after Wraparound services have started, DCFS ICWA team is alerted by the Wraparound Facilitator for guidance and support in engaging youth Tribe of origin. The CFT matrix allows for this discussion and information is documented in the CFT matrix’s cultural considerations section page 1- see supporting document CFT Matrix page 1. Brainstorming and action planning is documented in the Action Planning section of the CFT Matrix- see supporting document page 3.
9.7 Community-based Training Program
a) While DMH does not presently have or require a community-based training plan as part of their required trainings, DMH Parent Advocates survey parents and caregivers on a regular basis to obtain valuable feedback regarding service delivery and satisfaction, which in turn informs trainings provided by DMH (Wraparound Program Policies and Procedures, policy 20, page 42, policy 5, page 13). In addition, at a program level, training of new Wraparound staff involves role-playing with existing staff, including Parent Partners, as well as shadowing of CFT’s, outings, and sessions in the community. These opportunities allow new staff to observe as well as interact with families and youth to get first-hand experience prior to case assignment (see document: IFCCS Wraparound Training Schedule).
b) In addition to training new Wraparound staff, DMH also coordinates and provides engages to community partners and systems of care such as DCFS and Department of Probation regarding the Wraparound model, referral process and criteria, and assists with the development of interdepartmental strategies to support the Wraparound program. The Wraparound Steering Committee, composed of members from DMH, DCFS, Department of Probation, and representatives from provider agencies, provides a forum for collaboration and feedback related to Wraparound goals, directives, polices, and procedures (Wraparound Program Policies and Procedures, page 4)..
9.8 Coaching and Supervision
a) As a part of the onboarding process for all new Wraparound team members, a program training is conducted by the Wraparound Program Manager, Program Coordinator and Clinical Team Lead within the first two months of starting in the wraparound Program. A training schedule/checklist (see supporting document Wraparound IFCCS Training Schedule) is utilized to ensure timely training on the Wraparound process. New team member shadow all types of services being provided within the Wraparound process with client and family’s permission. The new team member is assigned to a supervisor who then connects the new Wraparound team member with an experienced team member within the same role whom this new team member is to shadow especially individual meetings. The Wraparound Supervisor also connects this new team member with a Facilitator who invites this new team member to all CFT related engagement meetings. This onboarding/ training period is about two months before a new team member starts building their own caseload.
b) Program Manager, Program Coordinator and Team Lead provide weekly supervision to all WA Team members- see supporting document Supervision of service delivery staff company policy. Program Manager provides supervision to Program Coordinator, Team Lead, Office Manager and all Clinicians. Program Coordinator provides weekly group supervision to Clinicians and individual supervision to all Facilitators and Parent Partners. Team Lead provides weekly individual supervision to all Child and Family Specialists and once a month group supervision. Monthly consultants are also brought in for consultations and supervision for Birth to 5 clients using Child and Parent Psychotherapy concepts such as how case conceptualization intersects with unmet underlying needs of both caregiver and youth. A Trauma Focused CBT consultant also meets monthly with the team for supervision. Furthermore, Wraparound team members rotate bi-monthly in meeting with with the DMH Wraparound Liaison for ongoing support and coaching.
If additional support is needed by any staff member outside of their supervision or consultation time, all Wraparound team members have access to Program Manager, Program Coordinator and Team Lead as needed. To ensure that all supervisors are accessible, oustaff are required to share their Outlook appointment calendar among all members of the Wraparound Program so that anyone can schedule an impromptu meeting if needed with any supervisors or any team members. A group chat that includes supervisors is created for cases that are high risk so that immediate support can be offered as needed.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
(a) Data is utilized to improve practice with youth and families, including giving staff timely feedback from data or reports relevant to their service provision and using data to identify staff training needs.
LA County DMH performs Technical Reviews and Caregiver and Child/Youth Satisfaction Surveys to collect information and data regarding a provider’s fidelity to the Wraparound Principles, Integrated Core Practice Model, quality, effectiveness and timeliness of services (see document Wraparound Policies and Procedure, Policy #20 Program Monitoring page 42). These data are provided to the provider agency following the review to discuss the provider’s strengths and areas of opportunity including training needs.
On a program level, a yearly Consumer Perception Survey is administered to all clients scheduled for a service during the Consumer Perception Survey week. These surveys are administered by our program’s administrative Staff Assistants. All completed surveys are sent to our agency’s QA Department. Data collected by the QA department are shared to the Wraparound Program Manager and Program Coordinator who then provide a summary to the team and utilizes the information to improve service delivery (See document Consumer Perception Survey form and Consumer Perception Survey Workflow)
The program utilizes data collected from each Wraparound team member’s Supervisee Case Load Dashboard report (see sample Supervisee Caseload Dashboard Report). Data in this report include – in the first column- “Caseload by client status”, information on age ranges in the supervisee’s case load so that age-appropriate clinical support, tools and training are specifically provided to this supervisee. On the second column “Active/Case Pending Case Details” identifies how many clients are classified as high risk, how many active cases the supervisee has, cancellation information etc. This informs supervisors which client need additional support, which clients are having engagement issues etc. Finally, the third column “ Client Status Alerts” provide information on how long a client is enrolled after assignment, how often are clients being seen. The data collected from these reports are discussed every other week during administrative supervision. This report provides the Wraparound supervisor concrete data that shows potential engagement challenges, consistency in care and timely access to care.
(b) Data is utilized to identify and address program needs to better serve families and improve overall program effectiveness.
LA County DMH performs Technical Review and Caregiver and Child/Youth Satisfaction Survey to collect information and data regarding a provider’s fidelity to the Wraparound Principles, Integrated Core Practice Model, quality, effectiveness and timeliness of services (see document Wraparound Policies and Procedure, Policy #20 Program Monitoring page 42). These outcomes are provided to the program following the review to discuss the provider’s strengths and areas of opportunity including but not limited to training needs, clinical needs and staffing needs
In the program level, a yearly Consumer Perception Survey is administered to all clients scheduled for a service within the Consumer Perception Survey week. These surveys are administered by our program’s administrative Staff Assistants. All completed surveys are sent to our agency’s QA department. Data collected by the Quality Assurance Department are shared to the Wraparound Program Manager and Program Coordinator who then utilize teh the data with the team to improve service delivery (See document Consumer Perception Survey form and Consumer Perception Survey Workflow)
Program uses CFT Tracker (see document Wraparound CFT Tracker) to collect information on how often CFT meetings are conducted as well as other 4 Step CFT related meetings such as staff engagement and family engagement. This allows Wraparound Supervisors to monitor timeliness and consistent service delivery by the Wraparound team or the lack thereof so that appropriate support is provided to the team if there are identified engagement, fidelity or clinical barriers.
(c) Data is utilized to identify and communicate system barriers to the Community Leadership Team which impacts the HFW model.
Wraparound Program Manager and Program Coordinator attends a Provider Meeting held every other month that is hosted by LA County Wraparound DMH Administration- Wraparound Program Head, Analysts, Parent Advocate and Liaisons and other Wraparound System of Care leadership attends such as Probation Lead Liaison and DCFS Wraparound lead. These meetings include case consultations, resource dissemination, training, updates, data sharing, contract and funding updates, forms and system updates, referral trends, etc. Any pertinent data collected from outcome measures, access to service data, number of child and families served, contract utilization are broadly discussed in these meetings (see sample Provider Meeting Agenda). Wraparound Providers Meetings functions as an equivalent to Community Leadership Meetings.
The Center’s Wraparound Program Manager and Program Coordinator attends the LACDMH Wraparound Roundtable Meeting held every other month in our Service Area to address specific and unique needs, barriers, issues that affect HFW locally.
Additionally, our agency’s senior leadership has a yearly meeting with LACDMH CMMD (Contract Management and Monitoring Division wherein data about service delivery and barriers are identified so that appropriate plans and supports are explored and identified and then shared with program level management and other staff for operationalization.
Fidelity Indicators
1.1 Timely Engagement and Planning
1.1a) Initial contact must be made within 24 hours of receiving the referral; the enrollment date is the date of first contact and family consent. If contact is not made within 24 hours, all outreach attempts must be documented. Within 72 hours, the team must consult with the referring agency (DCFS/Probation), the Indian Tribe Representative (if applicable), and the DMH Wraparound Service Area Liaison to support engagement.
FPS 3 ICBS Enrollment & Service Delivery (Page 2: 5.1.A)
1.1b) The Child and Family Team (CFT) works with the child/youth and family to develop and implement the CFT Matrix. A Child and Family Team Meeting (CFTM) must occur within 30 days of initial contact and include supports based on family voice and choice. CFTMs occur every 4–6 weeks thereafter. If a CFTM has not occurred within 90 days, the provider must consult with the DMH Wraparound Service Area Liaison.
100-ICBS CFT Meeting Matrix SCP (Page 2 1a and Page 3: 5.0-2b)
1.1c) CFTMs must occur every 4–6 weeks, or more frequently as needed. If a CFTM has not occurred within 90 days, the provider must consult with the DMH Wraparound Service Area Liaison. Check-ins may occur as needed, but services are not limited to CFTMs.
100-ICBS CFT Meeting Matrix SCP (Page 3: 5.0-1a)
1.1d) Teams update the CFT Matrix during Child and Family Team Meetings every 4–6 weeks, or sooner as needed. Updates are completed collaboratively, shared with the team—including the child and family—and documented in the EHR within the same week.
100-ICBS CFT Meeting Matrix SCP (Page 6: 5d)
1.1e) Aviva monitors documentation compliance through monthly reports identifying missing initial CFT Matrices and tracking meeting logs. Facilitators coordinate with note-takers to ensure timely submission, with unresolved issues escalated to supervisors to support timely CFT Matrix updates and accurate EHR documentation.
100-ICBS CFT Meeting Matrix SCP (Page 6 a-d)
1.1f) Aviva staff use timely engagement strategies to maintain family contact. When outreach is difficult, staff may collaborate with the referring party or Tribal Representative(s), adjust outreach efforts, or conduct home visits. If the family is unavailable, a letter is left to support continued engagement and involvement in care planning.
FPS 3 ICBS Enrollment & Service Delivery (Page 2: 5.3 a-b)
1.2 Led by Youth and Families
1.2a) Facilitators revisit the Family Vision to align with family goals. Families co-lead meetings, select team members, and identify natural and culturally relevant supports. Youth and Tribal representatives contribute to planning, with ongoing family feedback guiding adjustments.
FPS 4 Service planning procedure (Page 2: B1 a-e )
1.2b) Children and youth play a central role in CFTMs by sharing their goals, strengths, and preferences. Parents, caregivers, and informal supports contribute insight into the family’s history, culture, and needs, ensuring individualized and culturally responsive planning documented in the EHR.
FPS 5 Clinical Counseling Procedure (Page 2: A-1 and Page 5: G-2
1.2c) Supervisors observe CFT meetings using the CFT Meeting Observation Tool, as well as cross-agency meetings and client sessions. Feedback is provided to staff to clarify procedures and support skill development.
FPS 5 Clinical Counseling Procedure (Page 7: #4b-1 &2) and CFT Meeting Observation Tool
1.2d) The agency conducts caregiver check-ins and satisfaction surveys to monitor service progress, team engagement, and quality of support. Findings are reviewed to guide continuous quality improvement.
FPS 4 Service Planning Procedure (Page 4:D)
1.3 Strength-Based
1.3a) The team aligns service plans with identified strengths, beginning each meeting with a “strengths spotlight” to share successes. The IP-CANS tool identifies functional strengths, which are reviewed in team meetings and the Strengths worksheet is used to discover the families strengths.
100-CFT Meeting, Matrix SCP (Page 3-4: #2, b-ii)
1.3b) Team uses tools to identify strengths in all life domain areas (safety, family, school, cultural, financial, etc.
100-CFT Meeting, Matrix SCP (Page 3-4: #2, b-ii) SNCD Worksheet
1.3c) Supervisors review random CFT matrices and provide feedback during individual and group supervision, team meetings, and DMH trainings. Updates are reviewed at the next family meeting.
FPS 4 Service Planning Procedure (Page 4: A-1)
1.3d) The agency uses caregiver check-ins and surveys to monitor progress, engagement, and support quality, analyzing findings to guide continuous improvement.
FPS 4 Service Planning Procedures (Page4: D)
1.4 Needs Driven
1.4a) The team focuses on identifying and prioritizing the youth and family’s underlying needs. Facilitators ensure that the team’s efforts address the true drivers of behavior and support long-term positive change.
100-CFT Meeting, Matrix SCP (Page 4: #2-b-iv)
1.4b) Teams receive ongoing Wraparound training, coaching, and reflective practice to identify and address underlying needs, with continuous improvement guided by family feedback, quality checks, and performance data.
FPS 4: Service Planning Procedure (Page4: A-#1 and E-#1)
1.4c) During CFT Matrix development, the team reviews IP-CANS and the Needs and Services tool with the youth and family to identify strengths, needs, and underlying concerns. This ensures the Matrix reflects both assessment results and family priorities in a comprehensive, family-driven plan.
100-CFT Meeting, Matrix SCP (Page 4: #2-b-ii) and Needs and Services Tool
1.4d) The team and family determine when needs are met and can be sustained through natural supports. A family-driven Transition Plan outlines strengths, community resources, and next steps to maintain progress and stability.
FPS 5 Clinical Counseling Procedure (Page 4: #4-a & b)
1.5 Individualized
1.5a) The forms and paperwork the team uses are flexible so that each child or youth, and their family, can have a plan that fits their unique needs.
100-CFT Meeting Matrix SCP (Page 4: c- i, ii and iii)
1.5b) Teams receive ongoing Wraparound training and coaching to use flexible, ‘thinking outside the box’ approaches in individualized plans for each child/youth and family.
FPS 4 Service Planning Procedure (Page 5: E and #1 thru #3)
1.5c) Facilitators engage in role-specific training and ongoing coaching, including facilitator-focused or group sessions with specific topics for continuous support.
FPS 4 Service Planning Procedure (Page 5: #4)
1.5d) Plans are routinely reviewed to address the strengths and needs while leveraging the family’s natural and community supports.
100 CFT Meeting Matrix SCP (Page 5 d-#ii thru iv)
1.5e) The agency conducts caregiver check-ins and satisfaction surveys to monitor progress and ensure services meet family needs. Findings are analyzed and shared with staff and leadership to guide continuous quality improvement, coaching, and training.
FPS 4 Service Planning Procedure (Page4: D)
1.6 Use of Natural and Community Based Supports
1.6a) The Facilitator uses tools to identify natural and community supports during the development of the CFT Matrix and throughout the process. Families are encouraged to invite these supports, and ongoing check-ins ensure new supports are incorporated into the plan.
100-CFT Meeting Matrix SCP (Page 4: 2b-v)
1.6b) Staff receive ongoing training and coaching to identify, engage, and integrate natural supports, helping families strengthen community networks and promote sustainable, family-centered solutions.
FPS 4 Service Planning Procedure (Page 4: E)
1.6c) CFT Matrix plans are reviewed to integrate natural and community support, with staff trained to engage these resources and update plans as family needs evolve.
FPS 4 Service Planning Procedure (Page 4: A-2; a thru d)
1.6d) Family feedback on natural supports is collected via satisfaction surveys and quality check-ins. Results are analyzed and shared with staff and leadership to guide continuous improvement and targeted training.
FPS 4 Service Planning Procedure (Page 4; D)
1.7 Culturally Respectful and Relevant
1.7a) During engagement meeting, the Wraparound team introduces the process and roles, reviews referral documents, and consults with prior providers, CSW, and/or the DMH liaison to identify needs, strengths, and goals for enrollment. All engagement and planning meetings are documented in the client record.
FPS 5 Clinical Counseling Procedure (Page 3: F; 1-b & c)
1.7b) Staff incorporate the family’s cultural beliefs, values, and preferences into service planning, supported by ongoing cultural competency training, while documenting the family’s strengths, experiences, and community supports.
FPS 4 Service Planning Procedure (Page 2: B; 2 a-d)
1.7c) The agency collects family feedback through quality check-ins and satisfaction surveys. Once analyzed, results are shared with leadership and staff to guide training, coaching, and continuous improvement in care delivery.
FPS 4 Service Planning Procedure (Page 4:D)
1.8 High-Quality Team Planning and Problem Solving
1.8a) At the end of each meeting, participants review the plan and sign the signature page to confirm their roles and responsibilities. The signed agreement is documented in the youth’s file.
100-CFT Meeting Matrix SCP (Page 4: c-iv & v)
1.8b) The Data dept. and Supervisor gather feedback from families and team members through meeting observations, satisfaction surveys, and quality-assurance phone calls, which also helps track fidelity indicators. These methods provide regular insight into team engagement and collaboration.
FPS 5 Clinical Counseling Procedure (Page 7: 4- a & b)
1.8c) The feedback and data we collect is regularly use for continuous quality improvement. It is shared with staff and supervisor to guide training, coaching and practice enhancements.
FPS 5 Clinical Counseling Procedure (Page 7: #4- a-#2)
1.8d) CFT Matrix plans are reviewed by the Facilitator to monitor shared ownership and follow-through on action items. Progress is reviewed at each meeting, and strategies are adjusted with the team as needed.
FPS 5 Clinical Counseling Procedure (Page 4: #3-c & d)
1.9 Outcomes Based Process
1.9a) The CFT Matrix includes specific, measurable strategies and action items with timeframes. The plan is reviewed with the youth and family to ensure it reflects their preferences, goals, and requested changes.
100-CFT Meeting Matrix SCP (Page 5: d-iv)
1.9b) The team updates the plan at each follow-up based on family preferences and identified needs, reviews the CFT Matrix plan for strengths and shared ownership, and monitors task completion, revising strategies and action items when progress stalls.
100-CFT Meeting Matrix SCP (Page 5:d- iv)
1.9c) The CFT Matrix plan is updated as needed during CFT meetings where child/youth, family, informal and formal supports are present.
100-CFT Meeting Matrix SCP (Page 5: d-iv)
1.9d) Therapist completes the IP-CANS Assessment and shares results during the CFT meeting where the CFT matrix plan is developed and reviewed.
104-ICBS Outcomes Measure Policy and Procedure (page 4, 7.0-2b)
1.9e) The team implements the plan of care by monitoring action items, strategies, and successes, while regularly reviewing and updating the IP-CANS and Plan of Care, to stay aligned and support effective collaboration for a successful transition.
FPS 5 Clinical Counseling Procedure (Page 4-#3)
1.10 Persistence
1.10a) The team demonstrates persistence by maintaining engagement and re-evaluating strategies after crises or stalled progress, incorporating caregiver and youth feedback to guide ongoing support.
FPS 5-Clinical Counseling Procedures (Page 4-3d)
1.10b) Teams access support through Treatment Team Meetings (TTMs), supervision, coaching, or email consultation. Supervisors may attend meetings and provide guidance on resources, including flexible funding, to address barriers and support service delivery.
100-CFT Meeting Matrix SCP (Page 3: 1-d-i, ii)
1.10c) Facilitators are trained to plan and facilitate emergency CFT meetings post-crisis, review and amend safety plans as needed, and use standardized templates for meetings and plan revisions.
100-CFT Meeting Matrix SCP (Page 5: 3-d-i)
1.11 Transitions as a part of the Fourth Phase of HFW
1.11a) Transition begins when the team and family agree that needs have been met or can be sustained through natural support, reflecting family readiness to maintain progress.
FPS 5 Clinical Counseling Procedure (Page 4-#4)
1.11b) Transition plans include ongoing check-ins, celebrating accomplishments per the family’s preference, and ensuring connections to natural and community support, which are key indicators of a successful transition.
FPS 5 Clinical Counseling Procedure (Page 5-#c-1-3)
Expected Outcomes
2.1 Youth and Family Satisfaction
2.1 Aviva Family and Children’s Services utilize standardized measures to evaluate quality care, effectiveness, and Youth Satisfaction Surveys (YSS) to collect data on the family’s experience in services. YSS gathers demographics to identify if the family is affiliated with a Tribe to ensure we evaluate satisfaction for this population. Aviva utilizes the standardized survey for collecting youth and caregiver reported satisfaction in services with documented procedures for administration, analysis, and use in continuous quality improvement.
104-ICBS Outcome Measures Policy Page 3 (6.0-f), Page 4 (7.0 #6-a) and Page 5 (10.0-b)
2.2 Improved School Functioning
2.2 Aviva Family and Children’s Services evaluate improved school, educational, and vocational functioning by utilizing the Integrated Practice: Child and Family Adolescent Needs and Strengths (IP-CANS), Pediatric Symptom Checklist (PSC-35), Outcome Measure Application (Child and TAY OMA) and Key Event Change (KEC). IP-CANS and PSC-35 are completed with families through our Electronic Health Record (Exym). Outcome Measure Application: Baseline and 3M Child/TAY OMA and KEC are uploaded electronically into the client’s Electronic Health Record (Exym). Aviva utilizes data regarding improved school and vocational functioning to evaluate the client progress in services from intake to discharge.
104-ICBS Outcome Measure Policy and Procedure Page 2-3 (6.0 a-e), Page 4 (7.0 #1-5), and Page 4-5 (8.0 #2-a) (9.0 c) and (10.0-b)
2.3 Improved Functioning in the Community
2.3 Aviva Family and Children’s Services evaluate improved functioning in the community by utilizing the Integrated Practice: Child and Family Adolescent Needs and Strengths (IP-CANS), Outcome Measure Application (Baseline/3M Child and TAY OMA), Key Event Change (KEC), and Targeted Case Management Function Evaluation (TCM-CFE). IP-CANS and TCM-CFE are completed with families through our Electronic Health Record (Exym). Outcome Measure Application: Baseline/3M Child and TAY OMA and KEC are uploaded electronically into the client’s Electronic Health Record (Exym). Aviva utilizes data regarding improved functioning in the community to evaluate the client progress in services from intake to discharge.
104-ICBS Outcome Measure Policy and Procedure Page2-3 (6.0 a-b, d-e), Page 4 (7.0 #1-5), and Page 4-5 (8.0 #2-a), (9.0 c) and (10.0-b)
2.4 Improved Interpersonal Functioning
2.4 Aviva Family and Children’s Services evaluate improved interpersonal functioning by utilizing the Integrated Practice: Child and Family Adolescent Needs and Strengths (IP-CANS) and Pediatric Symptom Checklist (PSC-35). IP-CANS and PSC-35 are completed with families through our Electronic Health Record (Exym). Aviva utilizes data regarding improved interpersonal functioning to evaluate the client progress from intake to discharge.
ICBS Outcome Measure Policy and Procedure Page 2-3 (6.0 a-c), Page 4 (7.0 #1-3), Page 4-5 (8.0 #2-a), (9.0 c) and (10.0-b)
2.5 Increased Caregiver Confidence
2.5 Aviva Family and Children’s Services evaluate increased caregiver confidence by utilizing the Integrated Practice: Child and Family Adolescent Needs and Strengths (IP-CANS). IP-CANS are completed with families through our Electronic Health Record (Exym). Aviva utilizes data to evaluate success and confidence in services from intake to discharge.
ICBS Outcome Measure Policy and Procedure Page 2 (6.0 a-b), Page 4 (7.0 #3), Page 4-5 (8.0 #2-a), (9.0 c) and (10.0-b)
2.6 Stable and Least Restrictive Living Environment
2.6 Aviva Family and Children’s Services evaluate Stable and Least Restrictive Living Environment by utilizing the Integrated Practice: Child and Family Adolescent Needs and Strengths (IP-CANS), Outcome Measure Application (OMA), Key Event Change (KEC). IP-CANS are completed with families through our Electronic Health Record (Exym). Outcome Measure Application: Baseline Child/Tay OMA and KEC are uploaded electronically into the client’s Electronic Health Record (Exym). Special Incident Report (SIR) and Aviva Incident Report are completed by staff upon a reported placement change within 12 hours. Aviva utilizes data and analyzes through the experience related to stability from intake to discharge.
ICBS Outcome Measure Policy and Procedure Page 2-3 (6.0 a-b, d-e), Page 4 (7.0 #1-5), Page 4-5 (8.0 #2-a), (9.0 c) and (10.0-b)
Aviva Incident Reporting Policy and Procedures Page 1 (1.0), Page 2-3 (3.0), and Page 3 (5.3.1)
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
2.7 Aviva Family and Children’s Services evaluate Reduction in Inpatient, Emergency Department Admission for Behaviors Health Visits by utilizing the Integrated Practice: Child and Family Adolescent Needs and Strengths (IP-CANS), Pediatric Symptom Checklist (PSC-35), Outcome Measure Application (OMA), and Key Event Change (KEC). IP-CANS and PSC-35 are completed with families through our Electronic Health Record (Exym). Outcome Measure Application: Baseline Child/Tay OMA and KEC are uploaded electronically into the client’s Electronic Health Record (Exym). Aviva utilizes data and analyzes through family’s experience related to reduction of inpatient/emergency from intake to discharge.
ICBS Outcome Measure Policy and Procedure Page 2-3 (6.0 a-e), Page 4 (7.0 #1-5), and Page 4-5(8.0 #2-a) (9.0 c) and (10.0-b)
2.8 Reduction in Crisis Visits
2.8 Aviva Family and Children’s Services evaluate Reduction in Crisis Visits in utilizing the Integrated Practice: Child and Family Adolescent Needs and Strengths (IP-CANS), and Crisis Call Log. IP-CANS is completed with families through our Electronic Health Record (Exym). Crisis call log is documented by staff in documenting family contacting Aviva’s 24/7 Crisis Line following a crisis. Family decrease or no calls to crisis line evaluates the family’s ability to decrease a crisis utilizing interventions learned through the team and natural supports. Aviva utilizes data regarding reduction of crisis visits to evaluate the client progress in from intake to discharge.
104-ICBS Outcome Measure Policy and Procedure Page 2 (6.0 a-b), Page 4 (7.0 #1-3), Page 4-5 (8.0 #2-a) (9.0 c) and (10.0-b)
Crisis On-Call Rotation Policy and Procedure Page 2 and 3 (Documentation, paragraph 3)
2.9 Positive Exit from HFW
2.9 Aviva Family and Children’s Services evaluate Positive Exit from services by utilizing the Integrated Practice: Child and Family Adolescent Needs and Strengths (IP-CANS) and Pediatric Symptom (PSC-35) scores from intake to transition of discharge to evaluate family’s readiness to exit from services. KEC collects data in capturing if there is a discontinuation or interruption of services such as graduation in services from meeting treatment goals versus other reasons to capture positive exit of HFW. IP-CANS and PSC-35 are completed with families through our Electronic Health Record (Exym). KEC are uploaded electronically into the client’s Electronic Health Record (Exym). Aviva Family and Children’s Services evaluate Positive Exit from services in capturing the graduation percentage rate vs disenrollment percentage rate to determine the difference in reasoning in discharging from services.
ICBS Outcome Measure Policy and Procedure Page 2-3 (6.0 e), Page 4 (7.0 #5a) Page 4-5 (8.0 #2-a) (9.0 c) and (10.0-b)
Engagement
3.1 Orientation
3.1a) During enrollment, all team members are present to review roles and wraparound principles and phases of treatment. Intake paperwork is completed which includes limits to confidentiality, licensure status, agency orientation and information, grievance forms, authorization to release information and client rights to access their clinical record. Each team member reviews their role and contact information. The team reviews who is included in the family unit for future meetings and treatment involvement including natural supports and Tribes if client is an Indian child.
FPS 5 Clinical Counseling Procedure, page 2-3, 5.0 Procedures, A1&B.
3.1 subsection a) Team members meet with the family to review phases of treatment such as beginning (such as building rapport, supporting basic needs, safety and crisis planning, linkages to medical or psychiatric support and schedule of services with each team member and frequency of CFT meetings), middle (such as stabilization, progression in treatment goals and linkage to external activities) and end (decrease in frequency of sessions and CFT meetings, maintenance of treatment goals and long term planning for continuation of care, preparing for lower level of care). Team members embody, encourage and empower families to utilize the 10 principles of wraparound to support their treatment and success.
FPS 5 Clinical Counseling Procedure, page 2, 5.0 Procedures, A1.
3.1 subsection b) Intake paperwork is completed during the first meeting which includes limits to confidentiality, therapist licensure status, agency orientation and information, grievance forms, authorization to release information and client rights to access their clinical record.
FPS 5 Clinical Counseling Procedure, page 3, B. Legal and Ethical Documentation
3.1 subsection c) During initial meeting, each team member presents their role, purpose and creates tentative frequency and schedule. Team reviews who should be included in the treatment process including natural supports and Tribes if relevant.
FPS 5 Clinical Counseling Procedure, page 2, 5.0 Procedures, A, #1.
3.2 Safety and Crisis stabilization
3.2a) During initial meeting/enrollment, team reviews immediate safety concerns, team member contact information and provides the number to the crisis line to the client and family. The team will assess for safety risks and develop an immediate crisis plan if needed.
FPS 5 Clinical Counseling Procedure, page 6, C. Safety Crisis Planning, #1
3.2b) Within 30 days of enrollment, the team and family develop a safety crisis plan that reviews threats, risks, triggers, coping strategies and tools, numbers of all team members, crisis line and resources that support the family during a crisis. This is updated as clinically indicated, after a crisis or every 6 months.
FPS 3, ICBS Staff, Client, and Family Safety, page 2, 5.0 Procedures, 5.2 Safety Crisis Planning with the Family, A-C.
3.2c) All families are provided team member phone numbers, their availability 24/7 and the 24/7 crisis phone number upon enrollment.
FPS 5 Clinical Counseling Procedure, page 6, C. Safety Crisis Planning #3
3.3 Strengths, Needs, Culture and Vision Discovery
3.3a) During Engagement and Assessment phase, the therapist will complete the Mental Health Assessment to gather information about what brought the client and family to Wraparound, make an informed diagnosis and provide overview of treatment goals and pathway. The wraparound team will meet with the client and family to go over the family’s story which include: their relevant history, culture and needs, strengths and protective factors, safety risks and overview of how wraparound will support them.
100-CFT Meeting, Matrix, and Safety Crisis Plan, Page 4, 2b,iii.
3.3b) During CFT meetings, a designated team member, documents strengths, needs, cultural discovery, natural supports and progress towards goals in real time. Each area is updated throughout the treatment process based on client and family needs, after crises or when there is new information to represent the family’s voice and choice.
100-CFT Meeting, Matrix, and Safety Crisis Plan, Page 3, 4b.
3.4 Engage All Team Members
3.4a) During engagement and assessment, families are encouraged to identify natural supports, both informal and formal that will assist in client and family to achieve their goals. These individuals/groups are documented in the CFT matrix and updated as needed.
FPS 5 Clinical Counseling Procedure, page 3, D
3.4b) The team continuously updates, consults and invites all members of the children’s system of care partners to meetings/services provided to the family.
100-CFT Meeting, Matrix, and Safety Crisis Plan, Page 3, 1a.
3.4c) During engagement and assessment, families are encouraged to identify natural supports, both informal and formal that will assist in client and family to achieve their goals.
FPS 5 Clinical Counseling Procedure, page 3, D. Identification of Supports
3.4d) All services are documented in client’s electronic health record and CFT matrix.
FPS 5 Clinical Counseling Procedure, page 5, G. Documentation, 1.
3.5 Arrange Meeting Logistics
3.5a) The Wraparound team works to meet the client and family in a location, time and modality that works best for them.
FPS 5 Clinical Counseling Procedure, page 6, B. Service Delivery, #1
3.5b) The wraparound team encourages weekly meetings in order to build rapport, provide stabilization in resources and reduce safety risks and make adjustments to frequency based on client’s voice and choice and as clinically indicated.
FPS 5 Clinical Counseling Procedure, page 6, Section 5.0, B. Service Delivery #1-3
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
4.1-1) The team meet with client and family to discuss the purpose behind CFT meetings and develop “ground rules” that are collaborative discovered to support the family’s goals.
100-CFT Meeting, Matrix, and Safety Crisis Plan, Page 4, 2b, i.
4.1-2) The CFT meeting begins with sharing and documenting strengths of the youth and family in the CFT matrix.
100-CFT Meeting, Matrix, and Safety Crisis Plan, Page 4, 2b, ii.
4.1-3) The CFT matrix includes the family’s long-term view or goals and how each team member will support this goal throughout treatment.
100-CFT Meeting, Matrix, and Safety Crisis Plan, Page 4, 2b, iii.
4.1a) The team uses agency’s standard planning template to develop team agreements, team strengths inventory and mission statement and documented in the youth’s chart.
100-CFT Meeting, Matrix, and Safety Crisis Plan, Page 4, 2b, ii-iii.
4.1b) As treatment continues, each CFT matrix is updated to reflect current strengths, individualized goals, cultural beliefs and needs while all uploaded to youth’s chart.
100-CFT Meeting, Matrix, and Safety Crisis Plan, Page 4, 2b, ii.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
4.2a) Upon receipt of new referral, the team reviews all documentation related to the youth. The facilitator reaches out to schedule a staff meeting with the previous treatment team, CSW or referring party if applicable to gather information.
100-CFT Meeting, Matrix, and Safety Crisis Plan, Page 4, 2b, iv.
4.2b) During the staff engagement, the teams discuss progress towards goals, family’s goals and mission, identified needs that underly symptoms and behaviors and begin developing goals for continuation of care.
100-CFT Meeting, Matrix, and Safety Crisis Plan, Page 4, 2b, iv.
4.2c) After enrollment and the completion of the MH assessment by the therapist, the team develops with youth and family their goals, needs and safety concerns with the entire HFW team.
FPS 5, Clinical Counseling Procedures, page 4, F, #2, a-b
4.2d) All services to engage, schedule and gather information to support smooth transition and engagement with the youth are documented in the youth’s file (Exym). Any meeting minutes (Staff engagement or Treatment Team Meetings) are uploaded to External documents in the youth’s file.
FPS 5, Clinical Counseling Procedures, page 5, 5.0 Procedures, G
4.2e) Facilitators facilitate the family story meeting where goals, needs and safety risk are reviewed and identified together. The facilitator documents each team member’s roles and responsibilities to support the family’s ability to achieve their goals.
FPS 5, Clinical Counseling Procedures, Page 4, 3 c-d.
4.2f) All engagement and Plan Development meetings are used throughout treatment and to create a HFW Plan of Care, which informs progress towards treatment goals and needs as treatment continues.
FPS 5, Clinical Counseling Procedures, Page 4, 3 a & d.
4.3 Develop an Individualized Child or Youth and Family Plan
4.3 subsection 1) The Plan of Care, aka CFT Matrix establishes a family vision, team mission, strengths, needs and culture of the youth and family while continuously updated and reviewed each subsequent meeting.
FPS 5, Clinical Counseling Procedures, Page 4, 3, a-b.
4.3 subsection 2) The CFT Matrix reviews needs and the progress towards meeting those underlying needs each CFT meeting and documented on the matrix. Formal supports such as the family’s social worker, teachers and or probation officer are all identified and invited to attend any CFT meeting to contribute to the family’s mission and goals.
FPS 5, Clinical Counseling Procedures, Page 4, 3 b.
4.3 subsection 3) The facilitator or team member will document all action items, progression towards goals and clear deadline by each team member in the CFT Matrix. The intent is for the family to increase the utilization their own systems of support and to decrease the involvement of the HFW team.
FPS 5, Clinical Counseling Procedures, Page 4, 3 c.
4.3 subsection 4) The Plan of Care outlines the services, supports including all formal and informal parties, identifies the family’s needs, voice and choice, culture, history and is discussed in a location chosen by family.
FPS 5, Clinical Counseling Procedures, Page 4, 3, a-b.
4.3 subsection 5) Natural and informal supports are included in the transition plan as they play a key role in sustaining ongoing progress and success of the youth and family.
FPS 5, Clinical Counseling Procedures, Page 5-4C 2.
4.3 subsection 6) The transition plan shall document the youth and family’s demonstrated readiness for reduced team involvement, attainment of treatment goals, and appropriateness for transition to less intensive services.
FPS 5, Clinical Counseling Procedures, page 5, 4a.
4.3a) The supervisor works with the Facilitator to regularly collaborate and strategize their approach to improve treatment outcomes throughout the week. The supervisor works with the Facilitator to support the team’s action plans and goals to ensure progression towards outcomes while incorporating wraparound principles.
FPS 5 Clinical Counseling Procedures, Page 4, 2a; ICBS SharePoint Links Training Row 10-15 Column G
4.3b) All formal supports (CSW, PO, school teachers/admin and etc.) are invited to be included in CFT meetings and participate in developing and supporting the goals discussed with the youth and family. The team consults and communicates collaboratively with all supports identified by the youth and family.
FPS 5, Clinical Counseling Procedures, Page 4, 3b.
4.3c) All CFT Matrices and documentation are uploaded to the youth’s chart and accessible to all team members.
FPS 5, Clinical Counseling Procedures, Page 5, G.
4.3d) Supervisors review and ensure all CFT matrices and all documentation related to the youth and family are clear, complete and meet the agency standards.
FPS 5, Clinical Counseling Procedures, Page 7, #4
4.4 Develop a Crisis and Safety Plan
4.4a) During initial meeting/enrollment, team reviews immediate safety concerns, team member contact information and provides the number to the crisis line to the client and family. The team will assess for safety risks and develop an immediate crisis plan if needed. All families are provided team member phone numbers, their availability 24/7 and the 24/7 crisis phone number upon enrollment.
FPS 5 Clinical Counseling Procedure, Page 6, C. Safety Crisis Planning #1-4
4.4b) The team works together regularly to collaborate and strategize their approach to improve treatment outcomes. The Facilitator supports the team’s action plans and goals to ensure progression towards outcomes.
FPS 5 – Clinical Counseling Procedures, Page 6, C, # 2 & 4
4.4c) Within 30 days of enrollment, the team and family develop a safety crisis plan that reviews threats, risks, triggers, coping strategies and tools, numbers of all team members, crisis line and resources that support the family during a crisis. This is updated as clinically indicated, after a crisis or every 6 months.
FPS 3, ICBS Staff, Client, and Family Safety, Page 2, Section 5.1-5.3 – Safety Crisis Planning with the Family.
Implementation
5.1 Implement The Plan of Care
5.1a) The Facilitator guides the team by utilizing the developed plan of care (CFT Matrix) by monitoring completion of actions items, individualized strategies and celebrating achievements. CFT Matrix is reviewed and updated based on the family’s successes, underlying needs, and modifications needed.
FPS 5 Clinical Counseling Procedure (page 4 #3 and #3c-d) and 100-CFT Meeting Matrix SCP Policy and Procedure (page 5 #2d-iv)
5.1b) Staff receive ongoing training and coaching on implementing the plan of care (CFT Matrix). CFTM’s are observed by a supervisor utilizing the CFT observation tool to monitor fidelity to the HFW principles and provide feedback to the Facilitator for any modifications and acknowledge successes.
100-CFT Meeting Matrix SCP Policy and Procedure (page 6 #6e), FPS 5 Clinical Counseling Procedure (page 7 D#4-b1 and 104-ICBS Outcome Measure Policy and Procedure (page 3 #6h)
5.2 Review and Update The Plan of Care
5.2a) The Facilitator continuously documents/evaluates progress, implementation of strategies, and action items in leading into the follow-up CFT meetings and within the CFT meeting to identify successes and modifications needed.
100-CFT Meeting Matrix SCP Policy and Procedure (page 5 #2d-i-iv)
5.2b) During follow-up CFT meetings, the Facilitator reviews the existing plan of care (CFT Matrix) to assess progress, acknowledge successes, address challenges, and identify any new needs or required modifications. Updated plan of care (CFT Matrix) is clearly outlined for the family and team to support timely progress to the family goals and documented in the client’s record
100-CFT Meeting Matrix SCP Policy and Procedure (page 5 #2d-ii-iv) (page 6 #5c) and FPS 5 Clinical Counseling Procedure (page 4 5.0 #3)
5.2c) Facilitator and team clearly document completion of tasks, assignments, attendance, flex funds, natural supports, and updates are communicated in CFT meetings if any modification is made to the plan of care (CFT Matrix). Updates clearly outline each team members’ responsibilities along with flex funds to support the family’s needs.
FPS 5 Clinical Counseling Procedure (page 4 5.0 #3-c) and 100-CFT Meeting Matrix SCP Policy and Procedure (page 3 5.0 #1a and d-ii) (page 4 #2c-i-iv)
5.2d) Facilitator and team update all relevant information, including behavioral challenges, interventions, action steps, underlying needs, attendance, and team changing within the plan of care (CFT Matrix).
100-CFT Meeting Matrix SCP (page 6 #5d-e)
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
5.3a) Facilitator reviews the developed plan of care (CFT Matrix) agreements and communicates agreements during each CFT meeting to respect the family’s voice of choice to determine if modifications need to be made.
FPS 5 Clinical Counseling Procedure (page 3 5.0 F#2) (page 4 #3-a) and 100-CFT Meeting Matrix SCP (page 4 #2-b-i) (page 6 #5d)
5.3b) Facilitator receives ongoing training and coaching from the supervisor utilizing the CFT observation tool and Treat Team Planning Meeting (TTM) to maintain positive team morale and effective teamwork.
FPS 5 Clinical Counseling Procedure (page 4 5.0 F#3d) (page 7 5.0 D#4-b) and 100-CFT Meeting Matrix SCP (page 3 5.0 #1-di)
5.3c) Facilitator monitors and integrates the family’s natural supports through the plan of care (CFT Matrix) and consults with supervisor for feedback regarding the implementation of formal and natural supports into CFT meetings.
FPS 5 Clinical Counseling Procedure (page 4 5.0 F#3d)
5.3d) Facilitator collaborates effectively to ensure new team members, including natural supports are added to the family’s services within a timely manner and smoothly to respect the family’s voice and choice. Facilitator ensures all relevant information is communicated regarding the family’s needs and services appropriately.
100-CFT Meeting Matrix SCP (page 6 5.0 #5e i-iv)
Transition
6.1 Develop a Transition Plan
6.1a) The facilitator supports the team in determining readiness for transition by reviewing monitored benchmarks and indicators throughout the process.
FPS 5 Clinical Counseling Procedure (Page 5-#4)
6.1b) The facilitator leads the collaborative development of a Transition Plan that documents progress, identifies sustainable natural and community supports, and outlines next steps in the CFT matrix plan. Successful transition is reflected in the family’s continued progress and connection to supports, with accomplishments recognized according to family preference.
FPS 5 Clinical Counseling Procedure (Page 5-#4a-c)
6.1c) The Facilitator leads the Child and Family Team (CFT) meeting, bringing together all team members to develop the transition plan. Facilitators receive guidance and coaching on the appropriate timing for initiating these discussions, based on the family’s stage in the process.
FPS 5 Clinical Counseling Procedure (Page 5-#4 last sentence)
6.1d) Formal team members are assigned specific tasks to ensure the transition plan is effective and that the family is appropriately connected to all necessary resources, which are in place to support the family after Wraparound services end.
FPS 5 Clinical Counseling Procedure (Page 5-c 2 & 3)
6.2 Develop a Post-Transition Safety Plan
6.2a) The Facilitator updates the Safety Crisis Plan during the CFT meeting to ensure crisis procedures and family-identified natural supports are current, then enters the finalized plan into the EHRS.
100-CFT Meeting Matrix SCP (Page 6- #4 a)
6.2b) Trained and coached by their supervisor, during the CFT meeting, the Facilitator, leads the Safety Plan review and update, ensuring key elements remain in place and formal supports transition to natural supports.
100-CFT Meeting Matrix SCP (Page 6- #4a)
6.2c) Safety and Crisis Plans are reviewed through established supervisory processes to ensure individualized, culturally responsive strategies; appropriate progression of proactive and reactive interventions; and the inclusion of family-identified natural supports. These reviews are used to support continuous quality improvement, as well as ongoing training and coaching of staff.
100-CFT Meeting Matrix SCP (Page 6- #4a-i)
6.3 Create a Commencement and Celebrate Success
6.3a) The team invites the family to share how they’d like to celebrate their Wraparound graduation, honoring their successes, culture, values, and preferences.
FSP 5 Clinical Counseling Procedure (Page5-4c)
6.3b) After the family confirms the graduation plan, the team will coordinate needed supports, request flex funds (as needed), and attend the celebration.
FSP 5 Clinical Counseling Procedure (Page5-4c-2)
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
7.1a) The Impact and Innovations department gathers feedback from surveys where the data is analyzed and presented at Program Committee and Line of Sight meetings, where program leadership is present. Program leadership then reviews this information and utilizes this information to improve practices and change policies and procedures.
PQI Handbook (page 4-5 How Aviva Uses Data, The PQI Process in Action)
7.1b) Families are involved in service planning and implementation during the CFT process, as well as through surveys. Aviva plans to implement bi-annual focus groups via the Parent Support group to survey families about how the policies impact treatment and what they would like to see differently and how services can be improved.
PQI Handbook (page 4-5 How Aviva Uses Data, The PQI Process in Action), FPS2 ICBS Caseloads (page 2 5.1#5)
7.2 Community Leadership Team
7.2a) The Director of Wraparound and/or alternates attend all current Wraparound related meetings facilitated by the Los Angeles County Department of Mental Health.
Wrap Representation Policy (page 1 #3)
7.3 Eligibility and Equal Access
7.3a) Aviva has established eligibility criteria based on LA County DMH guidelines. As long as they meet criteria, services are provided.
FPS 3 ICBS Enrollment and Service Delivery (page 2 5.1b)
7.3b) Policies and procedures address caseload assignments that take into account the severity, intensity, and frequency of services needed to meet families needs.
FPS 2 ICBS Staff Availability Policy (page 2 4.0, 5.2, 5.3)
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
8.1a) As a contracted provider with LACDMH, Aviva’s budgeting and contracting processes prioritize the allocation of flex funds and resources to support essential Wraparound operations.
Accounting Manual 2025 (page 8-9 Accounts Receivable-DMH (Outpatient Mental Health Services); page 77 Fee for service contracts, provider rate based)
8.1b) Aviva’s fiscal practices are developed in accordance with LACDMH contract requirements, and are designed to sustain required staffing, workforce development, data collection infrastructure, and data management systems, and the full costs of individualized services for the youth and families.
Accounting Manual 2025 (page 13 Cost Allocation, page 19 Annual Budgets Process Overview; page 76 Functions)
8.1c) Programmatic support such as the Impact and Innovation department that performs data collection and analysis is essential to program improvements, staff training, and policy and procedures. The general cost is allocated to various programs supported by those functions.
Accounting Manual 2025 (page 13 cost allocation)
8.2 Equitable Funding Across System Partners
N/A
8.3 Cost Savings are Reinvested
N/A
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
8.4a) The Los Angeles County Department of Mental Health contract provides allocated Flexible Funds for the Wraparound program.
Accounting Manual 2025 (page 76 Functions)
8.4b1) There is a 2 day time frame from discussing the need with the family to submitting the requested documentation.
ICBS Flex Fund Policy and Procedure (page 7 5.11)
8.4b2) The approval process for flex funds is clearly delineated in the Flex Fund policy. Staff must document the needs of the family, including being culturally relevant, build on family strengths, and be a good value for the investment, amongst other requirements.
ICBS Flex Fund Policy and Procedure (page 2 5.1, 5.2.1)
8.4b3) If flex funds are denied, there is an appeals process in place.
ICBS Flex Fund Policy and Procedure (page 8 5.12.4)
8.5 Collaborative Oversight of Flex Funds
8.5a) The LACDMH and Aviva have shared oversight and collaborate as needed regarding the use and availability of flex funds. All flex fund related documentation is submitted through the LACDMH WTS provider portal and stored in the client chart.
ICBS Flex Fund Policy and Procedure (page 1 3.0)
8.5b) Flex funds are processed through Aviva’s billing department which bills to LACDMH and is reimbursed monthly.
Accounting Manual 2025 (page 8-9 Accounts Receivable –DMH (Outpatient Mental Health Services), page 76 Functions, Process)
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
8.6a) Aviva braids multiple funding sources to ensure flex funds and program resources remain available. When one source is limited, we proactively identify and leverage alternative funding options.
ICBS Flex Fund Policy and Procedure (page 9 5.12.5.3)
8.6b) In cases where flex funds are limited, Aviva may reallocate internal resources, access unrestricted funds, or increase reliance on other compatible funding streams to address service gaps without disruption.
ICBS Flex Fund Policy and Procedure (page 9 5.12.5.3)
8.6c) Should clients needs not meet the requirements of the flex fund criteria, Aviva utilizes community resources and explores unrestricted funds to meet the clients basic needs.
ICBS Flex Fund Policy and Procedure (page 9 5.12.5.3)
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
9.1a) Aviva’s Impact and Innovation department gathers demographic data from our electronic healthcare records system and presents the information in quarterly Program Committee meetings. Leadership utilizes this information to inform HR of recruitment preferences, as well as include preferences on job descriptions.
Program Committee January 2026 slide 3, HR-05 Hiring Policy and Procedures (page 1-2 5.1-5.5), see sample of Wraparound Facilitator ICBS FINAL (page 2 last item)
9.1b) Aviva reviews referrals and assigns team members that can most closely meet the cultural needs of the family.
FPS 3-ICBS Enrollment and Service Delivery (page 3-5.6B)
9.1c) If unable to assign team members that can most closely meet the linguistic needs of the family, Aviva staff utilize translation services as necessary.
FPS 3-ICBS Enrollment and Service Delivery (page 3-5.6C)
9.2 Tribally Responsive Workforce
9.2a) All staff adhere to a training plan which includes working with Indian clients.
ICBS Orientation and Training Checklist page 5 boxes 21, 24
9.2b) The team is trained to recognize and address the cultural identity and connection to the tribe or Indian organization when serving an Indian client.
FPS 3 Enrollment and Service Delivery (page 3-4 5.9-5.10)
9.3 Flexible and Creative Work Environment
9.3a) Aviva’s QI department routinely conducts soft audit and in-depth chart reviews to ensure program compliance. The ICBS Program Assistant provides leadership with monthly status reports of matrices, safety plans, and outcome measures. The Director of Impact and Innovation will also present relevant client survey results in the ICBS department meeting where the department collaborates on ways to improve services. CFT meetings are also periodically observed and feedback is provided to the team.
Aviva Fall 2025 Survey results slide 2, QI soft audit template, ICBS CRR template, CFT Meeting Observation Tool, 100—CFT Meeting Matrix SCP (page 6 6a-e)
9.3b) The department has annual staff retreats focused on team building, collaboration, and communication.
ICBS 2026 Retreat
9.3c) Staff are provided with group supervision by roles, and weekly one-on-one meetings where staff can share their program related thoughts or ideas.
1 to 1 Meeting Procedures (page 1 purpose, page 2 procedures)
9.3d) The department has monthly meetings which highlights client success stories, peer recognition, and addresses one core principle each month by talking about the principle and recognizing a staff or team with an award for their outstanding demonstration of the core principle.
ICBS February 2026 Department meeting minutes
9.4 Hiring, Performance Evaluation, and Job Descriptions
9.4a) Each job description defines a unique job summary and essential functions. The Wrap Lead position has combined Facilitator and Fidelity Coach responsibilities. Their supervisory responsibilities are delineated as supervisees provide services in a different service area and there is no reason to believe they would ever work together on a team. There is a Wrap Supervisor who essentially functions as a Fidelity Coach.
See job descriptions for: Wraparound Parent Partner, Wraparound Facilitator, Wrap Child and Family Specialist (Family Specialist), Wraparound Lead (Fidelity Coach), Wraparound Supervisor (Fidelity Coach), ICBS Clinical Supervisor, Director of Wraparound (HFW Supervisor/Manager). The agency is currently recruiting for a Wraparound Youth Partner.
9.4b) Each job description has the summary (role purpose), essential functions (functions), and competencies (qualities).
See job descriptions for: Wraparound Parent Partner, Wraparound Facilitator, Wrap Child and Family Specialist (Family Specialist), Wraparound Youth Partner, Wraparound Lead (Fidelity Coach), Wraparound Supervisor (Fidelity Coach), ICBS Clinical Supervisor, Director of Wraparound (HFW Supervisor/Manager).
9.4c) Each job description includes competencies (qualities) to help identify individuals who will be successful in the position. Additionally, interview responses give us a better understanding of how a person can be successful in the position.
See job descriptions for: Wraparound Parent Partner, Wraparound Facilitator, Wrap Child and Family Specialist (Family Specialist), Wraparound Youth Partner, Wraparound Lead (Fidelity Coach), Wraparound Supervisor (Fidelity Coach), ICBS Clinical Supervisor, Director of Wraparound (HFW Supervisor/Manager). Interview Q’s-all, Interview Q’s-in person
9.4d) Each candidate goes through a HR screening and if candidate meets minimum requirements for the position, the hiring manager uses standardized questions during the first telehealth interview. If the candidate has been selected to move forward, they are invited to an in-person interview, where there are also standardized questions.
HR pre-screening tool, Interview Qs-all, Interview Qs – In Person.
9.4e) Employees review and sign their job description on their day of hire. Through the first month of hire, staff go through rigorous agency and program trainings. Staff are provided with weekly and as needed supervision. Staff are also observed within the first 90 days of hire, annually, and as needed utilizing an observation tool with feedback given after session or the following week. Staff are also observed during a CFT Meeting periodically using the CFT Observation tool.
ICBS Orientation and Training Checklist (page 1 program role/orientation box 7), see sample of Wrap Facilitator Job description, Annual Review FY 25-26 blank, Staff observation tool, Observation for Supervision policy (page 1 4a and page 2 5.1 last paragraph), CFT Observation tool, 100—CFT Meeting Matrix SCP (page 6 6e), 1 to 1 Meeting Procedures (page 2 4-5, page 3 7-8)
9.5 Workforce Stability
9.5a) Aviva participates in the Association of Community Human Service Agencies (ACHSA) Salary Survey, and in exchange, ACHSA provides a report of positions and salaries (ranges and median) across Los Angeles county of the various agencies that participate. Aviva uses the Salary Survey to ensure our salaries are equitable, and competitive. When we identify salaries that are below market rate, we make parity adjustments as appropriate and as we are able to within the parameters of the contracts.
9.5b) CBS Leadership is responsible for ensuring staff workflow is manageable. Supervisors review cases and caseloads weekly with staff, and discuss making changes as appropriately indicated.
FPS 2 ICBS Caseload Policy (page 3 5.3)
9.5c) Complete job descriptions for open positions are posted on Aviva’s website. Organizational charts are available on the Sharedrive for all staff to access.
ICBS org chart, See job descriptions for: Wraparound Parent Partner, Wraparound Facilitator, Wrap Child and Family Specialist (Family Specialist), Wraparound Youth Partner, Wraparound Lead (Fidelity Coach), Wraparound Supervisor (Fidelity Coach), ICBS Clinical Supervisor, Director of Wraparound (HFW Supervisor/Manager).
9.5d) Staff are evaluated annually. Scores correlate to salary percentage increases. The agency has a Performance and Quality Improvement Committee that meets 10 times annually where new projects are proposed and introduced by staff at all levels. Leadership disseminates information in the department meeting for staff to voluntarily participate. Staff are also encouraged to participate and lead various agency related committees (i.e., Safety committee, Staff Retreat Planning committee, Agency Party Planning committee, etc.)
PQI Handbook 2025 (page 4 CLS, page 8 Direct Care Staff last bullet), HR eval increases email
9.6 High Fidelity Training Plan
9.6b) All staff adhere to a training plan, which includes role specific and general wrap trainings. Staff participate in peer shadowing initially and as needed, receive coaching and feedback from their supervisor utilizing observation of staff tool, observation of CFT tool, and/or supervisor joining client sessions, treatment team meetings and/or staffing meetings.
ICBS SharePoint Links Trainings, Wrap Training Certificate Tracker-blank, 100-CFT Meeting Matrix SCP (page 6 6e), CFT Meeting Observation Tool, Observation for Supervision Policy (page 2 5.1 ), Observation of Staff Tool
9.6c) All staff adhere to an ongoing training plan, which includes role specific and general wrap trainings.
ICBS SharePoint Links Trainings, Wrap Training Certificate Tracker-blank
9.6d) All supervisors adhere to an ongoing training plan, which includes general wraparound training, and supervisory training.
ICBS SharePoint Links Trainings, Wrap Training Certificate Tracker-blank
9.6e) All staff adhere to a training plan, which includes ICWA and Tribal sovereignty trainings, as well as other specific populations, such as LGBTQIA+.
ICBS SharePoint Links Trainings, Wrap Training Certificate Tracker-blank
9.7 Community-based Training Program
9.7a) Aviva utilizes external training providers, such as the Parent Partner Training Academy, that incorporate youth, family members, and parent partners with lived experience into their training delivery. We prioritize agencies that include lived experience through co-trainers, panels, or content development. Additionally, new hires shadow all roles, including Parent Partners.
ICBS SharePoint Links Trainings, Wrap Training Certificate Tracker-blank, ICBS Orientation and Training Checklist In Vivo section last box
9.7b) Aviva participates in and refers community partners to external Wraparound trainings provided by other agencies. While we do not provide trainings, we share information about available training opportunities with partners and encourage their participation to strengthen their role on the team and within the System of Care.
9.8 Coaching and Supervision
9.8a) Staff adhere to a New Hire orientation training plan that orients them to the agency and program.
ICBS Orientation Training Checklist (page 2 understanding roles in ICBS, page 3 program specific trainings box 1, page 4-5 For Wraparound only, for all ICBS Programs), ICBS SharePoint Links Trainings, Wrap Training Certificate Tracker-blank
9.8b) Staff are informed during their first week that they can contact any ICBS Leader for supervision or guidance on any situation, if their supervisor is unavailable. All supervisors are on-call 24/7, as indicated in their job description.
FPS2 ICBS Staff Availability Policy (page 2 5.1)
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
N/A Aviva is waiting on LA County DMH Guidelines.
10.2 Evaluation Metrics & Outcomes
10.2a) The Impact and Innovations department gathers and provides quarterly data summary to provide to leadership, which then identifies areas for program improvements and training needs. Higher level information is then shared with department staff to provide context for any additional required trainings or program changes.
104-ICBS Outcome Measure Policy and Procedures (Page 5 10.0 b-c)
10.2b) The Impact and Innovations department collects and delivers quarterly data summaries to leadership, enabling them to identify areas for program improvement and training needs.
104-ICBS Outcome Measure Policy and Procedures (Page 5 10.0 b-c)
10.2c) Data collected and analyzed can be shared at DMH meetings to communicate strengths and barriers to program implementation.
104-ICBS Outcome Measure Policy and Procedures (Page 5 10.0 d)
Fidelity Indicators
1.1 Timely Engagement and Planning
1. Wellnest Emotional Health and Wellnest strives to ensure that clients receive timely intake and services and regularly updated Plans of Care, which are shared with our agency partners. Efforts include:
(a) The High Fidelity Wraparound (HFW) teams are instructed to contact families within 24 hours of receiving a referral as outlined Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.10 p. 26-28 and Program Manual Appendix 2 p. 7-8 and 3 (Wraparound Statement of Work Section 2.8 p. 8).
(b) HFW Facilitators, in conjunction with the CFT members, are responsible for completing the Plan of Care within the first 30 days of enrollment as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.2 p. 15-18 and Program Manual Appendix 2 p. 21-23, 4 p. 19-22 and 16.
(c) Facilitators are responsible for scheduling CFT meetings every 30 days during which the CFT members review and update the Plan of Care as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.2 p. 15-18 and Program Manual Appendix 2 p. 21-23, 4 p. 19-22 and 16.
(d) HFW Facilitators are responsible for updating the Plan of Care, emailing the Plan of Care to all CFT members, and uploading the Plan of Care to the client’s chart in the organization’s designated Electronic Health Record system as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.3 p. 19-20.
(e) HFW staff and their supervisors are provided with feedback on their ability to meet timelines for CQI purposes as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.10 p. 28 and Program Manual Appendix 30 and 31.
(f) HFW staff are trained to timely engagement strategies that include encouraging alternate strategies when contact with the family is difficult as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.10.1 p. 29-31 and Program Manual Appendix 2 p. 10 and p. 52-57 and 37.
1.2 Led by Youth and Families
Wellnest Emotional Health and Wellness’ HFW teams works to honor youth and family’s perspectives and voices and incorporate them throughout the entire treatment process and decision making. Efforts include:
(a) HFW Facilitators conduct a Strengths, Needs, and Culture Discovery and gather information on the Family Story in order to develop the Family Vision and Team Mission statements that drive the treatment process as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 1.1 p. 1.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 35 and
Program Manual Appendix 24, 25 and 26.
(b) Family values, culture, expertise, capabilities, interests and skills are elicited and clearly documented in the youth’s case file as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.10 p. 27-28.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 35 and
Program Manual Appendix 24, 25 and 26.
(3) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.2 p. 45 and
Program Manual Appendix 2 p. 42
(4) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.3 p. 45 and
Program Manual Appendix Section 2.1.1.2-2.1.1.3 p. 4, 27 and 28.
(5) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.8 p. 48 and
Program Manual Appendix 1 p. 8-9, 2 p. 21-24 and 3 (Wraparound Statement of Work Section 2.2.3-2.2.4 p. 3-4).
(c) The HFW Program Coordinator/Fidelity Coach and Clinical Supervisor regularly observe CFT meetings, utilize HFW tools and Continuous Quality Improvement (CQI) reports to deliver direct and detailed feedback to staff to improve fidelity, promote skill building and increase staff confidence in implementing High Fidelity Wraparound practice and associated interventions, as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 64-67 and Program Manual Appendix 20, 33, 34, and 37.
(d) The HFW Program Coordinator/Fidelity Coach and Clinical Supervisor support in collecting feedback from families through intermittent client satisfaction surveys (haven’t yet received final guidance on the use of the WFI and TOM 2.0 for HFW implementation from the Los Angeles County Department of Mental Health or the Department of Health Care Services). Feedback is utilized to inform program implementation/improvement and ensure youth and family’s experience and voices are represented and honored throughout the Wraparound process as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1 p. 52-53 and Program Manual Appendix 30 and 31 p. 1-5..
1.3 Strength-Based
Wellnest Emotional health and Wellness’ HFW team collectively review and utilize functional strengths of the youth, the family, all team members, and the family’s community throughout the HFW process. Efforts include:
(a) A strengths inventory is developed using CANS, LOCUS, Genogram and Ecomap assessments that are updated for every member of the team, which includes other resources in the family’s local community, and is posted at HFW team meetings as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 1.1 p. 1.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 35-36
and Program Manual Appendix 24, 25 and 26.
(3) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.2 p. 45 and
Program Manual Appendix 2 p. 43.
(4) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.3 p. 45 and
Program Manual Appendix 4 Section 2.1.1.2-2.1.1.3 p. 4, 27 and 28.
(5) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.4 p. 45-46.
(6) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.5 p. 45-46.
(7) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.6 p. 46.
(b) The identification of individualized strengths include the utilization of CANS, LOCUS, Genogram and Ecomap assessments as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.2 p. 45 and
Program Manual Appendix 2 p. 43.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.3 p. 45 and
Program Manual Appendix 4 Section 2.1.1.2-2.1.1.3 p. 4, 27 and 28.
(3) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.4 p. 45-46.
(4) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.5 p. 45-46.
(c) HFW staff receive ongoing coaching and training in providing strengths-based, solution-focused services as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1. p. 36-37.
(d) Feedback from families regarding their experience of strengths-based services is routinely elicited through intermittent client satisfaction surveys (haven’t yet received final guidance on the use of the WFI and TOM 2.0 for HFW implementation from the Los Angeles County Department of Mental Health or the Department of Health Care Services). Feedback is utilized to inform program implementation/improvement and ensure youth and family’s experience and voices are represented and honored throughout the Wraparound process as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1 p. 52-53 and Program Manual Appendix 30 and 31 p. 1-5..
1.4 Needs Driven
Wellnest Emotional Health and Wellness’ HFW services and supports are focused on addressing the high priority underlying needs of the youth, as well as their family members. Efforts include:
(a) Underlying needs are identified and prioritized before goals and strategies are established for the youth and family using CANS, LOCUS, Genogram and Ecomap assessments as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.3 p. 19 and
Program Manual Appendix 3 Section 2.3-2.3.4 p. 4-5.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 35-36
and Program Manual Appendix 24, 25 and 26.
(3) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.2 p. 45 and
Program Manual Appendix 2 p. 43.
(4) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.3 p. 45 and
Program Manual Appendix 4 Section 2.1.1.2-2.1.1.3 p. 4, 27 and 28.
(5) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.4 p. 45-46.
(6) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.5 p. 45-46.
(b) HFW staff receive ongoing training and coaching in identifying needs, developing needs statements that are reflective of the underlying reasons why problematic situations or behaviors are occurring, and utilizing needs-focused planning over problematic behavior-focused planning as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1. p. 36-37.
(c) The identification of individualized needs include the utilization of CANS, LOCUS, Genogram and Ecomap assessments as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.2 p. 45 and
Program Manual Appendix 2 p. 43.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.3 p. 45 and
Program Manual Appendix 4 Section 2.1.1.2-2.1.1.3 p. 4, 27 and 28.
(3) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.4 p. 45-46.
(4) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.5 p. 45-46.
(d) Transition is planned according to team and family agreement that needs are sufficiently met as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 43-44 and Program Manual Appendix 1 p. 6-10 and 3 (Wraparound Statement of Work Section 2.2.2 p.3 and 2.2.2-2.2.4 p. 3-4).
1.5 Individualized
Wellnest Emotional Health Wellness’ HFW program is committed to finding creative, highly individualized strategies that are customized to match each youth and family’s needs, strengths, values, culture, preferences and reduce harm over time. Efforts Include:
(a) Forms/documentation allow for sufficient flexibility in creating individualized plans for each child/youth and family as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 1.1 p. 2.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.4 p. 45-46.
(3) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.5 p. 45-46.
(4) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.6 p. 46.
(5) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.7 p.
46-47 and Program Manual Appendix 1 p. 9, 2 p. 25-26, 3 (Wraparound Statement of Work Section 2.5-2.5.4 p. 7-8 and 23.
(6) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.8 p. 48 and
Program Manual Appendix 1 p. 8-9, 2 p. 21-24 and 3 (Wraparound Statement of Work Section 2.2.3-2.2.4 p. 3-4).
(b) HFW staff receive ongoing training and coaching in providing flexible, creative and highly individualized services and strategies as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.10 p.
27-28.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.10 p.
29-31 and Program Manual Appendix 2 p.52-57 and 37.
(3) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p.
34-35 and p. 36-37.
(4) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 64-67
and Program Manual Appendix 20, 33, 34, 37.
(5) Program Manual Appendix 53.
(c) HFW Facilitators receive ongoing training and coaching in leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.10 p.
27-28.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.10 p.
29-31 and Program Manual Appendix 2 p.52-57 and 37.
(3) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p.
34-35 and p. 36-37.
(4) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 64-67
and Program Manual Appendix 20, 33, 34, 37.
(5) Program Manual Appendix 53.
(d) HFW plans of care are routinely reviewed and assessed for use of individualized strengths, needs, outcomes, and strategies and for the presence of strategies that capitalize on the assets of the family’s community and informal networks as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 39-42.
(e) Family feedback regarding their experience of receiving customized services is routinely elicited through intermittent client satisfaction surveys (haven’t yet received final guidance on the use of the WFI and TOM 2.0 for HFW implementation from the Los Angeles County Department of Mental Health or the Department of Health Care Services). Feedback is utilized to inform program implementation/improvement and ensure youth and family’s experience and voices are represented and honored throughout the Wraparound process as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1 p. 52-53 and Program Manual Appendix 30 and 31 p. 1-5..
1.6 Use of Natural and Community Based Supports
Wellnest Emotional Health and Wellness HFW teams prioritize strategies in the HFW Plan of Care that utilize natural supports and that take place in the family’s community, to reduce reliance on formal supports while fostering sustainability within the youth and family’s community. Efforts include:
(a) A natural and community supports inventory using a Genogram and Ecomap are developed and updated for every family as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.4 p. 45-46.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.5 p. 45-46.
(b) HFW staff receive ongoing training and coaching identification, engagement and integration of natural supports in the HFW process and in decreasing reliance on formal supports as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 36-37.
(c) HFW plans of care are routinely reviewed and assessed for the inclusion of natural supports in the plan and for use of community and natural supports in the assigning of strategies and action items as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 39-42.
(d) Family feedback regarding their experience of having natural supports engaged on their team is routinely elicited through intermittent client satisfaction surveys (haven’t yet received final guidance on the use of the WFI and TOM 2.0 for HFW implementation from the Los Angeles County Department of Mental Health or the Department of Health Care Services). Feedback is utilized to inform program implementation/improvement and ensure youth and family’s experience and voices are represented and honored throughout the Wraparound process as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1 p. 52-53 and Program Manual Appendix 30 and 31 p. 1-5..
1.7 Culturally Respectful and Relevant
Wellnest Emotional Health and Wellness HFW teams use strategies that are relevant to and respectful of the youth and family’s culture, including Tribes in the case of an Indian child. Efforts include:
(a) A strengths, needs, culture discovery is completed before the HFW plan of care is developed and is clearly documented in the child or youth’s case file as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 35-36 and Program Manual Appendix 24, 25,26 and 55.
(b) HFW staff receive ongoing coaching and training in the elicitation and use of family and culture in planning and service delivery and in providing culturally respectful and relevant strategies as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 36-37.
(c) Feedback from families regarding their experience of culturally relevant and respectful services and strategies is routinely elicited through intermittent client satisfaction surveys (haven’t yet received final guidance on the use of the WFI and TOM 2.0 for HFW implementation from the Los Angeles County Department of Mental Health or the Department of Health Care Services). Feedback is utilized to inform program implementation/improvement and ensure youth and family’s experience and voices are represented and honored throughout the Wraparound process as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1 p. 52-53 and Program Manual Appendix 30 and 31 p. 1-5..
1.8 High-Quality Team Planning and Problem Solving
Wellnest Emotional Health and Wellness HFW teams are comprised of formal and natural supports across all Children’s System of Care partners who work together to develop, implement and monitor the individualized Plan of Care that meet the unique needs of the youth and family. Efforts include:
(a) Team agreements are created for each HFW team and documented in the youth’s file as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 37-38.
(b) Feedback from families and HFW team members regarding their experience of team engagement and collaboration is routinely elicited through intermittent client satisfaction surveys (haven’t yet received final guidance on the use of the WFI and TOM 2.0 for HFW implementation from the Los Angeles County Department of Mental Health or the Department of Health Care Services). Feedback is utilized to inform program implementation/improvement and ensure youth and family’s experience and voices are represented and honored throughout the Wraparound process as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1 p. 52-53 and Program Manual Appendix 30 and 31 p. 1-5..
(c) Feedback from families and HFW team members regarding their experience of team engagement and collaboration is used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 64-67
and Program Manual Appendix 20, 33, 34 and 37.
(2) Program Manual Appendix 53.
(d) HFW plans of care are routinely reviewed and assessed for the inclusion of natural supports in the plan and for use of community and natural supports in the assigning of strategies and action items as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 39-42.
1.9 Outcomes Based Process
Wellnest Emotional Health and Wellness’ HFW team monitors the success of the HFW Plan of Care—including progress toward meeting needs, strategy implementation and task completion. Efforts include:
(a) The HFW plan of care includes specific, measurable strategies and action items with timeframes as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 39-42.
(b) Action item completion is tracked by facilitators and updated at HFW team meetings, or more often as needed, as outlined by Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 39-42.
(c) Forms and processes allow strategies and action items to be adjusted or changed as needed. These changes are communicated to all team members as outlined by Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 39-42.
(d) The HFW Facilitator completes the CANS and is shared amongst all team members as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.2 p. 55-56.
(e) Data from the CANS is used to support tracking and team decision-making, but does not replace using tracking of needs, goal completion, and action item completion to plan for transition as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 57-64.
1.10 Persistence
Wellnest Emotional Health and Wellness’ HFW team views setbacks and challenges not as evidence of a youth, or parent failure, but as an indicator of a need to revise the Plan. Efforts include:
(a) HFW teams are supported to keep working with a youth and family even when faced with setbacks or limited progress until the HFW team (with preference given to family voice and choice) agrees that services should end as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 1.1 p. 3 and Section 5.1 p. 34-35 (Safety and Crisis Stabilization) and Program Manual Appendix 56.
(b) There are clear processes for HFW teams to access help when facing challenges including how to request additional coaching or supervision, how to access/request flexible funding, and how to access additional support as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 1.1 p. 3 and Program Manual Appendix 2 p. 52-57, 16 and 57.
(c) HFW Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 65-66.
1.11 Transitions as a part of the Fourth Phase of HFW
Wellnest and Emotional Health and Wellness’ HFW team plans transitions in advance, celebrated with full youth and family participation and only happen when the youth and family have had their needs met, not due to an adverse event or an administrative requirement. Efforts include:
(a) HFW teams provide adequate transitions and families do not experience sudden loss of services due to adverse events or due to administrative requirements as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 43-45
and Program Manual Appendix 1 p. 6-10 and 3 (Wraparound Statement of Work Section 2.2.2 p.3 and 2.2.2-2.2.4 p. 3-4).
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.9 p. 48-50
and Program Manual Appendix 2 p. 43-44, 21 and 29.
(b) Transitions out HFW are celebrated according to the youth and family’s culture, values and preferences and administrative structures are supportive of engaging in celebration including access to flex funds, accommodating staff time for community resourcing, developing community partnerships and ensuring staff are available to attend celebrations as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 44-45 and Program Manual Appendix 1 p. 6-10 and 3 (Wraparound Statement of Work Section 2.2.2 p.3 and 2.2.2-2.2.4 p. 3-4).
Expected Outcomes
2.1 Youth and Family Satisfaction
Wellnest Emotional Health and Wellness utilizes various surveys to measure youth and family satisfaction with their HFW experience and their progress including: Los Angeles County Department of Mental Health annual state-wide mandated Consumer Perception Surveys, Wellnest Client Satisfaction Surveys as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1 p. 51-53 and Program Manual Appendix 2 p. 42, 30 and 31 p. 1-5..
2.2 Improved School Functioning
(1) Wellnest Emotional Health and Wellness utilizes various outcome measure assessments to record and evaluate child or youth school attendance and performance that include CANS, LOCUS, PSC-35, OMA and KEC OMA assessments. These assessments and how they are currently administered in the organization are outlined in:
(a) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.2 p. 53-57
and Program Manual Appendix 2 p. 43-44.
(b) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.2 p. 45 and
Program Manual Appendix 2 p. 43.
(c) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.3 p. 45 and
Program Manual Appendix 4 Section 2.1.1.2-2.1.1.3 p. 4, 27 and 28.
(2) Data from these assessments are monitored by the Los Angeles County Department of Mental Health as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 57-60 and Program Manual Appendix 3 (Wraparound Statement of Work Section p. 18-20).
(3) Currently, the Department of Health Care Services provided preliminary guidance on requirements that will be monitored once HFW implementation begins as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 60-62 and Program Manual Appendix 4 Section 4.0 p. 4.
(4) Wellnest Emotional Health and Wellness is working on CQI processes to monitor and evaluate child or youth school attendance and performance as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 62-64 and Program Manual Appendix 38, 39, 40 and 41.
2.3 Improved Functioning in the Community
(1) Wellnest Emotional Health and Wellness utilizes various outcome measure assessments to record and evaluate child or youth engagement with community activities that include CANS, LOCUS, PSC-35, OMA and KEC OMA assessments. These assessments and how they are currently administered in the organization are outlined in:
(a) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.2 p. 53-57
and Program Manual Appendix 2 p. 43-44.
(b) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.2 p. 45 and
Program Manual Appendix 2 p. 43.
(c) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.3 p. 45 and
Program Manual Appendix 4 Section 2.1.1.2-2.1.1.3 p. 4, 27 and 28.
(2) Data from these assessments are monitored by the Los Angeles County Department of Mental Health as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 57-60 and Program Manual Appendix 3 (Wraparound Statement of Work Section p. 18-20).
(3) Currently, the Department of Health Care Services provided preliminary guidance on requirements that will be monitored once HFW implementation begins as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 60-62 and Program Manual Appendix 4 Section 4.0 p. 4.
(4) Wellnest Emotional Health and Wellness is working on CQI processes to monitor and evaluate child or youth engagement with community activities as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 62-64 and Program Manual Appendix 38,39, 40 and 41.
2.4 Improved Interpersonal Functioning
(1) Wellnest Emotional Health and Wellness utilizes various outcome measure assessments to record and evaluate the interpersonal functioning of families that include CANS, LOCUS, PSC-35, OMA and KEC OMA assessments. These assessments and how they are currently administered in the organization are outlined in:
(a) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.2 p. 53-57
and Program Manual Appendix 2 p. 43-44.
(b) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.2 p. 45 and
Program Manual Appendix 2 p. 43.
(c) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.3 p. 45 and
Program Manual Appendix 4 Section 2.1.1.2-2.1.1.3 p. 4, 27 and 28.
(2) Data from these assessments are monitored by the Los Angeles County Department of Mental Health as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 57-60 and Program Manual Appendix 3 (Wraparound Statement of Work Section p. 18-20).
(3) Currently, the Department of Health Care Services provided preliminary guidance on requirements that will be monitored once HFW implementation begins as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 60-62 and Program Manual Appendix 4 Section 4.0 p. 4.
(4) Wellnest Emotional Health and Wellness is working on CQI processes to monitor and evaluate the interpersonal functioning of families as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 62-64 and Program Manual Appendix 38,39, 40 and 41.
2.5 Increased Caregiver Confidence
(1) Wellnest Emotional Health and Wellness utilize data from Wellnest and Emotional Health and Wellness client surveys and the organizations HFW Program’s Family/AIAN client surveys (monthly) to record and evaluate the caregiver’s confidence in their abilities and connectedness to resources in their community as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1. p. 52-53 and Program Manual Appendix 30 and 31 p. 1-5.
(2) The Los Angeles County Department of Mental Health conducts it own Client Satisfaction Survey for the organization’s Wrapround clients to record and evaluate the caregiver’s confidence in their abilities and connectedness to resources in their community as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1 p. 52 and Program Manual Appendix 2 p. 42..
(3) Currently, the Department of Health Care Services provided preliminary guidance on requirements that will be monitored once HFW implementation begins as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 60-62 and Program Manual Appendix 4 Section 4.0 p. 4.
(4) Wellnest Emotional Health and Wellness is working on CQI processes to monitor and evaluate the caregiver’s confidence in their abilities and connectedness to resources in their community as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 62-64 and Program Manual Appendix 38, 39, 40 and 41.
2.6 Stable and Least Restrictive Living Environment
(1) Wellnest Emotional Health and Wellness utilizes various outcome measure assessments to record and evaluate the frequency of and types of placement changes when they occur that include CANS, LOCUS, PSC-35, OMA and KEC OMA assessments. These assessments and how they are currently administered in the organization are outlined in:
(a) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.2 p. 53-57
and Program Manual Appendix 2 p. 43-44.
(b) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.2 p. 45 and
Program Manual Appendix 2 p. 43.
(c) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.3 p. 45 and
Program Manual Appendix 4 Section 2.1.1.2-2.1.1.3 p. 4, 27 and 28.
(2) Data from these assessments are monitored by the Los Angeles County Department of Mental Health as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 57-60 and Program Manual Appendix 3 (Wraparound Statement of Work Section p. 18-20).
(3) Currently, the Department of Health Care Services provided preliminary guidance on requirements that will be monitored once HFW implementation begins as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 60-62 and Program Manual Appendix 4 Section 4.0 p. 4.
(4) Wellnest Emotional Health and Wellness is working on CQI processes to monitor and evaluate the frequency of and types of placement changes when they occur as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 62-64 and Program Manual Appendix 38, 39, 40 and 41.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
(1) Wellnest Emotional Health and Wellness utilizes the KEC OMA assessment to record and evaluate the frequency of hospital visits. This assessment and how it is currently administered in the organization are outlined in:
(a) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.2 p. 54
and Program Manual Appendix 2 p. 43-44.
(2) Data from this assessment is monitored by the Los Angeles County Department of Mental Health as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 57-60 and Program Manual Appendix 3 (Wraparound Statement of Work Section p. 18-20).
(3) Currently, the Department of Health Care Services provided preliminary guidance on requirements that will be monitored once HFW implementation begins as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 60-62 and Program Manual Appendix 4 Section 4.0 p. 4.
(4) Wellnest Emotional Health and Wellness is working on CQI processes to monitor and evaluate the frequency of hospital visits as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 62-64 and Program Manual Appendix 38, 39, 40 and 41.
2.8 Reduction in Crisis Visits
(1) Wellnest Emotional Health and Wellness utilizes the PSC-35 assessment to record frequency of crises and level of involvement of professional support when crises occur. This assessment and how it is currently administered in the organization are outlined in:
(a) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.2 p. 53
and Program Manual Appendix 2 p. 43-44.
(2) Data from this assessment is monitored by the Los Angeles County Department of Mental Health as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 57-60 and Program Manual Appendix 3 (Wraparound Statement of Work Section p. 18-20).
(3) Currently, the Department of Health Care Services provided preliminary guidance on requirements that will be monitored once HFW implementation begins as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 60-62 and Program Manual Appendix 4 Section 4.0 p. 4.
(4) Wellnest Emotional Health and Wellness is working on CQI processes to record frequency of crises and level of involvement of professional support when crises occur as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 62-64 and Program Manual Appendix 38, 39, 40 and 41.
2.9 Positive Exit from HFW
(1) Wellnest Emotional Health and Wellness utilizes the OMA assessment and Wraparound Exit forms for DMH and Probation to record and evaluate when and why families exit HFW. These tools and how they are currently administered in the organization are outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.2 p. 53-57 and Program Manual Appendix 2 p. 43-44, 21 and 29.
(2) Data from this assessment is monitored by the Los Angeles County Department of Mental Health as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 57-60 and Program Manual Appendix 3 (Wraparound Statement of Work Section p. 18-20).
(3) Currently, the Department of Health Care Services provided preliminary guidance on requirements that will be monitored once HFW implementation begins as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 60-62 and Program Manual Appendix 4 Section 4.0 p. 4.
(4) Wellnest Emotional Health and Wellness is working on CQI processes to record and evaluate when and why families exit HFW as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 62-64 and Program Manual Appendix 38, 39, 40 and 41.
Engagement
3.1 Orientation
Wellnest Emotional Health and Wellness’ HFW team orients youth and families to the HFW process, including explaining the HFW principles and phases, addressing legal and ethical considerations and explaining the role of each member on the team including the family’s role and the role of natural supports, including Tribes in the case of an Indian child. Efforts include:
Procedures Ensure:
(a) The HFW team full explains the HFW process to every family including an overview of the principles and phases, legal and ethical considerations and the role of each team member including the family, natural supports and Tribes in the case of an Indian child as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 33-34 and Program Manual Appendix 2 p. 12 and 27, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67 and 68..
Explanations to the family include:
(a) The HFW team provides the family an overview of the principles and phases of HFW as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 33-34 and Program Manual Appendix 58 p. 1-2 and 59.
(b) The HFW team provides the family legal and ethical considerations as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 33-34 Section Orientation and Program Manual Appendix 58 p.2-4 and Program Manual Appendix 2 p. 12 and 27, 60, 61, 62, 63, 64, 65, 66, 67 and 68.
(c) The HFW team explains the role of each team member including the family and natural supports and Tribes in the case of an Indian child as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 33-34 and Program Manual Appendix 58 p. 4-5.
3.2 Safety and Crisis stabilization
Wellnest Emotional Health and Wellness’ HFW team addresses pressing needs and concerns so that the family and team can focus on the HFW process. Efforts include:
(a) The HFW team discusses initial crisis and safety concerns during engagement. If pressing concerns are brought forward, the team develops an immediate crisis response plan which is provided to the family and is documented in the chart as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 34-35
and Program Manual Appendix 23.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.8 p. 25 and
Program Manual Appendix 2 p. 45-46, 3 (Wraparound Statement of Work Section 2.5-2.5.4 p. 7-8) and 19.
(b) The crisis plan is used to inform, but not replace, the HFW Safety Plan developed during the Plan Development phase as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 34-35 and Program Manual Appendix 23.
(c) All families are provided with information regarding how to access 24/7 crisis response when needed as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 34-35
and Program Manual Appendix 23.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.8 p. 25 and
Program Manual Appendix 2 p. 45-46, 3 (Wraparound Statement of Work Section 2.5-2.5.4 p. 7-8) and 19.
3.3 Strengths, Needs, Culture and Vision Discovery
Wellnest Emotional Health and Wellness’ HFW team facilitates conversations and activities with the youth and family to identify individual and family strengths, needs, culture and their vision for a better future. Efforts include:
(a) A Family Vision is completed with every family and documented in the youth’s chart during the Engagement phase as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 35-36 and Program Manual Appendix 24, 25 and 26.
(b) A Strengths, Needs, Culture Discovery document is initiated with every youth, and family, is included in the youth’s chart, is updated at least every 90 days and the team adds new strengths, needs, and cultural preferences as they are discovered. The document is provided to new team members as they are identified as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 35-36 and Program Manual Appendix 24, 25 and 26.
3.4 Engage All Team Members
Wellnest Emotional Health and Wellness’ HFW team engages the participation of team members across all Children’s System of Care partners (including formal, natural supports, and Tribes, in the case of an Indian child), who care about and can aid the youth and family. Efforts include:
(a) A natural supports inventory is completed with all youth and families and is documented in the child or youth’s case file. as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 35-36 and Program Manual Appendix 25 (Ecomap used for natural supports).
(b) Children’s System of Care partners who should be included on the HFW team are identified and engaged.as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 37 and Program Manual Appendix 69.
(c) The HFW team works with the youth and family to identify potential team members (including formal, natural supports and Tribes, in the case of an Indian child) and discusses their role on the team as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 37.
(d) Engagement and team building activities are documented in the youth’s file as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 37.
3.5 Arrange Meeting Logistics
Wellnest Emotional Health and Wellness’ HFW team ensures that meetings take place at a time and in a location that is convenient and accessible to all team members with priority given to family needs and family voice and choice, taking into consideration family schedules, culture, and history of trauma and ensuring equitable access for all youth and families. Efforts include:
(a) HFW staff are flexible in working hours and scheduling meeting time and locations to accommodate family and Wraparound Team needs as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 37 and Program Manual Appendix 70.
(b) HFW staff are trained to work collaboratively with families and the other members of the HFW team to schedule meetings that are in alignment with family needs and preferences as well as maximize participation as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 36-37.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.10.1 p. 29-
31.
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
Wellnest Emotional Health and Wellness’ HFW Facilitator leads the team in developing formal agreements on how the team will engage during meetings and make decisions, identifying and documenting additional strengths of the youth and family, other team members, and the community and creating a team mission statement that defines the overall purpose of the HFW team in alignment with the family vision. Efforts include:
(a) Before the HFW plan of care is developed, team agreements, a team strengths inventory and a mission statement are completed with each family and documented in the youth’s file as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 37-38.
(b) The youth’s and family members’ strengths identified in engagement are updated to reflect any additionally discovered strengths as they are identified and are documented in the youth’s file as outlined Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 37-38.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
The HFW Facilitator guides the HFW team in reviewing needs identified during engagement, adding any additional needs and prioritizing them to develop specific, measurable goals and outcomes. Efforts include:
(a) Before the HFW plan of care is developed, underlying needs are identified and prioritized for each family and are documented in the youth’s file as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 38-39.
(b) Measurable goals and outcomes are developed from these identified needs, as opposed to behavior or deficit-based goal development, as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 38-39.
(c) Goals and outcomes are developed collaboratively with the youth, family, and the rest of the HFW team as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 38-39.
(d) Multiple individualized brainstormed strategies are documented in the youth’s file that can be referred to as needed as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 38-39.
(e) HFW Facilitators are trained to lead teams in identifying, prioritizing and selecting strategies and developing action items as outlined in Program Manual Appendix 53 (Wellnest Emotional Health and Wellness CQI Plan for the Implementation Process of HFW).
(f) All aforementioned steps are utilized to develop the individualized HFW Plan of Care in a team-based, collaborative environment as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 38-39.
(2) Program Manual Appendix 53 (Wellnest Emotional Health and Wellness CQI Plan for the Implementation Process of
HFW).
4.3 Develop an Individualized Child or Youth and Family Plan
Wellnest Emotional Health and Wellness’ HFW team develops a comprehensive initial Plan of Care that is based on the prioritized needs, goals, and strategies of the family and youth that is accomplished via a high‐quality team process across all Children’s System of Care partners, including the Tribe in the case of an Indian child, that elicits multiple perspectives, builds trust and shared vision amongst team members and demonstrates the HFW principles. Efforts include:
(a) HFW Facilitators will receive ongoing training and coaching to engage the team in a planning process that elicits multiple perspectives, builds trust and shared vision and demonstrates the HFW principles as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 34.
(2) Program Manual Appendix 53 (Wellnest Emotional Health and Wellness CQI Plan for the Implementation Process of
HFW).
(b) The Plan of Care comprehensively integrates goals and objectives identified by all Children’s System of Care partners as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 39-41.
(c) The Plan of Care is documented in the child/youth’s file, is distributed to all team members and meets all the criteria defined above (items 1-6) as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 39-41.
(d) Wellnest Emotional Health and Wellness are working on putting processes in place to review Plans of Care for continuous quality improvement and to provide feedback to staff and supervisors/coaches for training and coaching purposes as outlined in Program Manual Appendix 53 (Wellnest Emotional Health and Wellness CQI Plan for the Implementation Process of HFW).
4.4 Develop a Crisis and Safety Plan
Wellnest Emotional Health and Wellness’ HFW Facilitator leads the team in developing a crisis and safety plan that identifies and prioritizes safety needs, potential risk and crisis situations, as well as highly individualized proactive and reactive strategies for the youth, family and team members to respond effectively. Efforts include:
(a) An individualized crisis and safety plan is documented in the youth’s file, which identifies potential safety, high risk and crisis situations with proactive and reactive crisis management strategies chosen by the family members and including who should be called for support 24/7 as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 41 and Program Manual Appendix 19 (example of the organization’s on-call calendar) and 23.
(b) The development of the plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 41.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 34-35.
(3) Program Manual Appendix 54 (Wellnest Emotional Health and Wellness CQI Plan for Crisis and Safety Planning).
(c) Crisis and safety plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy and the use of natural supports for continuous quality improvement and training and coaching purposes as outlined in Program Manual Appendix 54 (Wellnest Emotional Health and Wellness CQI Plan for Crisis and Safety Planning).
Implementation
5.1 Implement The Plan of Care
Wellnest Emotional Health and Wellness’ HFW team carries out the initial Plan of Care, monitoring completion of action items and strategies and their success in meeting needs and achieving outcomes in a manner consistent with HFW principles. Teams celebrate successes as they occur. Efforts include:
(a) The HFW facilitator leads the team to review strategies and action items at HFW team meetings, track individual assignments, check-in to support meeting timelines and deliverables and adjust strategies and action items as needed as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 41-42.
(b) Wellnest Emotional Health and Wellness’ HFW staff will receive training and coaching on implementing the plan of care in alignment with the HFW principles. Training and processes will address celebrating successes as they occur as outlined in Program Manual Appendix 53 (Wellnest Emotional Health and Wellness CQI Plan for the Implementation Process of HFW).
5.2 Review and Update The Plan of Care
Wellnest Emotional Health and Wellness’ HFW Facilitator engages the team to continually review the Plan; assess the progress and the effectiveness of strategies and update the Plan as needed, including changing goals and strategies if the needs of the youth and family change. Efforts include:
(a) Reviews of strategies, progress and action items occurs in a HFW team meeting setting as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 42. .
(b) The HFW Facilitator leads the team to adjust the plan accordingly as successes occur, as new needs are identified, or as new strategies and action items are selected and the updated plan is documented in the youth’s file as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 42.
(c) The HFW Facilitator documents and communicates completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds and updates to the plan. These updates are communicated to all team members, at a minimum, through the use of team meeting minutes as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 42.
(d) Forms are able to be updated and individualized to meet the youth, family, and team’s changing needs as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 42.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
Wellnest Emotional Health and Wellness’ HFW Facilitator continually assesses and addresses team cohesion, trust and commitment to ensure effective collaboration. When appropriate, HFW teams seek and develop potential natural supports and add them to the team. Teams orient and engage new team members as they are added. Efforts include:
(a) Team agreements are utilized, reviewed regularly and present at HFW team Meetings as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 42-43.
(b) HFW Facilitators receive ongoing training and coaching on building, engaging and maintaining effective teams as outlined in Program Manual Appendix 53 (Wellnest Emotional Health and Wellness CQI Plan for the Implementation Process of HFW).
(c) The families use of natural supports are monitored over time and HFW teams are provided feedback through coaching and supervision as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 42-43.
(2) Program Manual Appendix 53 (Wellnest Emotional Health and Wellness CQI Plan for the Implementation Process of
HFW).
(d) Wellnest Emotional Health and Wellness is working on creating processes for orienting new team members (including formal and natural supports) to the team which include explaining the HFW process, reviewing current plans and strategies and engaging in team building exercises as outlined in Program Manual Appendix 53 (Wellnest Emotional Health and Wellness CQI Plan for the Implementation Process of HFW).
Transition
6.1 Develop a Transition Plan
Wellnest Emotional Health and Wellness’ HFW team begins developing a formal individualized transition plan when the family has reached pre-determined benchmarks indicating sufficient progress towards completing the team mission and goals and the youth, family and team agree the family is ready for transition. Efforts include:
(a) The HFW Facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 43-44.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.9 p. 48-49
and Program Manual Appendix 2 p. 43-44, 21 and 29.
(b) Once the HFW team determines the youth and family are ready for transition, the HFW Facilitator leads the team in creating an individualized transition plan that identifies needs, services and supports, distributes the plan to all team members and documents the plan in the youth’s file as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 44.
(c) The HFW Team develops the individualized transition plan in a team based, collaborative environment and HFW Facilitators receive training and coaching to this process as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 43-44.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.9 p. 48-49
and Program Manual Appendix 2 p. 43-44, 21 and 29.
(3) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 66.
(4) Program Manual Appendix 52 (Wellnest Emotional Health and Wellness CQI Plan for Transition Planning).
(d) The Department of Health Care Services has preliminarily recommended HFW providers utilize the Wrapround Fidelity Index (WFI, which can be used to verify that services and supports identified in the transition plan will persist past formal HFW and that the family is able to access them, including post adoption services if applicable. Wellnest Emotional Health and Wellness is waiting for further guidance with for the possible implementation of this tool, but current efforts being planned for are outlined in:
(1) Program Manual Appendix 4 Section 2.1.7-2.1.7.5 p. 10-11.
(2) Program Manual Appendix 52 (Wellnest Emotional Health and Wellness CQI Plan for Transition Planning).
6.2 Develop a Post-Transition Safety Plan
The HFW Facilitator leads the team in developing a crisis and safety plan (or adjusting the current crisis and safety plan) that identifies potential crisis situations that may occur after transitioning from formal HFW. Efforts include:
(a) The individualized crisis and safety plan is updated by Wellnest Emotional Health and Wellness’ HFW team to reflect transition (or a new transition crisis and safety plan is completed) and documented in the youth’s file. This plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies that maximize use of natural support and that are chosen by the family as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 44.
(b) The development of the crisis and safety transition plan occurs in a team based, collaborative environment and HFW Facilitators receive training and coaching to this process as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 44.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 66.
(3) Program Manual Appendix 52 (Wellnest Emotional Health and Wellness CQI Plan for Transition Planning).
(c) Wellnest Emotional Health and Wellness is working on plans to review crisis and safety plans for individualized strategies, proactive and reactive progression of strategies, cultural relevancy and the use of natural supports for continuous quality improvement and training and coaching purposes as outlined in Program Manual Appendix 52 (Wellnest Emotional Health and Wellness CQI Plan for Transition Planning).
6.3 Create a Commencement and Celebrate Success
Wellnest Emotional Health and Wellness’ HFW team ensures that the conclusion of formal HFW is celebrated in a manner that reflects a positive transition, is culturally relevant and is meaningful to the youth and family. Efforts include:
(a) Transitions out of the Wraparound process are celebrated according to the family’s culture, values and preferences as
outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 44-45
and Program Manual Appendix 1 p. 6-10 and 3 (Wraparound Statement of Work Section 2.2.2 p.3 and 2.2.2-2.2.4 p. 3-4).
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1.9.1 p. 50-51
and Program Manual Appendix 2 p. 34.
(b) Administrative structures are supportive of engaging in celebration (e.g., access to flex funds, time for community resourcing, community partnerships, ensuring staff are available to attend celebrations, etc.) as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 5.1 p. 44-45 and Program Manual Appendix 1 p. 6-10 and 3 (Wraparound Statement of Work Section 2.2.2 p.3 and 2.2.2-2.2.4 p. 3-4).
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
Wellnest Emotional Health and Wellness will establish mechanisms for family participation in HFW implementation requires embedding “family voice and choice” into the governance, planning and evaluation levels, not just at the individual treatment planning level. Efforts include:
(a) Wellnest Emotional Health and Wellness will establish mechanisms in place for families to participate in decisions regarding local HFW implementation as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 8.0 p. 83-84.
(b) Wellnest Emotional Health and Wellness will use family feedback in decision-making regarding service planning and implementation, policy and procedure development, workforce development and quality improvement as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 8.0 p. 84-85.
7.2 Community Leadership Team
7.3 Eligibility and Equal Access
Wellnest Emotional Health and Wellness’ HFW program eligibility and referral criteria and processes ensure adequate, appropriate and equitable access to HFW services and do not exclude families because of the severity or nature of their needs. Efforts include:
(a) Wellnest Emotional Health and Wellness serve youth that meet established eligibility criteria and are not excluded based on severity or nature of their needs as outline in Program Manual Appendix 2 p. 5 and 4 Section 2.1.1.2 p. 4.
(b) Wellnest Emotional Health and Wellness plans staffing to ensure appropriate case load assignments that support the intensity and frequency of services necessary to meet families’ complex needs and enable staff to provide 24/7 support to families in crisis as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 2.1.3 p. 10 and
Program Manual Appendix 2 p. 15.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.5 p. 79.
(3) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.8 p. 25 and
Program Manual Appendix 2 p. 45-46.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
Wellnest Emotional Health and Wellness has fiscal practices that are aligned with the values and principles of Wraparound and ensure the CA Wraparound Standards are met regardless of county or provider-based service provision funding for essential Wraparound operations, including required staffing, workforce development data collection, and data management systems and the costs of services. Efforts include:
(a) Wellnest Emotional Health and Wellness ensures that services are immediately accessible regardless of the county or specific provider network through several core mechanisms as outlined in Program Manual Appendix 2 p. 52-57 and 71 p. 1-2.
(b) Wellnest Emotional Health and Wellness ensures that required workforce development and staffing are accessible regardless of the county or specific provider network through several core mechanisms as outlined in Program Manual Appendix 2 p. 52-57 and 50.
(c) Wellnest Emotional Health and Wellness ensures that required data collection and/or data management systems are accessible regardless of the county or specific provider network through several core mechanisms as outlined in Program Manual Appendix 71 p. 4-5.
8.2 Equitable Funding Across System Partners
8.3 Cost Savings are Reinvested
8.4 Availability, Access, and Approval of Flex Funds
8.5 Collaborative Oversight of Flex Funds
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
Wellnest Emotional Health and Wellness strives to hire staff that can appropriately meet the cultural, racial and linguistic needs of youth and families, where staffing reflects the cultural, racial and linguistic diversity of the youth, families and communities served. Efforts include:
(a) Wellnest Emotional Health and Wellness monitors the demographic composition of the populations served to recruit/hire staff according to population needs as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.0-7.1 p. 69-71
and Program Manual Appendix 1 p. 10, 17, 18 p. 3-4, 39 p. 2, 42 and 43.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.4 p. 76-77.
(3) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 3.1-3.1.3 p. 11-13
and Program Manual Appendix 2 p. 13-14, 3 (Wraparound Statement of Work Section 5.9 p.16) and 15 p. 3-4.
(b) Wellnest Emotional Health and Wellness makes efforts are to meet families’ needs for cultural representation through alternative means such as engaging natural or formal supports on the HFW team when unable to recruit/hire according to cultural, racial and linguistic needs as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1 p. 70-71.
(c) Wellnest Emotional Health and Wellness utilizes a translator or natural support person when unable to provide a staff member who can provide services in the family’s language as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1 p. 71.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.7 p. 24-25
and Program Manual Appendix 1 p. 13, 3 (Wraparound Statement of Work Section 2.2.2 p. 3, 17 and 18 p. 3-4.
9.2 Tribally Responsive Workforce
In the cases of Indian children, Wellnest Emotional Health and Wellness will prioritize respect for tribal sovereignty, traditions and values and ensure respectful communication, collaboration and advocacy. Efforts include:
(a) Wellnest Emotional Health and Wellness HFW staff will be trained on tribal sovereignty, traditions, and values, as well as how to ensure respectful communication, collaboration and advocacy as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.2 p. 71 and Program Manual Appendix 50.
(b) Wellnest Emotional Health and Wellness HFW teams will build partnerships with tribal representatives, encouraging participation in tribal traditions and ceremonies and understanding the value of services and supports that the Tribe can offer when serving an Indian child as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.2 p. 71.
9.3 Flexible and Creative Work Environment
Wellnest Emotional Health and Wellness is committed to creating structures that promote staff creativity and flexibility. Efforts include:
(a) Wellnest Emotional Health and Wellness is committed to program quality and improvement and has specific processes to engage staff as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.3 p. 71-73.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 6.1.3 p. 62-69
and Program Appendix 20, 31, 33, 34, 37, 38, 39, 40 and 41.
(b) Wellnest Emotional Health and Wellness is committed to cohesion and has specific processes to engage staff as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.3 p. 73-74.
(c) Wellnest Emotional Health and Wellness is committed to cohesion and has specific processes to engage staff as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.3 p. 74.
(d) Wellnest Emotional Health and Wellness is committed to creating a clear sense of mission and compliance with HFW philosophy and has specific processes to engage staff as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.3 p. 74-76
and Program Manual Appendix 50.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Policy Manual) Section 6.1-6.1.3 p. 51-65
and Program Manual Appendix 2 p. 42-44, 3 p. 1-2, 14, 19, 20, 30, 31 p. 1-4, 32, 33 p. 5, 34, 35, 36, 37, 38, 39, 40 and 41.
9.4 Hiring, Performance Evaluation, and Job Descriptions
Wellnest Emotional Health and Wellness’ has rigorous hiring practices and use meaningful performance assessments to hire HFW staff. Efforts include:
(a) Wellnest Emotional Health and Wellness’ job descriptions for all required HFW positions reflect best practices regarding HFW skills and expertise, have clear expectations for performance and the roles and functions of these positions will be met within the HFW program as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.4 p. 76 and Program Manual Appendix 5, 6, 7, 8, 10 and 11.
(b) Wellnest Emotional Health and Wellness HFW job descriptions are specific to HFW and reflect the attitudes, skills, knowledge and experience most likely to identify individuals who will be successful in the position as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.4 p. 76 and Program Manual Appendix 5, 6, 7, 8, 10 and 11.
(c) Wellnest Emotional Health and Wellness’ HFW job description and responsibilities of each required HFW role include role purpose, functions and qualities (including skills, competencies and attributes) specific to each role or function as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.4 p. 76 and Program Manual Appendix 5, 6, 7, 8, 10 and 11.
(d) Wellnest Emotional Health and Wellness’ hiring hiring process includes opportunities that allow candidates to demonstrate specific attitudes and skills essential to the position as outline in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.4 p. 76-77.
(e) Wellnest Emotional Health and Wellness provides employees clear expectations for their performance and receive frequent feedback and coaching to support their success as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.4 p. 77-78
and Program Manual Appendix 31.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Policy Manual) Section 6.1-6.1.3 p. 51-65
and Program Manual Appendix 2 p. 42-44, 3 p. 1-2, 14, 19, 20, 30, 31 p. 1-4, 32, 33 p. 5, 34, 35, 36, 37, 38, 39, 40 and 41.
9.5 Workforce Stability
Wellnest Emotional Health and Wellness’ Human Resource Management Team recognize that workforce turnover disrupts care and reduces treatment effectiveness, making retention critical for success of HFW. . As a result, the following strategies and processes are utilized to maintain a stable workforce. Efforts include:
(a) Wellnest Emotional Health and Wellness matches wages to cost of living in the location of the organization’s service implementation area as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.5 p. 78-79 and Program Manual Appendix 44.
(b) Wellnest Emotional Health and Wellness maintains manageable workloads for staff as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.5 p, 79 and
Section 2.1.3 p. 10 and Program Manual Appendix 2 p. 15.
(c) Wellnest Emotional Health and Wellness has clearly communicated and accessible promotion/advancement structures that are not prohibitive for those with lived experience as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.5 p. 79-81 and Program Manual Appendix 46, 47, 48, 49, 50 and 51.
(d) Wellnest Emotional Health and Wellness provides wage increases or leadership opportunities that do not require a position change to achieve as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.5 p. 79-81 and Program Manual Appendix 46, 47, 48, 49, 50 and 51.
9.6 High Fidelity Training Plan
Wellnest Emotional Health and Wellness has a high fidelity training plan that incorporates initial, annual, booster trainings and ongoing trainings that includes both general HFW training and role-specific training for all roles and specific training for all Clinical Supervisors and Wraparound Supervisors/Managers. Efforts include:
(a) Wellnest Emotional Healing and Wellness HFW staff will be trained externally by attending the Statewide Standardized Foundational HFW training through the UC Davis RCFFP, as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 3.1-3.1.3 p. 11-13 and Program Manual Appendix 2 p. 13-14, 3 (Wraparound Statement of Work Section 5.9 p.16), 15 p. 3-4 and 50 (Wellnest Emotional Health and Wellnest Training Plan).
(b) All Wellnest Emotional Health and Wellness HFW staff receive ongoing training both in general Wraparound and in their specific role through formal trainings, meetings, coaching, peer shadowing and/or supervision as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 3.1-3.1.3 p. 11-13
and Program Manual Appendix 2 p. 13-14, 3 (Wraparound Statement of Work Section 5.9 p.16), 15 p. 3-4 and 50 (Wellnest
Emotional Health and Wellnest Training Plan).
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.6 p. 81-83.
(c) All Wellnest Emotional Health and Wellness HFW staff will receive booster trainings at least annually in general Wraparound and in their specific roles as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 3.1-3.1.3 p. 11-13 and Program Manual Appendix 2 p. 13-14, 3 (Wraparound Statement of Work Section 5.9 p.16), 15 p. 3-4 and 50 (Wellnest Emotional Health and Wellnest Training Plan).
(d) Wellnest Emotional Health and Wellness Clinical Supervisors and HFW Supervisors/Managers will attend general Wraparound training as well as receive initial, ongoing and booster trainings specific to their leadership/supervisory role as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 3.1-3.1.3 p. 11-13 and Program Manual Appendix 2 p. 13-14, 3 (Wraparound Statement of Work Section 5.9 p.16), 15 p. 3-4 and 50 (Wellnest Emotional Health and Wellnest Training Plan).
(e) All Wellnest Emotional Health and Wellness HFW staff will receive ICWA and Tribal sovereignty training and mechanisms are in place to identify and provide training that supports populations with specific and unique needs as needed as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 3.1-3.1.3 p. 11-13 and Program Manual Appendix 2 p. 13-14, 3 (Wraparound Statement of Work Section 5.9 p.16), 15 p. 3-4 and 50 (Wellnest Emotional Health and Wellnest Training Plan).
9.7 Community-based Training Program
Wellnest Emotional Health and Wellness will administer a community-based training plan in collaboration with community members and families with HFW experience as part of the training team. Efforts include:
(a) Wellnest Emotional Health and Wellness recognizes that youth, families and peer partners are essential in leading HFW trainings for HFW staff that bridge lived experience with professional practice, fostering authentic engagement and empowerment and they will be incorporated into the delivery of required Wraparound trainings as outlined in Program Manual Appendix 51 (Wellnest Emotional Health and Wellness Community-Based Training Program).
(b) Wellnest Emotional Health and Wellness will invite community partners to attend Wraparound trainings and will offer trainings on Wraparound to strengthen their participation on HFW teams or to strengthen their role in supporting HFW within the System of Care as outlined in Program Manual Appendix 51 (Wellnest Emotional Health and Wellness Community-Based Training Program).
9.8 Coaching and Supervision
Wellnest Emotional Health and Wellness recognizes HFW coaching and supervision) is a critical component of program fidelity that is designed to equip staff with the necessary knowledge and skills to support families effectively. Efforts include:
(a) All Wellnest Emotional Health and Wellnest HFW staff are provided with an initial apprenticeship that covers values, skills, and knowledge related to HFW principles, phases and activities, and the effective use of flex funds to meet a family’s needs as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness4.1.High-Fidelity Wrapround Program Manual) Section 7.1.6 p. 81-83
and Program Manual Appendix 50 and 51.
(2) Attachment 1 (Wellnest Emotional Health and Wellness4.1.High-Fidelity Wrapround Program Manual) Section 4.1.10.1 p. 31
and Program Manual Appendix 2 p. 52-57.
(b) Wellnest Emotional Health and Wellness HFW staff have access to supervision or coaching 24/7 as needed as outlined in:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 7.1.6 p. 83.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.8 p. 25 and
Program Manual Appendix 2 p. 45-46, 3 (Wraparound Statement of Work Section 2.5-2.5.4 p. 7-8) and 19.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
Wellnest Emotional Health and Wellnest will utilize data decided upon by the Los Angeles County Department of Mental Health for program evaluation and improvement at all levels.to improve practice with youth and families, improve overall program effectiveness and improve system supports that impact the HFW implementation. As the organization awaits for further guidance, current efforts include:
(a) Wellnest Emotional Health and Wellness and the Los Angeles County Department of Mental Health collect data to improve practice with youth and families, including giving staff timely feedback from data or reports relevant to their service provision and using data to identify staff training needs as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Policy Manual) Section 6.0-6.1.3 p. 51-65 and Program Manual Appendix 2 p. 42-44, 3 p. 1-2, 14, 19, 20, 30, 31 p. 1-4, 32, 33 p. 5, 34, 35, 36, 37, 38, 39, 40 and 41.
(b) Wellnest Emotional Health and Wellness and the Los Angeles County Department of Mental Health collect data to identify and address program needs to better serve families and improve overall program effectiveness as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Policy Manual) Section 6.0-6.1.3 p. 51-65 and Program Manual Appendix 2 p. 42-44, 3 p. 1-2, 14, 19, 20, 30, 31 p. 1-4, 32, 33 p. 5, 34, 35, 36, 37, 38, 39, 40 and 41.
(c) Wellnest Emotional Health plans to partner with the Los Angeles County Department of Mental Health Community Leadership Team and share data to identify and communicate system barriers that impact HFW implementation as outlined in Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Policy Manual) Section 8.0 Part A. p. 84 and Program Manual Appendix 72.
Fidelity Indicators
1.1 Timely Engagement and Planning
A – Upon receipt of referral, first contact is made with families by an intake coordinator within 3 business days (Reference: Statement of Work (SOW) page 39 – 8.5.1). The intake coordinator will inform families of receipt of referral, and provide a brief explanation of our services and intake session logistics. During this call, the intake coordinator confirms whether the client/family accepts a scheduled, initial session. Routine referrals are offered first appointments within 10 business days of contact , and urgent referrals are offered first appointments within 48-hours (Reference: SOW page 39- 8.5.2 and 8.5.3, respectively). Please see our referral protocol PDF for processes.
B – Due to the nature of being a BHS program, our intensive care coordinators utilize life domain cards and behavioral health assessment findings to inform an individualized treatment plan (Care Plan) within 30-days of opening. The initial wraparound plan of care is created during the first session with the youth and caregiver(s) together. This initial version is based on their identification of initial needs and any safety-related concerns, and it outlines that a comprehensive assessment will be completed during the engagement phase to further detail the care plan. (Reference: Clinical Documentation Timelines, Treatment Care Plans PDF, Wrap Process Checklist)
C – Teams review progress towards plan of care goals during weekly or bi-weekly wrap meetings utilizing the R.A.A.A.R tool or CFT meeting notes during the ‘what is working well?’ and ‘what are we worried about’ discussions – (Reference: RAAAR.docx, RTWB-training PDF pages 43, 116-119, RTWB Tool Kit pgs. 22-23, CFT meeting notes, RTWB page 105 see presenter notes re: monthly expectation around plan of care review)
D – Intensive Care Coordinator updates the plan of care at a minimum of every 90 days during CFT meetings and during the utilization management process at the 6/12/18 month marks. Updated plans are distributed to team members electronically or in person at meetings. The care plan is updated in our electronic medical record, Smartcare, and is copied into every progress note teams write. (Reference: CFT Quarterly Audit Compliance Standard & CDSS CFT Brochure , UM Request Form 2025 section E, Clinical Documentation Timelines)
E – Managers reviews all care plans/updates at the 30 day mark through oversight of the intake checklist and at UMs to provide CQI related to timeliness for staff – feedback for CQI occurs when the director meets weekly with the managers and when the managers meet for supervisions with their staff. The QA specialist and assistant director oversee all QA for the program and provide feedback in real time as paperwork is reviewed (Reference: Intake Checklist). Wraparound process timelines and progress are regularly discussed during both individual and group supervision, both of which occur weekly for every staff member (see manager responsibilities 8.A, 10.E, 10.D) .
1.1F – Staff discuss families each week in individual and group supervisions where brainstorming occurs to encourage different strategies to build rapport/engagement where this is a struggle. Staff also receive “Ready to Wrap Basics” (RTWB) training as part of new hire orientation and are taught engagement strategies first, with emphasis on utilizing persistence (Reference: persistence policy) from the start of services (Reference: RTWB training- PDF pages 28, page 45)
1.2 Led by Youth and Families
1.2A – The intensive care coordinator elicits the family and Tribe’s perspectives through the use of domain cards, needs eggs, and mission statements, in developing strategies to meet needs throughout all phases of wrap. The wrap process checklist, which guides teams and families during wrap treatment, outlines several activities (ex: domain cards; needs egg; mission statement) used from the start of services to elicit and use families’ perspectives. (Reference: RTWB training – PDF pages 14-15)
1.2B – The wrap tools used during the engagement phase support the team in eliciting values, culture, expertise, capabilities, interests and skills. Our wraparound teams utilize strengths assessments and cultural discovery activities to gather this information (such as – the “helping hand”, “functional web” activity, timelines, genograms, and discussions based on the Hays ADDRESSING model). The information gathered is used to inform assessment and documented in client’s file via the CalAim assessment. (Reference: RTWB training – PDF pages 78-81, 59; CalAIM Assessment Explanation Sheet/domain 6, ADDRESSING model questions)
1.2C – Our wrap fidelity specialists (WFS) shadow team meetings in the field. WFS meet with managers/supervisors on a monthly basis (see manager responsibilities 3.E) to discuss families and team members that could use their support in shadowing. Managers, supervisors, and team members can make a request for shadowing at any point during the wraparound process. They use TOMS 2.0 to observe meetings and provide feedback through individual and team coaching to staff. (Reference: TOMS-notes and WFS Coaching Tracker)
1.2D – Feedback from families is elicited annually by use of the WFI-EZ and the YSS Survey; and bi-annual parent advisory groups hosted by our wraparound staff (Reference: SOW, page 28, PDF 42, and page 28 3.18 respectively). Teams also routinely illicit feedback from families as to how they believe the wraparound process is going during meetings. Additionally, at the end of formal CFT meetings scaling questions are asked to ensure voices are heard (REFERENCE: CFT Meeting Notes, WFI-EZ Data Collection Instructions Document, WFI-EZ, YSS Presentation PDFs, PAG Survey Questions, QSR for PAG).
1.3 Strength-Based
A – An intensive care coordinator assesses the functional strengths of the youth by the 30-day mark with the help of the CANS. Strengths of all team members are gathered through a strength’s discovery activity led by the ICC within the first 45 days of treatment and documented for future reference. (Reference: wrap process checklist, RTWB training PDF page 78, RTWB Tool Kit pg. 12)
B – Upon completion of the initial CANS by intensive care coordinators with clients, the clinician reviews the “Strengths” domain with the client and utilizes that information to inform the functional strengths for the client’s care (treatment) plan. Staff are instructed to use those strengths rated a “0” or “1” as core strengths to inform treatment. (Reference: CANS-form.pdf, CANS-San-Diego.pdf)
C – Wrap fidelity specialists provide quarterly wrap refresh training to all staff. Additional coaching is provided based on needs identified during group supervisions and/or requests for coaching (Reference: RTWB training, PDF page 40) Staff also receive 1 hour of individual and 2 hours of group supervision each week with a wraparound expert/veteran of services (see manager responsibilities 8.A, 10.E, 10.D). Supervision reminds staff to stay strength-based in how they view families and plan with them.
D – Feedback from families is elicited by the wraparound team by use of the WFI-EZ, annually; the YSS Survey; and bi-annual parent advisory groups (Reference: SOW, page 28, page 42, and page 28 3.18 respectively, WFI-EZ Data Collection Instructions Document, WFI-EZ, YSS Presentation PDFs, PAG Survey Questions, QSR for PAG).
1.4 Needs Driven
A – Members of the wraparound team complete the needs egg activity and/or other individualized needs discovery exercises with families during phase 2 of the wrap process (Reference: wrap process checklist, phase 2, RTWB PDF pages 99-101, RTWB Tool Kit pg 16)
B – Staff receive ongoing training by the wraparound fidelity specialists, initially through ready to wrap basics training then during ongoing shadows/scheduled coaching sessions in identifying needs, developing needs statements that are reflective of the underlying reasons why problematic situations or behaviors are occurring, and utilizing needs-focused planning over problematic behavior focused planning. The frequency of these trainings is individualized based on the needs of the staff. These items are also discussed regularly and as appropriate during individual and group supervisions (Reference: RTWB training – PDF pages 47-48)
C – Intensive care coordinators use needs identified by a score of 2 or 3 in the CANS to guide areas in which to focus needs egg and needs statements for treatment planning. In addition to the CANS, unmet needs of clients and families is identified during the assessment process for the CalAIM assessment (Reference: CANS form, CalAim Assessment Explanation Sheet)
D – Transition is discussed from the start of services and the team utilizes the transition tool form to plan transition according to team and family agreement that needs have been successfully met (Reference: BHA Supplemental and Transition Tool, RTWB Toolkit page 25). As the wrap process progresses, and needs are being adequately addressed, the team will create a transition tool to outline ways to sustain progress.
1.5 Individualized
A – Wrap team members use wrap planning formats which are prioritized based on the domains which families rate, in order of highest to lowest need. Each segment of the wrap plan allows for individualization through consideration of client/family’s goals and varied brainstorming styles for identifying strategies. (Reference: wrap-plan)
B – WFS provides quarterly wrap refresh training for all staff. Additional coaching is provided based on needs identified during group supervisions and/or requests for coaching (Reference: RTWB training, PDF page 47) Staff also receive 1 hour of individual and 2 hours of group supervision each week with a wraparound expert/veteran of services. Ongoing coaching is based on individualized needs of the staff member and focuses on providing flexible, creative, and high individualized services and strategies.
C – Facilitators will complete the CFT training from UC Davis, in addition to completing quarterly wrap refresh trainings (Reference: RTWB training, PDF page 48). Staff receive 1 hour of individual and 2 hours of group supervision each week with a wraparound expert/veteran of services (see manager responsibilities 8.A, 10.E, 10.D).
D – Teams review the wraparound plan during wrap meetings utilizing the R.A.A.A.Ring tool – (Reference: RTWB PDF pages 113, 115-119)
E – Feedback from families is elicited annually by use of the WFI-EZ and the YSS Survey; and bi-annual parent advisory groups hosted by our wraparound staff (Reference: SOW, page 28, page 42, and page 28 3.18 respectively). Teams also routinely illicit feedback from families as to how they believe the wraparound process is going during meetings. Additionally, at the end of formal CFT meetings scaling questions are asked to ensure voices are heard (REFERENCE: CFT Meeting Summary, WFI Data Collection Instructions Document, YSS Presentation PDF pages, PAG Survey Questions, QSR screenshot for PAG). During formal CFT meetings the scaling tool is utilized to ensure families are having their needs met (Reference: CFT Meeting Summary).
1.6 Use of Natural and Community Based Supports
A – The natural supports inventory is completed within the first 30-days of services and is updated throughout the process (Reference: process checklist – phase 1; RTWB training – PDF page 46, informal supports log, RTWB toolkit pg 13)
B – Staff attend wrap basics training at new hire and again after 6 months for ongoing support (Reference: new hire checklist, page 3); they also participate in quarterly wrap refresher trainings (Reference: RTWB training, PDF page 48). Staff receive 1 hour of individual and 2 hours of group supervision each week with a wraparound expert/veteran of services (see manager responsibilities 8.A, 10.E, 10.D).
C – Teams complete review of natural supports ongoingly during the wrap process, most specifically during phases 2 and 3 – Planning and Implementation Phases (Reference: Wrap Process Checklist)
D – Feedback from families is elicited annually by use of the WFI-EZ and the YSS Survey; and bi-annual parent advisory groups hosted by our wraparound staff (Reference: SOW, page 28, page 42, and page 28 3.18 respectively). Teams also routinely illicit feedback from families as to how they believe the wraparound process is going during meetings. Additionally, at the end of formal CFT meetings scaling questions are asked to ensure voices are heard (REFERENCE: CFT Meeting Summary, WFI Data Collection Instructions Document, YSS Presentation PDF pages, PAG Survey Questions, QSR screenshot for PAG).
1.7 Culturally Respectful and Relevant
A – Wraparound team utilizes the wraparound process checklist to do a culture discovery; we use the ADDRESSING model to further explore cultures/identity and discuss it with the culture domain card. These are documented in the youth’s working file and medical record (Reference: Wrap Process Checklist, ADDRESSING model)
B – Each team member is required to complete four (4) hours of cultural competency training required of all staff (including sub-contractors) that interface with clients/caregivers. (Reference: SOW, page 38, section 7.14 RTWB PDF page 48). Trainings vary year to year based on needs of program to ensure trainings are meeting the needs of those serving the community. Ongoing coaching is provided in individual and group supervisions (see manager responsibilities 8.A, 10.E, 10.D), as well as with wraparound fidelity specialists as appropriate/necessary.
C – Feedback from families is elicited annually by use of the WFI-EZ and the YSS Survey; and bi-annual parent advisory groups hosted by our wraparound staff (Reference: SOW, page 28, page 42, and page 28 3.18 respectively). Teams also routinely illicit feedback from families as to how they believe the wraparound process is going during meetings. Additionally, at the end of formal CFT meetings scaling questions are asked to ensure voices are heard (REFERENCE: CFT Meeting Summary, WFI Data Collection Instructions Document, YSS Presentation PDF pages, PAG Survey Questions, QSR screenshot for PAG).
1.8 High-Quality Team Planning and Problem Solving
A – Team agreements are a part of the process checklist to ensure we’re doing them with every family. They’re documented in the working file for the client (Reference: wrap process checklist, see RTWB 44-45 about how to use/make working files).
B – Feedback from families is elicited annually by use of the WFI-EZ and the YSS Survey; and bi-annual parent advisory groups hosted by our wraparound staff (Reference: SOW, page 28, page 42, and page 28 3.18 respectively). Teams also routinely illicit feedback from families as to how they believe the wraparound process is going during meetings. Additionally, at the end of formal CFT meetings scaling questions are asked to ensure voices are heard (REFERENCE: CFT Meeting Summary, WFI Data Collection Instructions Document, YSS Presentation PDF pages, PAG Survey Questions, QSR screenshot for PAG).
C – Feedback received from families is routinely discussed in weekly supervision with supervisors (see manager responsibilities 8.A, 10.E, 10.D). and staff members. These items are also brought to our weekly leadership team meeting (see manager responsibilities 3.B) and elevated to C suite members during the directors weekly meeting (see John and Aisha meeting) when we are unable to resolve them in the wraparound leadership team.
D – These are discussed in each wraparound meeting to ensure there’s a plan in place that everyone agrees on. There is also the wraparound plan that identifies who’s working on what action items (REFERENCE: CFT Meeting Summary)
1.9 Outcomes Based Process
A – The wrap intensive care coordinator develops with the client/family a treatment care plan within 30-days of intake which includes SMART goals. Throughout treatment, the use of the CFT meeting summary and action plan supports ongoing conversations about progress toward action items and goals within specific timeframes. (Reference: Treatment Care Plans PDF)
B – Wrap facilitators use the CFT meeting summary and action plan to track action plan completion during weekly team meetings. Our wrap facilitators also utilize regular team member collaboration meetings to monitor progress of completed action items, as needed. (RTWB PDF p.34, 42-43, RTWB Toolkit page 3)
C – Our wrap teams use the following tools within the wrap process to review strategies and action items for progress and/or need for adjustment: wrap plan document, CFT meeting summary and action plan, and through implementation of RA.A.A.Ring. (Reference: wraparound process checklist, RTWB Toolkit pgs 20-23)
D – Considering that the IP-CANS is client-specific with our electronic health record (SmartCare), all BHS providers have a copy of the CANS in SmartCare. CANS completion and timeline is dependent on whether our program is the first provider to render specialty mental health services to the client. If so, the assigned clinician will complete the IP-CANS with the client/family. If not, the current IP-CANS will be reviewed, and care coordination will occur between providers to update the IP-CANS, if significant variances are assessed. (Reference: PSCs-CANS-The-What-How pg 4, RTWB pg 35)
E – Upon completion of the CANS training, program leadership emphasize to clinicians that they are to use identified CANS needs rated a “2” or “3” to inform client care plan development, as well as incorporate centerpiece strengths rated “0” and “1” into their assessment. (Reference: CalAim Assessment Formatting Guide – OneNote page)
1.10 Persistence
A – All team members receive 1 hour of weekly individual supervision with their supervisor in addition to two hours of group supervision (see manager responsibilities 8.A, 10.E, 10.D). If necessary, the teams can have a team coaching session (RTWB PDF page 48) with a wraparound fidelity specialist at any time to receive feedback on how the wraparound process is going. Reference – persistence policy.
B – All team members receive 1 hour of weekly individual supervision with their supervisor in addition to two hours of group supervision (see manager responsibilities 8.A, 10.E, 10.D). If necessary, the teams can have a team coaching session with a wraparound fidelity specialist at anytime to receive feedback on how the wraparound process is going. Upon hire, staff are trained on how to request flex funds. (REFERENCE – flex funds policy.)
C – All team members receive an initial safety training that reviews our suicide prevention protocol (SPP checklist) (see new hire checklist page 3). All facilitators receive 1 hour of individual and 2 hours of group supervision each week (see manager responsibilities 8.A, 10.E, 10.D) and can receive on-going clinical consultation as needed by a licensed clinician for safety issues. Additionally, supervisors frequently discuss conflict resolution strategies. Our wrap basics training covers brainstorming in multiple areas (RTWB PDF pg 63, 65). (Reference: SPP Checklist)
1.11 Transitions as a part of the Fourth Phase of HFW
A – Wrap teams engage families in discharge planning conversations from the start of services to include the family’s voice in identifying what a successful discharge looks like (Reference: BHA Supplemental Form) They ensure that the transition phase is clear and engage families in completion of the transition tool, updates to the safety plan, connections to resources, as needed, and a celebration. (Reference – process checklist, transition tool, RTWB PDF Page 138). If needed, team will engage in pro-bono services to ensure a warm handoff to another provider is completed. Reference SOW pg 34 6.30.
B – Our teams are trained on the importance of celebrating not just at the end of wrap, but throughout. We utilize flex funds to have celebrations and ensure our clients are connected to appropriate resources after closing. Staff consistently attend celebrations with families. REFERENCE – RTWB PDF page 137
Expected Outcomes
2.1 Youth and Family Satisfaction
Feedback from families is elicited annually by use of the WFI-EZ and the YSS Survey; and bi-annual parent advisory groups hosted by our wraparound staff (Reference: SOW, page 28, page 42, and page 28 3.18 respectively). Teams also routinely illicit feedback from families as to how they believe the wraparound process is going during meetings. The results from these items are discussed during weekly wraparound leadership team meetings, monthly wraparound oversight meetings with county partners, and monthly TA call with county contract monitor. (REFERENCE: WFI Data Collection Instructions Document, YSS Presentation Slides, PAG Survey Questions, QSR screenshot for PAG, TA-calls-schedule.png, wrap-oversight.png, Monthly-Wrap-Oversight-Agenda.docx).
2.2 Improved School Functioning
We track this with our partnership assessment form and then every 3 months with the 3M form that’s entered into the DCR database and KET form as events occur to accurately track them (Reference: SOW page 28 3.26, 3.27, DCR Admin Guide, KET.pdf, 3M form.pdf)
2.3 Improved Functioning in the Community
We track this information on our referral tracking log spreadsheet to ensure compliance with our contract. Level of involvement is evaluated by use of the WFI-EZ, annually; the YSS Survey; and bi-annual parent advisory groups (Reference: SOW, page 28, page 42, and page 28 3.18 respectively, PAG questions, QSR for PAG, closed cases.xlsx, WFI-EZ, WFI data collection instructions, SOW Page 28. 3.15, 3.16, 3.21, 3.24.)
2.4 Improved Interpersonal Functioning
We measure these by CANS, YSS, WFI EZ, and consistent feedback from families throughout the wraparound process. We utilize the CANS at intake, every 6 months, and discharge, we do the YSS and WFI-EZ annually. (Reference: CANS form, YSS caregiver, YSS youth, WFI-EZ, WFI EZ Data collection instructions, YSS presentation).
2.5 Increased Caregiver Confidence
We evaluated caregiver confidence by use of the WFI-EZ, annually; the YSS Survey annually; and bi-annual parent advisory groups . Families are provide at intake a Medi-Cal Guide in order to assist them with accessing resources (References: PAG questions, QSR for PAG, closed cases.xlsx, WFI-EZ, WFI data collection instructions, RTWB pg 135, BHS Member Quick Guide, Intake-Family Folder Guidelines.xlsx, reference: SOW, page 28, page 42, and page 28 3.18 respectively.
2.6 Stable and Least Restrictive Living Environment
We track youth placements using the DCR. A KET is done when youth move placements. if necessary. This data is stored in the DCR database. (Reference: SOW page 28 3.22, 3.23, reference PAF & KET for placement changes, DCR-SDCC-WrapWorks-FY-25-26-Q1-Report.pdf)
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
YES – we track all hospital admissions on our referral tracking log and report this quarterly on our QSR to the county. (Reference: SOW – 3.13 – see psych hospital redacted spreadsheet, psychiatric hospitalization checklist, psych hospital qsr.png)
2.8 Reduction in Crisis Visits
We track these in our online medical record system with a crisis intervention code. All hospitalizations and arrests are recorded in the data collection reporting database. Visits to the mobile crisis team or emergency screening unit are tracked on ICC stats sheet every month (SEE KET, ICC stats).
2.9 Positive Exit from HFW
The KET asks for information on why services are ending/disrupted. We also track this on our referral tracking log with more detailed explanations. (Reference: KET, SOW page 34 6.30, closed cases. Xlsx column J)
Engagement
3.1 Orientation
A – All families receive a wraparound process users guide which explains the principles and phases. They also sign a consent form and receive a family handbook that discusses the legal and ethical considerations of engaging in services. The process users guide outlines the importance of natural supports and facilitators begin discussing natural supports at the initial meeting when discussing who should be present. REFERENCE – family handbook, Wraparound-Process-Users-Guide.pdf, SDCC consent. These topics are covered throughout.
B – The wraparound process users guide outlines the principles and phases. The intensive care coordinator reviews this at intake with families. All families receive their own copy of the process users guide within the family folder at intake. (Reference Wraparound-Process-Users-Guide.pdf, Intake-Family Folder Guide)
C – Legal and ethical considerations are discussed during intake and referenced in our consent form. (REFERENCE SDCC Consent)
D – The wraparound process users guide and the family handbook discuss the role of each team member and natural supports. Each family receives a copy of these items during intake. (Reference wraparound process users guide, family handbook, intake checklist)
3.2 Safety and Crisis stabilization
A – During our initial screening process of referrals a clinician determines whether the youth should be placed onto our suicide prevention protocol. Every facilitator conducts an initial safety assessment upon meeting the family and completes a safety plan with the client and family if indicated. Safety plans are on duplicate forms, one goes with the family and the other gets stored in the client’s chart. The facilitator also writes a progress note in the EHR that discusses what they did and how the family responded related to safety issues. Crisis procedures are referenced in the family handbook and reviewed verbally with the family. (reference safety plan, suicide prevention protocol, family handbook)
B – The crisis plan is in the family handbook (Page 4) and reviewed at intake by the facilitator.
C – Families can access 24/7 care via PERT or the access and crisis line. Staff are available 24/7 per our contract. Both are referenced on the safety plan and in the family handbook. On call expectations are outlined in our policy attached On-call-staff-expectations.docx.
Also, see attached our agency Crisis-Response-Protocol.pdf
3.3 Strengths, Needs, Culture and Vision Discovery
A – The family’s vision is explored during the engagement phase as wrap team members learn the family’s story and documented in youth’s file (Reference: wrap process checklist, working files RTWB 44-45, mission statement is RTWB pg 93)
B – We coach our teams that the strengths, needs, and cultural discovery are all “living documents” that are to be updated throughout the process and at minimum during CFT meetings which are required to happen at least every 90 days (CFT quarterly audit compliance standard). . They are kept in the working files (working files RTWB 44-45)
3.4 Engage All Team Members
A – A natural supports/informal supports inventory is discussed initially upon intake and woven into all activities within the wraparound process (RTWB pg 30,41 82-87). It is done formally when clinically appropriate during the engagement phase as determined by the family, facilitator, and other wrap team members. The supports inventory is stored in the working file (RTWB pg 44-45) and the medical record upon closure. The family is offered a copy of the supports inventory. (Reference: Wrap process checklist, natural Supports Log & SOW – pg. 33 6.20.1)
B – All of our referrals are from Child and Family Well-Being and probation. We get a release of information at intake and begin coordinating with the immediately. Our intake/outreach coordinator also reaches out to the social worker or probation officer to let them know that we’ll be opening or if we’re having trouble getting the client to respond to calls/texts for services. See SOW pg. 25 2.10. At minimum, we coordinate care with probation officers and social workers 1x monthly and every 90 days at CFTs. (See: Referral protocol PDF)
C – The HFW team facilitates an individualized supports inventory activity where team members are identified and how they can be of assistance to the family. See attached example, however please note that this activity is highly individualized depending on the family needs and culture. (REFERENCE natural support log (RTWB pg 12, 30,41, 52 82-87)
D – All activities are documented in the electronic health record and working file (RTWB 44-45). Meeting minutes are distributed at each meeting as appropriate (RTWB 42-43, RTWB Toolkit page 3). Reference: working file instructions doc file
3.5 Arrange Meeting Logistics
A – Our wraparound teams meet families and routinely have flexible working hours and schedule meetings at locations and times that accommodate the needs of our families. (Reference: family handbook pg2 service locations/evening appointments) document.
B – Our wraparound teams are trained to work collaboratively with families and other members of the HFW team to schedule meetings that are in alignment with family needs/preferences and maximize participation. (REFERENCE: RTWB PDF page 53 arranging meeting logistics, RTWB Toolkit page 10)
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
A) The wrap team completes the listed wrap activities (team agreements, strengths inventory, and mission statement) before completing the HFW plan of care (reference: wrap process checklist)
B) The strengths assessment is a living document which is reviewed throughout the process as new strengths are identified by CFT members (reference RTWB page 78)
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
A) The wrap team completes the “Needs Egg” activity to identify individualized needs prior to wrap plan development. (Reference: RTWB PDF pages 98-100, wrap process checklist, RTWB Toolkit page 16)
B) Wrap teams are trained to conduct goal setting following identification of the underlying need (Reference: RTWB PDF pages 103-105, RTWB Toolkit page 17)
C) All wrap team members, including but not limited to the youth and family, participate in developing goals and outcomes (Reference: RTWB PDF pages 103)
D) Wrap teams brainstorm strategies using varied formats and keep them available for easy reference in working files, meeting boards/notes, and hybrid file(Reference: RTWB PDF pages 106-108, RTWB Toolkit page 18)
E) Facilitator training about wrap plan development is completed during RTWB (Reference: RTWB PDF pages 89-110, RTWB Toolkit page 19)
F) Yes (Reference: RTWB PDF pages 33-34, 89-110
4.3 Develop an Individualized Child or Youth and Family Plan
A) Staff receive 1 hour of individual and 2 hours of group supervision each week (see manager responsibilities 8.A, 10.E, 10.D) where ongoing support, coaching, and training take place. Staff are also able to meet with wraparound fidelity specialists as needed, request team coaching for the entire team, and are mandated to participate in quarterly wraparound refresh trainings. (Reference: Art of Facilitation PDF)
B) All CFT members are invited to participate in plan development and review during wrap and CFT meetings to identify goals and objectives that comprehensively support client in meeting their identified needs. (Reference: Wrap plan)
C) The plan of care is developed to include all components listed and a copy is provided via email or in person to all identified CFT members. The plan of care is documented in the youth’s working file (RTWB 44-45, RTWB Toolkit page 19)
D) Staff are trained to plans of care being living document which are reviewed during CFT meetings (RTWB pg 117), and ongoingly during staff supervision (see manager responsibilities 8.A, 10.E, 10.D) with managers and coaching sessions with wrap fidelity specialists (RTWB pg 48). (Reference: Manager QA Responsibilities)
4.4 Develop a Crisis and Safety Plan
A) We use 3 different safety plans to individualize the safety planning process for families. These are documented in the youth’s file and the families are provided copies of it. (REFERENCE: Wrap Safety Plan, Calming & Crisis prevention – adolescent, Calming and Crisis Prevention – child.)
B) Please see the safety training PDF and the suicide prevention protocol word doc for things we do to ensure client safety. Staff are trained on this during new hire orientation and are consistently speaking about these things during their supervisions with a licensed mental health professional. The default is that the safety plan is done in a team environment, however if the youth isn’t willing to engage with the team the safety plan is done individually. (RTWB 63, 65, 97)
C) Safety plans are reviewed during supervision (see manager responsibilities 8.A, 10.E, 10.D) with staff’s managers to ensure individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for CQI and training/coaching purposes. (Reference: manager responsibilities P.3 managing high risk situations.)
Implementation
5.1 Implement The Plan of Care
A) Our teams use agendas for every meeting – see page 4 of the RTWB tool kit. We also train staff on RAAARing (reference pg 22-23 of RTWB toolkit) and use of meeting minutes (reference pg 4 RTWB tool kit).
B) Wrap teams are trained on implementing the plan of care and celebrating successes as they occur during RTWB. (Reference: RTWB PDF page 112)
5.2 Review and Update The Plan of Care
A) Our teams consistently RAAAR with families (reference pg 22 of RTWB toolkit) to review strategies, progress, and action items. This takes place on our wrap plan (see wrap-plan.docx). During CFT meetings, the CFT Progress Summary and Action plan is utilized to review strategies, progress, and action items (reference CFT Progress Summary and Action plan).
B) Facilitators consistently are RAAARing (reference pg 22 of RTWB toolkit) with families. The updated plans are documented in the youth’s working file working file (reference working file instructions) and medical record.
C) These items are documented on the meeting minutes (PDF page 34 – 35 RTWB) and distributed to team members through e-mail, text, or other methods that the family deems acceptable and protects PHI. This is also documented in the progress note for the youth and on the wrap plan. Flex funds are documented according to our flex funds policy (reference flex funds policy.docx & flex funds training.pdf & RTWB p. 41-42).
D) All forms can be updated and individualized based on the needs of the family, youth, and team’s changing needs. (RTWB PDF pg 4, 8, 105)
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
A) We train on team agreements to be utilized throughout the wraparound process, reviewed regularly, and present in all meetings (reference RTWB PDF page 45, 63-64, 75, RTWB tool kit pg 10)
B) All team members receive a quarterly wraparound refresh training. Team members receive 1 hour individual and 2 hours of group supervision every week with wraparound experts (see manager responsibilities 8.A, 10.E, 10.D) . Wraparound fidelity specialists regularly shadow meetings and are available for individual and team coaching sessions as needed or assigned by managers/requested by team members. (Reference: Teaming and Collaboration Training PDF)
C) Natural supports are monitored during coaching and supervision (see manager responsibilities 8.A, 10.E, 10.D). Teams are provided feedback during these meetings and are able to access coaching if needed (RTWB PDF 48). Our program also audits all working files every quarter (reference working file invite).
D) When new team members join a wraparound team they can be offered a wraparound process users guide, a family handbook, review of the current wrap plan, and engage in team building activities as appropriate, clinically indicated, and at the discretion of the youth/family permission related to confidentiality. (Reference: RTWB PDF page 87)
Transition
6.1 Develop a Transition Plan
A) The wrap team considers several factors to identify when the youth and family are ready for transition (Reference: WrapRefresh.Purposeful.Transition PDF page 18-19)
B) The wrap team utilizes the WrapWorks Transition Tool to create an individualized transition plan for the family to utilize throughout the transition phase and after services have concluded. (Reference: Transition Tool and Reference List and RTWB PDF page 134, RTWB Toolkit page 25)
C) Wraparound teams receive initial training in transition plan completion during ready to wrap basics and ongoingly through coaching and quarterly wrap refresher trainings. Teams are also support during the transition phase in both individual and group supervisions which occur weekly (see manager responsibilities 8.A, 10.E, 10.D). Emphasis is provided about the completion of transition activities required to be done in a team setting. (Reference: RTWB PDF pages 126-140 and WrapRefresh.Purposeful.Transition PDF throughout).
D) Yes, teams ensure that services are going to be available past our program closing. There are no services in the county that require us to be open in order for them to continue providing their services. If there are other providers we’re referring the client to, we do our best to ensure that there is a warm handoff between service providers to ensure continuity of care. (Reference: RTWB PDF page 133)
6.2 Develop a Post-Transition Safety Plan
A) The safety plan is updated during the transition phase, added to the client’s file, and a copy is provided to the family. The plan outlines functional strategies and identifies natural supports chosen by the family (References: wrap process checklist and transition tool, RTWB PDF page 135).
B) Wrap teams receive initial training in transition-focused safety plan completion during RTWB and ongoingly through coaching and quarterly wrap refresher trainings. Emphasis is provided about the completion of transition activities required to be done in a team setting. (Reference: RTWB PDF page 135 and WrapRefresh.Purposeful.Transition PDF throughout).
C) We have a suicide prevention protocol that youth are placed onto should they meet criteria for it. Safety plans are routinely reviewed in individual and group supervision (see manager responsibilities 8.A, 10.E, 10.D) as clinically indicated by the clinical supervisors and staff. This data is brought back to our weekly leadership meeting where quality improvement and training ideas are routinely discussed. (Reference: Manager responsibilities page 3, 9.G)
6.3 Create a Commencement and Celebrate Success
A) We celebrate transitions out of the wraparound process in accordance with the family’s culture, values, and preferences (see RTWB PDF page 137-138). Team members collaborate with the family around planning the celebrations to ensure they’re how the family would like to celebrate.
B) Wraparound team members can utilize flex funds for celebrations throughout the wraparound process in accordance with our flex funds policy (see attached Flex funds training PDF page 24). Team members are encouraged to attend the celebrations and routinely plan celebrations with families collaboratively (RTWB PDF page 137)
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
A) Families are invited to participate in a bi-annual program advisory group (PAG) (see: pg. 28 section 3.18, QSR for PAG, PAG-Survey-Questions-Example.pdf) where feedback on services and suggestions are given, annual youth services survey (see: SOW pg 42 section 9.3.4, YSS Presentation Slides, YSS survey), and at least annual WFI-EZ (see SOW pg 28 section 3.28, 3.29, pg. 29 3.31 – 3.35, WFI Data Collection Instructions Document, WFI-EZ form). Additionally, families are invited to give consistent feedback to their wraparound teams on things that could improve. Per our contract section 8.14 on pg 39 of the statement of work, families/youth are to partner with us re: program design organizational advancement, and service delivery. Our program also employs certified peer support specialists in leadership roles including wraparound fidelity and supervisors. Their lived experience is consistently shared to inform policies (see wrapworks job descriptions 2026 page 37). Families will be invited to the to attend the community leadership team where decisions regarding HFW implementation are discussed. (see HFW-CLT-Charter-Agreement.docx).
7.2 Community Leadership Team
The program director participates in all community leadership team events. If they are unavailable, the assistant director is present. (see page 3 wrapworks job descriptions 2026 page)
7.3 Eligibility and Equal Access
A) No youth are excluded based on the severity or nature of their needs. Our eligibility criteria is clearly defined in our statement of work (see: SOW pg 29-30 section 4). Our department does not have a policy around this due to our statement of work clearly defining the population we’re allowed to serve, so there’s no need for a policy.
B) Staffing is defined in our statement of work (see: SOW pg 36-37, 7.5 – 7.7) as having 16 clinical staff, 25 paraprofessionals, and 4 therapists. Caseload assignments are determined by the staff’s supervisors based on their availability to meet the family’s needs. Caseloads are monitored on our referral tracking log to ensure adequate staffing (see redacted caseload tracking log). All clinical staff, including supervisors, are available to provide 24/7 support to families based on our SOW (pg 31 section 5.8), page 2 family handbook, and our attached on-call staff expectations.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
A) San Diego Center for Children has accepted the payment schedule outlined in attached SDCC-RFP.docx on page 14 and page 120. Our budget includes 3 WFS to assist in promoting and training to high fidelity wrap standards. We also check run rates monthly in collab with the county (see: TA-calls-schedule.png). We request county contract budgets that escalate annually 2-3% to consider inflation. We review budgets annually and look for cost savings prior to approving new budgets, negotiate pass throughs, and rates with the county annually or as needed.
B) Workforce development and staffing roles and functions are outlined on page 27 of the attached SOW.pdf that include wraparound facilitator, youth/peer partner, parent/peer partner, family specialist/coach, and wraparound clinician (RTWB PDF Pgs 20-25). The program manager/director must be a licensed mental health professional with at least 3 years of full-time direct clinical experience post masters working with children and adolescents. See page page 36 of the SOW.pdf.
C) Our program utilizes several data management systems, including the SmartCare electronic health record, which complies with county standards as outlined on pages 39–40 of the Statement of Work (SOW.PDF). This is where staff store assessments, progress notes, and other clinical paperwork related to the youth. The Data Collection and Reporting (DCR) system, described on pages 32 and 42 of the SOW, where outcomes and quarterly updates are entered. In addition, we use proprietary spreadsheets and internal data collection tools supported by Microsoft Excel and Power BI. (Citations – DCR guide for admins, SmartCare access request form ARF.pdf, Closed-cases.xlsx, redacted QSR)
8.2 Equitable Funding Across System Partners
8.3 Cost Savings are Reinvested
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
A) Yes, flexible funding is available and included as part of the funding plan for high fidelity wraparound and can support families in a variety of ways (see SOW pg 32 section 6.5, flex funds policy, and flex funds training).
B)
1. Families are able to access flex funding the same day if necessary and criteria if met based on the attached flex funds policy and flex funds training.
2. Our approval process is outlined in the attached flex funds policy and throughout the flex funds training as well as in section 6.5 on pg 32 of our SOW.pdf. It supports the plan and team goals, builds on family strengths, meets identified needs, is culturally relevant, builds on natural supports, represents a good deal for the investment, and includes a plan for sustainability.
3. Appeals are taken to the program director as defined in the attached flex funds policy on pg 2. The program director has final say on whether flexible funds can be spent, based on county policy.
8.5 Collaborative Oversight of Flex Funds
A) All flex funds are tracked and submitted to the county on a monthly basis with our invoice as defined in section 6.5 pg 32 of the statement of work. This information includes the amount and purpose of the request (Reference redacted BHS flex funds wrapworks).
B) Our flex funds budget is $15,000 per year. Each families limit is $1,300 but it could be exceeded with pre-approval from our contracting officer (see attached flex funds policy)
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
A) There is not current braided funding, but programs (BHS, CFWB, Probation) are working together looking at this. In the future, additional funds will be explored.
B) Flex funds are used as a last resort after other funding has been explored (pg 9 flex funds training). Other funding is regularly explored with families including scholarships, reduced rates, natural supports, and unrestricted funds available through the agency. Our process for utilizing flex funds is described throughout the flex funds training power point, including a step by step process (pg 13-16 flex funds training). There is also the possibility that the agency could use fundraising money to pay for items as outlined on pg30 of the flex funds training.
C) There are no funding source requirements that a family accesses that would prohibit their ability to also access flex funds. If families are unable to receive flex funding due to county or agency policy, other avenues are explored to help the family meet their needs such as on pg22-23 of the flex funds training.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
A) The demographic information of youth in our services is documented in their medical record and on our internal tracking spreadsheet. We hire bilingual and bicultural staff that reflect the culture, ethnicity, and language of the client population as outlined on pg 36 of the statement of work. To help recruit staff that meet population needs, we pay an extra differential for bilingual staff and pay extra for staff that are certified peer support specialists (see Pay Scales attachment). Hiring managers/supervisors are trained in asking questions to assess candidate knowledge of working with diverse populations (reference ICC hiring questions). Although this only has ICC cited, all roles are interviewed with similar questions to meet this requirement.
B) Our department has contracts with two external linguistic interpreter services: Interpreters Unlimited and Native Interpreters, if we are unable to meet the linguistic needs of the family. Our teams are trained consistently on the importance of natural supports and cultural humility outlined throughout the attached RTWB training slide deck and RTWB toolkit. (RTWB slides 82-87, RTWB Toolkit pg. 1 and 16)
C) Per our statement of work (SOW.pdf), pg 39 section 8.11 our program is to utilize interpretation services as appropriate when we do not have team members who speak the family’s language. Our agency has contracts with two interpreter services: Interpreters Unlimited and Native Interpreters to meet this need (see interpreters unlimited contracts).
9.2 Tribally Responsive Workforce
A) Our program has access to trainings related to supporting tribal youth and families including utilizing an internal trainer, and through UC Davis: https://humanservices.ucdavis.edu/course/echo-icwa-tribal-engagement. Our agency also has an internal training available to staff and will conduct this training as needed to ensure all staff are trained. (see referenced ICWA presentation powerpoint).
B) Our staff orient services to tribal youth and families in accordance with the values of their tribe (Reference: RTWB pages 14-15)
9.3 Flexible and Creative Work Environment
A) Our team is consistently engaged in program quality and improvement. Each year we host an annual leadership retreat where we strategically plan our initiatives for the year ahead and reflect on the previous year’s growth (see attached Leadership Retreat PowerPoint). This includes both managers/supervisors and direct service staff. Members of the C suite visit our programs every quarter to answer staff questions and provide updates on larger agency initiatives (reference senior leadership invite).
B) Our team hosts an all-staff annual anniversary party where we celebrate when our program began. This includes lunch for the team, teambuilding activities, and superlative awards for everyone (see photo from anniversary party 2025). Additionally, each office hosts a quarterly teambuilding internally with rotating themes. We also do smaller, more informal teambuilding activities to promote a positive team environment throughout the year and an annual holiday party (see holiday party invite).
C) All WrapWorks managers/supervisors have an open door policy and staff are encouraged to give feedback whenever they have it (see manager responsibilities page 1).
D) Our team receives a clear sense of mission and compliance with high fidelity wraparound philosophy throughout their ready to wrap basics training (see attached), with on going quarterly wraparound refresh trainings (see: 2025-2026 training calendar) , and during weekly individual/group supervision with their supervisor (see manager responsibilities page 3.
9.4 Hiring, Performance Evaluation, and Job Descriptions
A) Yes, all of these roles are met within our program. Please see the wrapworks job descriptions 2026.
B) Yes, each job description includes the purpose, functions, and qualities of the role. wrapworks job descriptions 2026.
C) Yes, job descriptions for all positions are specific to high fidelity wraparound. wrapworks job descriptions 2026.
D) Our second interviews include vignettes and specific questions where the candidates are to demonstrate specific attitudes and skills. See the attached ICC hiring questions. Although this only speaks to ICCs, all roles have similar questions and use a vignette when hiring.
E) Employees meet 1x yearly for a full performance evaluation with their manager. Each quarter, staff meet with their managers to complete a quarterly staff development plan to ensure feedback is given and coaching is taken place around specific goals. This is trained to staff during new hire orientation. (Page 2 new hire orientation “90 day/annual evaluation process, “staff development meetings with supervisor quarterly).
9.5 Workforce Stability
A) Yes, our agency matches wages related to cost of living in our implementation area. Please see: SDCC HR Policy page 1 for details.
B) Yes, we have a policy on maintaining manageable workloads for staff. Please see the attached policy: SDCC HR Policy page 2 for details.
C) Yes, all staff have the opportunity for career advancement within their roles. Please see the attached career pathing document that outlines the requirements for each position.
D) Wage increases are provided when the fiscal health of the agency allows for it or rate increases are provided by our funding sources. Please see the attached career pathing-path.docx that outlines ways that staff can move up within our department based on their success and desire for further development. Staff can move up to supervisor/manager/WFS based on meeting criteria outlined in wrapworks job descriptions 2026 attachment.
9.6 High Fidelity Training Plan
B) All direct services providers in our department receive 1 hour of individual supervision and two hours of group supervision every week. All staff members are available to receive coaching and shadowing if they request it from a wraparound fidelity specialist (RTWB pg 48), or it is assigned for them by a supervisor of fidelity specialist.
C) Our program conducts quarterly wraparound refresh training based on the HFW wraparound CA standards. The topics are chosen based on current needs of staff. Please see our attached 2025-2026 training calendar.
D) All managers and supervisors participate in all training that our team is offered. All our managers/supervisors are either certified peer support specialists or licensed mental health professionals, maintaining the appropriate CEUs for the respective disciplines as defined by their licensing board. All managers/supervisors participate in monthly reflective supervision with an outside contractor (see reflective supervision invite), having completed the course on supervising certified peer support specialists, and have the opportunity to attend booster training specific to their role.
E) All staff will be trained in ICWA and tribal sovereignty using the attached ICWA presentation PDF. Additionally, training can be provided as clinically indicated and appropriate for specific populations. Our statement of work with the county defines that we must have 4 hours of cultural competency training (SOW pg 38, 7.14). The topic of the cultural competency training changes from year to year based on program/staff needs to be support the needs of those we serve.
9.7 Community-based Training Program
A) Our wraparound fidelity team has two certified peer support specialists that have lived experience with the system of care who facilitate our ready to wrap basics training and ongoing wraparound refresh training with all staff members. Additionally, youth, families, and peer partners will be meaningfully incroprorated into the delivery of wraparound trainings. (Reference Community Based Training Program)
B) Our team will invite community partners to future wraparound training to strengthen their participation in our wraparound teams. (Reference Community Based Training Program)
9.8 Coaching and Supervision
A) Please see our attached new hire checklist that outlines all of the things they are trained on upon hire. Additionally, our initial wrap basics training (RTWB) is attached.
B) All managers are available 24/7 for supervision or coaching as outlined in the statement of work and in their job descriptions (see: SOW pg 31, section 5.8, manager job descriptions in wrapworks job descriptions 2026).
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
A) Data and outcomes are discussed as needed during the weekly leadership meeting and shared with staff during our biweekly staff meeting related to service provisions. This data could include WFI results, CANS data, outcomes data that goes into our tracking databases, and anecdotal feedback from staff about how things are going. Data is also discussed with our community leadership team and county contract representative during our monthly meeting. Training needs are brought from staff to the weekly leadership team during supervisions and then decided upon how to best implement. (See WFI-results, DCR SDCC WrapWorks Report, CANS Form, ICC monthly stats form)
B) Yes, all data collected is utilize to identify and address program needs that results in better services to families and increase program effectiveness. This takes place during the weekly leadership meeting and shared with staff during our biweekly staff meeting
C) Yes, data is utilized to identify and communicate system barriers to the community leadership team during our scheduled monthly meetings (see attached wrap oversight agenda from previous meeting). It is also discussed during our monthly TA call with our county contract representative (see TA calls schedule), who is also a member of the CLT. Data is given each quarter to our county contract representative with the QSR (see redacted QSR) and discussed during the above mentioned meetings.
Fidelity Indicators
1.1 Timely Engagement and Planning
(a) The HFW Facilitator will make initial contact with the family must occur as soon as possible and no later than ten (10) calendar days from referral or self-referral. See Staff Responsibilities Policy, page 1, paragraph 2.
(b) HYC teams are required to complete the initial Wraparound Plan of Care within thirty (30) calendar days of service initiation. See Staff Responsibilities Policy, page 1, paragraph 3.
(c) HFW team will review the plan during team meetings every thirty (30) to forty-five (45) days. See Staff Responsibilities Policy, page 1, paragraph 3.
(d) HFW team will update and distribute the Plan of Care at least every ninety (90) days or more frequently when changes occur. All plan updates must be documented in the client record and shared with team members to ensure coordinated service delivery. See Staff Responsibilities Policy, page 1, paragraph 3.
(e) HFW Fidelity Coach will monitor staff adherence to required timelines and provide feedback as part of ongoing Continuous Quality Improvement (CQI) efforts. See Staff Responsibilities Policy, page 1, paragraph 4.
(f) HFW team will receive training in timely engagement and alternative outreach strategies when families are difficult to reach to support consistent and uninterrupted care. See Staff Training Requirements Policy, page 1, paragraph 4.
1.2 Led by Youth and Families
(a) HFW team actively elicit and incorporate the perspectives, values, culture, strengths, and preferences of the youth and family into all planning and decision-making. See Staff Responsibilities Policy, page 1, paragraph 5.
(b) HFW team will use family input to form the foundation of the Family Vision and Team Mission and guides problem-solving through services. When serving an Indian child, Tribal representatives are included as equal partners on the team. See Staff Responsibilities Policy, page 1, paragraph 5.
(c ) HFW Fidelity Coach support fidelity to this practice through observation, documentation review, and coaching. See Staff Training Requirements Policy, page 1, paragraph 6.
(d) HFW team will collect family feedback, which is routinely gathered and used to improve service delivery. See HFW Consumer Satisfaction Survey.
1.3 Strength-Based
(a) The HFW Facilitator ensures that a comprehensive strengths inventory is developed for all team members, including natural and community supports, is documented, updated regularly, and visibly shared during HFW team meetings. The Parent Partner and Youth Partner support the youth and family in identifying and expressing their strengths, while all team members contribute to maintaining a strengths-focused and solution-oriented approach. See Staff Responsibilities Policy, page 2, paragraph 7.
(b) The IP-CANS is completed by trained HFW team members and is used to guide the identification of individualized strengths, ensuring that strengths include, but are not limited to, those identified in the IP-CANS. See Staff Responsibilities Policy, page 2, paragraph 8.
(c) The HFW Program Supervisor and/or Clinical Supervisor are responsible for ensuring that HFW team members receive ongoing training and coaching in strengths-based and solution-focused practices. See Staff Training Requirements Policy, page 1, paragraph 6.
(d) Additionally, the HFW team routinely elicits feedback from families regarding their experience of strengths-based services through surveys, tools such as the WFI or TOM 2.0, and quality assurance follow-up, with the HFW Program Supervisor and/or Clinical Supervisor reviewing this feedback to inform continuous quality improvement and provide targeted coaching and support to staff. See HFW Consumer Satisfaction Survey.
1.4 Needs Driven
(a) The HFW Facilitator ensures that underlying needs are clearly identified and prioritized in collaboration with the team before goals and strategies are developed. See Staff Responsibilities Policy, page 2, paragraph 9.
(b) The HFW Program Supervisor and/or Clinical Supervisor at HYC are responsible for ensuring that HFW team members receive ongoing training and coaching in identifying needs, developing needs statements that reflect underlying causes, and implementing needs-focused planning over behavior-focused approaches. See Staff Training Requirements Policy, page 1, paragraph 6.
(c) The IP-CANS is completed by trained HFW team members at HYC and is used to guide the identification of individualized needs, ensuring that needs include, but are not limited to, those identified in the IP-CANS. Needs are reviewed and updated regularly during team meetings, and the HFW process continues until identified needs are sufficiently met. See Staff Responsibilities Policy, page 2, paragraph 10.
(d)The HFW Facilitator leads transition planning in collaboration with the youth, family, and team, ensuring that transition occurs only when the team and family agree that needs have been sufficiently met, with oversight from the HFW Program Supervisor and/or Clinical Supervisor at HYC. See Staff Responsibilities Policy, page 2, paragraph 11.
1.5 Individualized
(a) The HFW Facilitator ensures that services, supports, and strategies are individualized and adapted to fit the unique circumstances of each youth and family, rather than using standardized approaches, and that HYC forms and documentation allow for sufficient flexibility in creating individualized Plans of Care. See Staff Responsibilities Policy, page 2, paragraph 12.
(b) The HFW Program Supervisor and/or Clinical Supervisor at HYC ensure that HFW staff receive ongoing training and coaching in providing flexible, creative, and highly individualized services and strategies. See Staff Responsibilities Policy, page 2, paragraph 12.
(c) The HFW Program Supervisor and/or Clinical Supervisor at HYC ensure that HFW Facilitators receive ongoing training and coaching in leading the HFW team to customize the Wraparound process and Plan of Care according to each youth and family’s individual needs, strengths, values, culture, and preferences. See Staff Responsibilities Policy, page 2, paragraph 12.
(d) The HFW Facilitator ensures that Plans of Care are developed at the onset of services and are routinely reviewed and assessed during team meetings for alignment with individualized strengths, needs, outcomes, and strategies, including the use of community resources and natural supports. See Staff Responsibilities Policy, page 2, paragraph 12.
(e) The HFW team routinely gathers and documents feedback from youth and families regarding their experience of receiving individualized and customized services through surveys, quality assurance activities, and standardized tools, and the HFW Program Supervisor and/or Clinical Supervisor at HYC use this feedback to inform continuous quality improvement, staff coaching, and training. See Staff Responsibilities Policy, page 2, paragraph 13.
1.6 Use of Natural and Community Based Supports
(a) The HFW Facilitator ensures that a natural and community supports inventory is developed for each family, documented in the file, and updated regularly throughout services. See HYC Natural & Community Supports Inventory.
(b) The HFW Program Supervisor and/or Clinical Supervisor at HYC are responsible for ensuring that HFW team members receive ongoing training and coaching in identifying, engaging, and integrating natural supports and reducing reliance on formal supports. See Staff Responsibilities Policy, page 2, paragraph 14.
(c) The HFW Facilitator ensures that Plans of Care are routinely reviewed to assess the inclusion of natural supports and that strategies and action items actively utilize community and informal supports. See Staff Responsibilities Policy, page 2, paragraph 14.
(d) The HFW team routinely elicits feedback from families regarding their experience of natural supports being engaged, and the HFW Program Supervisor and/or Clinical Supervisor at HYC use this feedback to support continuous quality improvement, staff coaching, and training. See Staff Responsibilities Policy, page 2, paragraph 15.
1.7 Culturally Respectful and Relevant
(a) The HFW Facilitator ensures that a strengths, needs, and culture discovery process is completed prior to development of the Plan of Care and is clearly documented in the youth’s case file. See Staff Responsibilities Policy, page 3, paragraph 16.
(b) The HFW Program Supervisor and/or Clinical Supervisor at HYC ensure that HFW staff receive ongoing training and coaching in eliciting and integrating family culture, values, and preferences into planning, service delivery, and the development of culturally respectful and relevant strategies. See Staff Responsibilities Policy, page 3, paragraph 18.
(c) The HFW team routinely gathers and documents feedback from families regarding their experience of culturally respectful and relevant services and strategies (e.g., through satisfaction surveys, WFI/TOM tools, and quality assurance activities), and the HFW Program Supervisor and/or Clinical Supervisor at HYC use this information to support continuous quality improvement, staff coaching, and training. See HFW Consumer Satisfaction Survey.
1.8 High-Quality Team Planning and Problem Solving
(a) Team agreements are created for each HFW team by the Facilitator and documented in the youth’s file to support shared expectations and accountability. See Staff Responsibilities Policy, page 4, paragraph 19.
(b) The HFW team routinely collects feedback from families and team members regarding engagement and collaboration through meetings, observations, and quality assurance tools. See Staff Responsibilities Policy, page 4, paragraph 19.
(c) The HFW Program Supervisor and/or Clinical Supervisor at HYC use this feedback to inform continuous quality improvement, coaching, and staff development. See Staff Responsibilities Policy, page 4, paragraph 20.
(d) The HFW Facilitator ensures that Plans of Care and meeting minutes are routinely reviewed to assess shared ownership, follow-through action items, and effective collaboration across the team. See Staff Responsibilities Policy, page 4, paragraph 20.
1.9 Outcomes Based Process
(a) The HFW Facilitator ensures that the Plan of Care includes specific, measurable strategies and action items with defined timeframes. See Staff Responsibilities Policy, page 4, paragraph 21.
(b) The Facilitator tracks completion of action items and updates progress during HFW team meetings. See Staff Responsibilities Policy, page 4, paragraph 21.
(c) The Facilitator ensures that Plan of Care tools and processes allow for timely adjustments to strategies and that all changes are communicated to the team. See Staff Responsibilities Policy, page 4, paragraph 21.
(d) The HFW Program Supervisor and/or Clinical Supervisor at HYC oversee the process for completion and sharing of the IP-CANS assessment, ensuring trained HFW team members complete the assessment and results are shared with the team. See Staff Responsibilities Policy, page 4, paragraph 22.
(e) The HFW team uses IP-CANS data to support tracking and decision-making in conjunction with ongoing monitoring of needs, goals, and action item completion to inform transition planning. See Staff Responsibilities Policy, page 4, paragraph 22.
1.10 Persistence
(a) The HFW team continues services until the Facilitator, team, and family agree that services should end based on progress and needs being met. See Staff Responsibilities Policy, page 4, paragraph 23.
(b) The HFW Facilitator ensures that clear processes are in place for accessing additional support, including coaching, supervision, flexible funding, and crisis consultation when needed. See Staff Responsibilities Policy, page 5, paragraph 24.
(c) The HFW Program Supervisor and/or Clinical Supervisor at HYC provide ongoing training and coaching in safety planning, conflict resolution, and effective team-based problem-solving and plan revision. See Staff Responsibilities Policy, page 5, paragraph 24.
1.11 Transitions as a part of the Fourth Phase of HFW
(a) The HFW Facilitator ensures that transitions are not sudden and do not occur due to adverse events or administrative requirements, but are planned collaboratively with the youth and family. See Staff Responsibilities Policy, page 5, paragraph 25.
(b) The HFW Facilitator ensures that transitions are culturally responsive, celebratory, and aligned with the youth and family’s values and preferences, including coordination of supports such as flex funds, staff participation, and community engagement as appropriate. See Staff Responsibilities Policy, page 5, paragraph 25.
Expected Outcomes
2.1 Youth and Family Satisfaction
The HFW Facilitator ensures feedback is gathered through conversations, surveys, and tools. Parent and Youth Partners support open sharing. Feedback is documented and addressed. Supervisors review trends and guide improvements. Tribal feedback is included when applicable. See Outcomes and Quality Improvement Policy Page 1, Paragraph 2.
2.2 Improved School Functioning
HFW teams support youth in improving attendance, participation, and performance, including vocational goals. The Facilitator tracks progress and coordinates with schools. Parent and Youth Partners support engagement. Information is reviewed and used to adjust strategies. See Outcomes and Quality Improvement Policy Page 1, Paragraph 3.
2.3 Improved Functioning in the Community
HFW teams support youth in building community connections. The Facilitator documents participation and justice involvement. Teams use this to strengthen engagement. Parent and Youth Partners assist with connections. See Outcomes and Quality Improvement Policy Page 1, Paragraph 4.
2.4 Improved Interpersonal Functioning
HFW teams support improved relationships and communication. The Facilitator documents family dynamics. Parent and Youth Partners support relationship-building. Progress is reviewed regularly. See Outcomes and Quality Improvement Policy Page 1, Paragraph 5.
2.5 Increased Caregiver Confidence
HFW services build caregiver confidence. The Facilitator documents caregiver skills and connections. Parent Partner mentors caregivers. Teams ensure caregivers can manage challenges independently. See Outcomes and Quality Improvement Policy Page 2, Paragraph 6.
2.6 Stable and Least Restrictive Living Environment
HFW teams prioritize stable, least restrictive environments. The Facilitator tracks living arrangements and changes. Teams implement strategies to prevent disruptions. See Outcomes and Quality Improvement Policy Page 2, Paragraph 7.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
The Facilitator tracks hospital visits. Teams review patterns and adjust strategies to prevent crises. Parent and Youth Partners support prevention. See Outcomes and Quality Improvement Policy Page 2, Paragraph 8.
2.8 Reduction in Crisis Visits
The Facilitator documents crisis events. Teams strengthen safety planning and natural supports. Parent and Youth Partners support coping skills. See Outcomes and Quality Improvement Policy Page 2, Paragraph 9.
2.9 Positive Exit from HFW
Services end based on readiness. The Facilitator leads transition planning and documentation. Parent and Youth Partners support preparation. Decisions are collaborative. Supervisors review outcomes. See Outcomes and Quality Improvement Policy Page 2, Paragraph 10.
Engagement
3.1 Orientation
(a) During the initial engagement phase, the HFW Facilitator ensures that the full Wraparound process is explained to every family. The Parent Partner and Youth Partner support the youth and family in understanding this information during engagement, and orientation is documented in the client record. See Engagement and Preparation for High Fidelity Wraparound Services Policy, Page 1, Paragraph 2.
At a minimum, this explanation includes:
(a) An overview of the Wraparound principles and phases is explained by the HFW Facilitator. See Engagement and Preparation for High Fidelity Wraparound Services Policy, Page 1, Paragraph 2;
(b) Legal and ethical considerations, including consent, confidentiality, and grievance procedures s explained by the HFW Facilitator. See Engagement and Preparation for High Fidelity Wraparound Services Policy, Page 1, Paragraph 2.
(c) The role of each team member, including the youth, family, natural supports, and Tribes is explained by the HFW Facilitator in the case of an Indian child. See Engagement and Preparation for High Fidelity Wraparound Services Policy, Page 1, Paragraph 2.
3.2 Safety and Crisis stabilization
(a) During initial engagement, the HFW Facilitator ensures that safety and crisis concerns are discussed. If pressing concerns are identified, the Facilitator develops an immediate crisis response plan with the team, provides it to the family, and documents it in the client record at that time. See Engagement and Preparation for High Fidelity Wraparound Services Policy, Page 1, Paragraph 3.
(b) The crisis response plan developed during engagement is used to inform, but does not replace, the comprehensive HFW Safety Plan developed during the Plan Development phase. See Engagement and Preparation for High Fidelity Wraparound Services Policy, Page 1, Paragraph 3.
(c) At the time of engagement, the HFW Facilitator ensures that all families are provided with clear information on how to access 24/7 crisis response supports when needed. See Engagement and Preparation for High Fidelity Wraparound Services Policy, Page 1, Paragraph 3.
3.3 Strengths, Needs, Culture and Vision Discovery
(a) During the engagement phase, the HFW Facilitator ensures that a Family Vision is developed with every youth and family and documented in the client record. See Strengths Needs and Cultural Discovery Assessment.
(b) The HFW Facilitator initiates a Strengths, Needs, and Culture Discovery document during engagement, ensures it is included in the client record, updates it at least every 90 days, and continues to add information as new strengths, needs, and cultural preferences are identified throughout the Wraparound process. The document is shared with all team members and provided to new team members at the time they join the team. The Parent Partner and Youth Partner support the youth and family in expressing their perspectives throughout the discovery process. See Engagement and Preparation for High Fidelity Wraparound Services Policy, Page 1, Paragraph 4.
3.4 Engage All Team Members
(a) During engagement, the HFW Facilitator ensures that a natural supports inventory is completed with the youth and family and documented in the client record. See HYC HFW Natural Support Inventory.
(b) The HFW Facilitator identifies and engages Children’s System of Care partners who should be included on the HFW team. See Engagement and Preparation for High Fidelity Wraparound Services Policy, Page 2, Paragraph 5.
(c) The HFW Facilitator works with the youth and family during engagement to identify potential team members and clarifies their roles and responsibilities on the team. See Engagement and Preparation for High Fidelity Wraparound Services Policy, Page 2, Paragraph 5.
(d) Engagement efforts, team-building activities, and participation are documented by the HFW Facilitator in the client record (e.g., meeting minutes, case notes) throughout the Wraparound process. See Engagement and Preparation for High Fidelity Wraparound Services Policy, Page 2, Paragraph 5.
3.5 Arrange Meeting Logistics
(a) The HFW Facilitator maintains flexibility in scheduling, including working varied hours when necessary, to accommodate the needs of the youth, family, and team members at the time meetings are arranged. See Engagement and Preparation for High Fidelity Wraparound Services Policy, Page 2, Paragraph 6.
(b) The HFW Facilitator collaborates with the youth, family, and team members to schedule meetings that align with family needs and preferences and maximize participation throughout the Wraparound process. The HFW Facilitator coordinates meeting logistics, including transportation, interpretation services, and telehealth access, at the time meetings are scheduled to reduce barriers and ensure equitable participation. See Engagement and Preparation for High Fidelity Wraparound Services Policy, Page 2, Paragraph 6.
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
(a) Before the HFW Plan of Care is developed, the HFW Facilitator ensures that team agreements, a team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file. See HFW CFT Prep Form.
(b) The HFW Facilitator ensures that the youth’s and family members’ strengths identified during engagement are reviewed and updated to reflect any additional strengths identified during the planning process, and that these are documented in the youth’s file. See HFW CFT Prep Form.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
(a) The HFW Facilitator leads the youth, family, and HFW team in identifying and prioritizing underlying needs before the HFW Plan of Care is developed and ensures the identified needs are documented in the youth’s file. See HFW CFT Planning Matrix.
(b) The HFW Facilitator supports the youth, family, and HFW team in developing measurable goals and outcomes based on identified needs rather than behaviors or deficits. See HFW CFT Planning Matrix.
(c) The youth, family, HFW Facilitator, and HFW team collaboratively develop goals and outcomes together during the planning process. See Plan of Care Development Policy Page 1, Paragraph 2.
(d) The HFW Facilitator guides the team in brainstorming multiple individualized strategies and ensures the strategies are documented in the youth’s file, including within the HFW Plan of Care, forms, meeting minutes, or progress notes for ongoing reference. See Plan of Care Development Policy Page 1, Paragraph 3.
(e) HFW Facilitators receive training and coaching on identifying needs, prioritizing concerns, selecting strategies, and developing action items within the HFW process. See Plan of Care Development Policy Page 1, Paragraph 4.
(f) The youth, family, HFW Facilitator, and HFW team use these collaborative steps to develop an individualized HFW Plan of Care within a team-based environment. See Plan of Care Development Policy Page 1, Paragraph 2.
4.3 Develop an Individualized Child or Youth and Family Plan
(a) Facilitators receive ongoing training and coaching in collaborative Plan of Care development. See Plan of Care Development Policy Page 1, Paragraph 4.
(b) The Plan of Care integrates goals from all Children’s System of Care partners. See HFW CFT Planning Matrix.
(c) The Plan of Care is documented in the youth’s file and shared with all team members. and meets all the criteria defined above (items 1-6). See Plan of Care Development Policy Page 1, Paragraph 4.
(d) The Plan of Care is reviewed regularly for quality improvement and coaching purposes. See Plan of Care Development Policy Page 1, Paragraph 4.
4.4 Develop a Crisis and Safety Plan
(a) The HFW Facilitator develops the crisis and safety plan with the youth and family prior to finalizing the Plan of Care and ensures it is documented in the youth’s file, including identified risks, proactive and reactive strategies, and 24/7 support contacts. See HYC HFW Safety Plan.
(b) The HFW Facilitator leads the team-based development of the crisis and safety plan and receives ongoing training and coaching at HYC to support effective implementation. See HFW Safety and Crisis Stabilization Protocol, Page 4, Section 8.
(c) The HFW Facilitator reviews and updates the crisis and safety plan with the team during HFW team meetings and in supervision, ensuring strategies remain individualized, culturally relevant, and inclusive of natural supports, and uses this process to support continuous quality improvement. HFW Safety and Crisis Stabilization Protocol, Page 3, Section 6.
Implementation
5.1 Implement The Plan of Care
(a) The HFW Facilitator ensures that assigned action items are carried out as documented and that responsible parties understand their roles and timelines. HFW team monitors progress toward meeting needs and achieving outcomes on an ongoing basis during team meetings and individual contacts. HFW team reviews whether strategies are effective and whether adjustments are necessary to support success. See Plan of Care Implementation and Review Policy Page 1, Paragraph 3-5.
(b) HFW team receives training and coaching from Clinical Supervisor and fidelity coach during supervision sessions. Clinical supervisor reviews implementation of care and provides training on celebrating successes as they occur. See Plan of Care Plan of Care Implementation and Review Policy Page 2, Paragraph 7.
5.2 Review and Update The Plan of Care
(a) The HFW Facilitator ensures that the plan of care is reviewed in a continuous manner. HYC Wraparound team reviews the Plan of Care at minimum every 90 days and more frequently when changes in circumstances occur. See Plan of Care Plan of Care Implementation and Review Policy Page 1, Paragraph 4.
(b) The HFW Facilitator leads structured plan reviews to assess progress toward goals, evaluate the effectiveness of strategies, and determine whether identified needs have changed or new needs have emerged. See Plan of Care Plan of Care Implementation and Review Policy Page 1, Paragraph 3.
(c) The HFW Facilitator is responsible for documenting and communicating any completion of tasks, new tasks, team attendance, flex funds needs, updates to actions steps. The facilitator ensures that all updates are communicated to everyone present in the meeting. See Plan of Care Plan of Care Implementation and Review Policy Page 1, Paragraph 5.
(d) The HFW Facilitator ensures that Plans of Care, meeting documentation, and related forms are updated and individualized as the needs of the youth, family, and team change throughout the Wraparound process. See Plan of Care Plan of Care Implementation and Review Policy Page 1, Paragraph 5.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
(a) The HFW Facilitator monitors, reviews and utilizes their team agreements during team meetings. See Plan of Care Plan of Care Implementation and Review Policy Page 2, Paragraph 8.
(b) The HFW Facilitator meets with clinical supervisor and fidelity coach on a weekly basis to receive ongoing training and coaching that will support building, engaging, and maintaining effective teams. See Plan of Care Plan of Care Implementation and Review Policy Page 2, Paragraph 7.
(c) The fidelity coach and the clinical supervisor provide feedback and monitor the use of natural support in client care. See Plan of Care Implementation and Review Policy Page 2, Paragraph 7.
(d) The HFW team ensures that any new team members who are natural and informal supports receive clear explanation of the HFW process, review current plan and strategies, and engage them in team building exercises. See Plan of Care Plan of Care Implementation and Review Policy Page 2, Paragraph 10.
Transition
6.1 Develop a Transition Plan
(a) The HFW Facilitator leads the youth, family, and HFW team in identifying when the youth and family are ready for transition based on benchmarks, progress, and indicators monitored throughout the HFW process. See Transition and Completion Policy Page 1, Paragraph 2.
(b) Once transition readiness is identified, the HFW Facilitator leads the youth, family, and HFW team in creating an individualized transition plan that identifies ongoing needs, services, and supports. The HFW Facilitator distributes the transition plan to all team members and ensures the plan is documented in the youth’s file. See HFW Transition Planning Form.
(c) The youth, family, HFW Facilitator, and HFW team collaboratively develop the individualized transition plan within a team-based environment. HFW Facilitators receive training and coaching on the transition planning process. See Transition and Completion Policy Page 1, Paragraph 3.
(d) The HFW Facilitator and HFW team verify that services and supports identified in the transition plan will continue after formal HFW services end and confirm the family is able to access those services and supports, including post-adoption services when applicable. See Transition and Completion Policy Page 1, Paragraph 3.
6.2 Develop a Post-Transition Safety Plan
(a) The HFW Facilitator leads the youth, family, and HFW team in updating the individualized crisis and safety plan to reflect transition or completing a new transition crisis and safety plan. The plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies chosen by the family that maximize the use of natural supports. The HFW Facilitator ensures the finalized plan is documented in the youth’s file. See Transition and Completion Policy Page 2, Paragraph 4.
(b) The youth, family, HFW Facilitator, and HFW team collaboratively develop the crisis and safety transition plan within a team-based environment. HFW Facilitators receive training and coaching on developing individualized crisis and safety transition plans. See Transition and Completion Policy Page 2, Paragraph 4.
(c) Supervisors, leadership staff, and HFW Facilitators review crisis and safety plans to ensure strategies are individualized, culturally relevant, include proactive and reactive progression of interventions, and maximize the use of natural supports for continuous quality improvement, training, and coaching purposes. See Transition and Completion Policy Page 2, Paragraph 4.
6.3 Create a Commencement and Celebrate Success
(a) The HFW Facilitator, youth, family, and HFW team plan and participate in transition celebrations that reflect the family’s culture, values, preferences, and accomplishments as they complete the Wraparound process. See Transition and Completion Policy Page 2, Paragraph 5.
(b) Administrative leadership and program staff support transition celebrations by providing access to flex funds when available, supporting community partnerships and resources, allowing time for planning and participation, and ensuring staff are available to attend and support celebrations when appropriate. See Transition and Completion Policy Page 2, Paragraph 5.
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
(a) Program leadership, supervisors, HFW Facilitators, youth, and families participate in processes that allow families to provide input regarding local HFW implementation. Family participation may occur through surveys, Child and Family Team (CFT) meetings, family feedback discussions, grievance procedures, exit interviews, and quality improvement activities. See HFW Family Voice, Community Participation, and Access Policy, Page 1, Paragraph 3.
(b) Program leadership, supervisors, and HFW staff review and use family feedback to support decision-making related to service planning and implementation, policy and procedure development, workforce development, staff training, and continuous quality improvement activities within the HFW program. See HFW Family Voice, Community Participation, and Access Policy, Page 1, Paragraph 3.
7.2 Community Leadership Team
(a) Program leadership identifies a designated agency representative to actively participate in Community Leadership Team meetings and community collaboration activities related to High Fidelity Wraparound implementation, system coordination, and quality improvement efforts. See HFW Family Voice, Community Participation, and Access Policy, Page 2, Paragraph 4.
7.3 Eligibility and Equal Access
(a) Program leadership, supervisors, intake staff, and HFW Facilitators ensure that youth who meet established eligibility criteria are able to receive HFW services and are not excluded based on the severity, complexity, or nature of their needs. See HFW Family Voice, Community Participation, and Access Policy, Page 2, Paragraph 5.
(b) Program leadership and supervisors monitor staffing and case assignments to ensure HFW Facilitators are able to provide the intensity, frequency, and level of support needed to meet families’ complex needs, including availability for 24/7 crisis response and support. See HFW Sample Crisis Coverage Schedule.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
(a) HYC Program Leadership ensures that budgets and contracts allocate funding for high fidelity direct services and supports that meet the immediate and individualized needs of youth and families participating in High Fidelity Wraparound services. HFW staff utilize these resources to implement services, supports, and strategies identified in the Plan of Care. See HFW Sample General Ledger.
(b) HYC Program Leadership ensures that budgets and contracts allocate funding for required workforce development, staffing, coaching, and required High Fidelity Wraparound roles and functions necessary to maintain fidelity to the Wraparound model. HFW Program Supervisors and/or Clinical Supervisors provide ongoing training, supervision, and coaching to staff. See HFW Sample General Ledger.
(c) HYC Program Leadership ensures that budgets and contracts allocate funding for required data collection, documentation, reporting, and data management systems necessary to support service coordination, compliance, quality improvement, and High Fidelity Wraparound operations. HFW staff are responsible for completing documentation and data entry in accordance with program and county requirements. See HFW Sample General Ledger.
8.2 Equitable Funding Across System Partners
8.3 Cost Savings are Reinvested
(a) HFW Program leadership and Fiscal staff are responsible for identifying, documenting, and reinvesting any HFW program savings (revenues exceeding expenditures) into services, supports, staffing, or resources that benefit youth and families. This includes maintaining records of the program description, budget use, and outcomes achieved, and ensuring the process is followed and transparently communicated to stakeholders. See HYC Savings Reinvestment Workflow.
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
(a) HYC Program Leadership ensures flexible funds are available and included as part of the High Fidelity Wraparound funding plan to support individualized youth and family needs identified through the Wraparound process. See HFW Flex Fund Request Form.
(b) HYC maintains clear processes for accessing and managing flexible funds. The HFW Facilitator is responsible for submitting requests in collaboration with the youth, family, and HFW team when a need is identified that supports the Plan of Care and team mission. Processes include:
1) The HFW Facilitator submits flexible fund requests as soon as an urgent youth or family need is identified. HYC Program Supervisors and/or designated leadership review requests in a timely manner to support immediate stabilization, reduce barriers, and maintain continuity of care. See Flexible Funds Request and Approval Policy Page 1, Paragraph 4.
2) The HFW Facilitator documents how the request supports the Plan of Care, team mission, identified needs, family strengths, cultural relevance, and use of natural or community supports. HFW Program Supervisors and/or designated leadership review and approve or deny requests based on established program criteria and available funding. See Flexible Funds Request and Approval Policy Page 1, Paragraph 4.
3) The HFW Facilitator communicates all funding decisions to the youth, family, and HFW team. If a request is denied, the reason for denial is explained to the youth and family, documented in the case record, and information regarding reconsideration or appeal procedures is provided when applicable. See Flexible Funds Request and Approval Policy Page 1, Paragraph 5.
8.5 Collaborative Oversight of Flex Funds
(a) HFW Program leadership, Fiscal staff, and HFW Supervisors are responsible for documenting and communicating flex fund use and availability to funders and providers. Documentation includes the amount requested, purpose of the request, approval status, and HFW team recommendation to ensure transparency and accountability. See HFW Flex Fund Request Form.
(b) HFW Program leadership and Fiscal staff are responsible for overseeing pooled flex funds to ensure funds remain available to meet the individualized needs of all families served through the HFW Program. Flex funds are monitored and managed collaboratively to support equitable access and timely assistance for youth and families. HFW Sample Flex Funds Tracker.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
(a) HFW Program leadership and Fiscal staff use available funding from different programs and partners to help ensure flex funds and other program resources remain available for youth and families. Funding Coordination and Flexible Resource Access Policy Page 1, Paragraph 2.
(b) If one funding source cannot cover a need or has restrictions, HFW Program leadership and Fiscal staff look for other funding options or resources to help meet the family’s needs. Funding Coordination and Flexible Resource Access Policy Page 1, Paragraph 3.
(c) HFW staff ensure that rules tied to one funding source do not stop youth and families from receiving needed flex funds or supports identified by the HFW team. Funding Coordination and Flexible Resource Access Policy Page 1, Paragraph 4.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
(a) HYC Human Resources and Program Leadership monitor the demographic and language needs of the youth and families served and implement recruitment and hiring practices to support staffing that reflects the cultural, racial, and linguistic needs of the community. See Workforce Diversity, Cultural Responsiveness, and Staff Support Policy Page 1, Paragraph 2.
(b) When HYC is unable to provide staff who reflect the identified cultural, racial, or linguistic needs of a family, the HFW Facilitator works with the youth and family to identify natural supports, formal supports, community representatives, or Tribal supports when applicable to promote culturally responsive services. See Workforce Diversity, Cultural Responsiveness, and Staff Support Policy Page 1, Paragraph 2.
(c) When HYC is unable to provide a staff member who speaks the family’s preferred language, the HFW Facilitator ensures interpretation services, bilingual supports, or identified natural supports are utilized to support communication and participation in services. See Workforce Diversity, Cultural Responsiveness, and Staff Support Policy Page 1, Paragraph 2.
9.2 Tribally Responsive Workforce
(a) HYC Program Supervisors and/or Clinical Supervisors ensure HFW staff receive training and coaching on tribal sovereignty, Tribal traditions and values, and culturally respectful communication, collaboration, and advocacy when working with Indian children and families. See Workforce Diversity, Cultural Responsiveness, and Staff Support Policy Page 1, Paragraph 3.
(b) When serving an Indian child, the HFW Facilitator engages and collaborates with Tribal representatives, supports participation in Tribal traditions and ceremonies when identified by the family and Tribe, and incorporates Tribal and culturally rooted services and supports into the Wraparound process when appropriate. See Workforce Diversity, Cultural Responsiveness, and Staff Support Policy Page 1, Paragraph 3.
9.3 Flexible and Creative Work Environment
(a) HYC Leadership, including Program Managers, HFW Program Supervisors, and Clinical Supervisors, engage staff in ongoing program quality improvement activities through supervision, training, audits, team meetings, and continuous quality improvement processes. See Workforce Diversity, Cultural Responsiveness, and Staff Support Policy Page 1, Paragraph 4.
(b) HYC Leadership promotes staff cohesion by maintaining a positive and collaborative team environment that supports teamwork, shared responsibility, and mutual support among HFW staff. See Workforce Diversity, Cultural Responsiveness, and Staff Support Policy Page 1, Paragraph 4.
(c) HYC Leadership maintains open communication with staff through regular supervision, team meetings, coaching, and opportunities for staff feedback and collaboration. See Workforce Diversity, Cultural Responsiveness, and Staff Support Policy Page 1, Paragraph 4.
(d) HYC Leadership ensures staff receive ongoing training, coaching, and guidance to support compliance with High Fidelity Wraparound principles, values, phases, and activities and to maintain a clear understanding of the HFW mission and model. See Workforce Diversity, Cultural Responsiveness, and Staff Support Policy Page 1, Paragraph 4.
9.4 Hiring, Performance Evaluation, and Job Descriptions
(a) HYC Program Leadership ensures all required High Fidelity Wraparound roles and functions are assigned and maintained within the program. Roles may be fulfilled through dedicated positions or combined positions, provided responsibilities are clearly defined and documented. See Job Descriptions.
(b) HYC Human Resources and Program Leadership maintain role descriptions that clearly define the purpose, responsibilities, required skills, competencies, knowledge, and qualifications associated with each High Fidelity Wraparound role or function. See Job Descriptions.
(c) HYC Human Resources and Program Leadership ensure job descriptions for High Fidelity Wraparound positions reflect the attitudes, skills, knowledge, experience, and competencies necessary to effectively implement the Wraparound model. See Job Descriptions.
(d) HYC Human Resources and Program Leadership utilize hiring practices that allow candidates to demonstrate the skills, values, and abilities required to successfully perform High Fidelity Wraparound responsibilities. See Job Descriptions.
(e) HYC Program Supervisors and/or Clinical Supervisors provide staff with clear performance expectations, regular feedback, coaching, and supervision to support professional development, job performance, and fidelity to the High Fidelity Wraparound model. See HFW Quarterly Supervision Evaluation Form.
9.5 Workforce Stability
(a) HYC Human Resources and Program Leadership review compensation practices and workforce needs to support wages that are competitive and responsive to the cost of living within the communities served. See Workforce Diversity, Cultural Responsiveness, and Staff Support Policy Page 2, Paragraph 5.
(b) HYC Program Leadership and Supervisors monitor staff assignments and caseloads to maintain manageable workloads and support effective High Fidelity Wraparound service delivery. See Workforce Diversity, Cultural Responsiveness, and Staff Support Policy Page 2, Paragraph 5.
(c) HYC Human Resources and Program Leadership maintain clearly communicated and accessible opportunities for staff advancement and leadership development, including opportunities for individuals with lived experience. See Workforce Diversity, Cultural Responsiveness, and Staff Support Policy Page 2, Paragraph 5.
(d) HYC Human Resources and Program Leadership support staff retention through opportunities for wage increases, professional growth, and leadership responsibilities that do not require staff to change positions in order to advance. See Workforce Diversity, Cultural Responsiveness, and Staff Support Policy Page 2, Paragraph 5.
9.6 High Fidelity Training Plan
(a) HYC Program Supervisors and/or Clinical Supervisors ensure all HFW staff complete initial High Fidelity Wraparound training through approved training processes, including the Statewide Standardized Foundational HFW Training through the UC Davis RCFFP when applicable. See High Fidelity Wraparound Training Requirements Policy Page 1, Paragraph 2.
(b) HYC Program Supervisors and/or Clinical Supervisors provide ongoing training, coaching, supervision, peer shadowing, and workforce development activities to support staff competency in general Wraparound practice and role-specific responsibilities. See High Fidelity Wraparound Training Requirements Policy Page 1, Paragraph 3.
(c) HYC Program Supervisors and/or Clinical Supervisors ensure all HFW staff complete booster trainings at least annually related to High Fidelity Wraparound principles, phases, activities, and role-specific practice expectations. See High Fidelity Wraparound Training Requirements Policy Page 1, Paragraph 4.
(d) HYC Program Leadership ensures Clinical Supervisors and HFW Supervisors/Managers complete general Wraparound training and receive ongoing leadership, supervisory, and booster trainings related to High Fidelity Wraparound oversight, coaching, and fidelity monitoring. See High Fidelity Wraparound Training Requirements Policy Page 1, Paragraph 4.
(e) HYC Program Leadership and Supervisors ensure all HFW staff receive training related to ICWA, Tribal sovereignty, cultural responsiveness, and additional specialized training necessary to support the unique needs of the populations served. See High Fidelity Wraparound Training Requirements Policy Page 2, Paragraph 5.
9.7 Community-based Training Program
(a) HYC Program Leadership and Supervisors ensure that youth, families, Parent Partners, Youth Partners, and individuals with current or prior Wraparound experience are meaningfully included in the delivery and support of required High Fidelity Wraparound trainings whenever possible. See High Fidelity Wraparound Training Requirements Policy Page 2, Paragraph 6.
(b) HYC Program Leadership and Supervisors invite community and system partners to participate in Wraparound trainings or provide training opportunities that strengthen understanding of the HFW process, improve collaboration on HFW teams, and support coordination within the Children’s System of Care. See High Fidelity Wraparound Training Requirements Policy Page 2, Paragraph 7.
9.8 Coaching and Supervision
(a) HYC Program Supervisors and/or Clinical Supervisors ensure all HFW staff complete an initial apprenticeship process that includes supervised training, coaching, observation, and guided practice related to High Fidelity Wraparound principles, phases, activities, and the effective use of flexible funds to support family needs. See HFW Staff Apprenticeship, Coaching, and Supervision Policy Page 1, Paragraph 2.
(b) HYC Program Supervisors and/or Clinical Supervisors ensure HFW staff have access to supervision, coaching, consultation, and crisis support as needed (24/7), including outside of standard business hours when necessary to support youth and families in crisis or urgent situations. See Clinical Consult & Crisis Protocol.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
(a) HYC Program Leadership, HFW Program Supervisors, and/or Clinical Supervisors review program data and reports to improve service delivery for youth and families. Supervisors provide staff with timely feedback and utilize data to identify training, coaching, and workforce development needs. Program Evaluation, Data Review, and Continuous Quality Improvement Policy, Page 1, Paragraph 2.
(b) HYC Program Leadership utilizes program data to identify trends, service gaps, and opportunities for improvement. Data is reviewed regularly to inform program planning, strengthen service delivery, and improve overall program effectiveness. Program Evaluation, Data Review, and Continuous Quality Improvement Policy, Page 1, Paragraph 4.
(c) HYC Program Leadership utilizes program data to identify system barriers that impact High Fidelity Wraparound implementation and communicates these barriers to community partners, system stakeholders, and leadership groups to support system-level improvement and collaboration. Program Evaluation, Data Review, and Continuous Quality Improvement Policy, Page 1, Paragraph 5.
Fidelity Indicators
1.1 Timely Engagement and Planning
a. Within 24 business hours of receiving the referral via SRTS OR WTS, a Wraparound team member will contact the client or caregiver to set up an enrollment appointment based on the caregivers’ availability. POLICIES–Service Delivery for Wraparound Services, Page 2, Procedures, 2a; AND Wraparound Training Plan–Page 9, Session 3, Enrollment Process.
b. CFTMs are held within 30 calendar days from the start of services, and will include the development of the Plan of Care. POLICIES–Child and Family Team Protocol, Page 2, Frequency of CFTMs, 1; AND Wraparound Training Plan–Page 12, Session 4, Timing of CFTMs.
c. The Plan of Care is reviewed and updated at every CFTM, which occur monthly within 30 calendar days. POLICIES–Child and Family Team Protocol, Page 2, Frequency of CFTMs, 1; AND Wraparound Training Plan–Page 14 Session 4, The Plan of Care.
d. The Facilitator updates The Plan of Care during every monthly CFTM, & it’s sent via encrypted e-mail to the client & caregiver and all team members within 48 business hours, at which time it’s saved in the C&FC server and uploaded into EHR. POLICIES–Child and Family Team Protocol, Page 2, Frequency of CFTMs, 1; AND Wraparound Training Plan–Page 15, Session 4, Plan of Care Documentation.
e. Every attempt to enroll the family is entered into SRTS or WTS daily by the Administrative Assistant, tracked thru this, and supervisors and staff are informed if a family is not reached within 7 business days. The Supervisor tracks that all CFTMs are held monthly and that The Plan of Care is completed within 48 business hours. POLICIES–Wraparound Training Plan–Page 9, Session 3, Enrollment process; AND Wraparound Training Plan–Page 16, Session 4, Supervisor Oversight of CFTMs and The Plan of Care; AND FORM–CFT Meeting Tracker.
f. Staff are trained in their new hire training in week 2 of employment, and in ongoing weekly supervisions, on individualized engagement strategies so if the staff is unable to reach the family within 48 business hours, they text the client and/or caregiver, reach out to the referring party, visit the home with another staff, and mail a letter to their home. POLICIES–Wraparound Training Plan–Page 9, Session 3, Enrollment process; AND Wraparound Training Plan–Page 19, Session 5, Team Supervisions, AND Individual Supervision.
1.2 Led by Youth and Families
a. The Wraparound team address any cultural perspectives and issues that the client and family share, present services in their chosen language when possible, and we have 2 Spanish-speaking teams. POLICIES–Service Delivery for Wraparound Services–Page 2, 4c; AND Wraparound Training Plan–Page 16, Session 4, Mission Statement; AND Wraparound Training Plan–Pages 6 & 7, Session 1, Our Team.
b. The team will elicit this information using both the CANS form and the Strengths, Needs and Culture Discovery form as tools so the team can discuss and document the client’s family values, culture and cultural issues, client expertise, capabilities, interests, and skills in The Plan of Care. This will be sent to all team members within 48 business hours and uploaded into EHR. POLICIES–Wraparound Training Plan–Page 24, Session 7, Child and Adolescent Needs and Strengths; AND Wraparound Training Plan–Page 25, Session 7, Strengths, Needs and Cultural Discovery Sheet; AND Wraparound Training Plan–Page 15, Session 4, Cultural Considerations, AND Plan of Care Documentation; AND FORMS–Plan of Care; AND CANS; AND Strengths, Needs and Culture Discovery Sheet.
c. The supervisors use a CFT Tracker for when the Plan of Care is due within 48 business hours of the CFTM, and each Supervisor will attend one CFTM per week to appropriately monitor teaming, clinical services and interventions with each client and family. In weekly supervisions, the Supervisor will engage in coaching and training of staff to solidify HFW expectations, interventions, and increase confidence in providing services. POLICIES–Wraparound Training Plan–Page 16, Session 4, Supervisor Oversight of CFTMs and The Plan of Care; AND Wraparound Training Plan–Pages 19 & 20, Session 5, Team Supervisions AND Individual Supervisions; AND FORM–CFT Meeting Tracker.
d. Two clients are randomly assigned every month to each supervisor for a quality review phone call to the family, the agency facilitates a separate survey annually for all clients, and the TOMS and WFI-EZ are both administered biannually. POLICIES–Clinical Quality Toolkit–Page 5, Quality Checks, Procedures, 1-3; AND Client Survey Protocol–Page 2, Administration, 1; AND Client Survey Protocol–Page 5, Other Programs & Services, Administration, 1; AND High Fidelity Wraparound CQI Plan 07.01.26, page 3, Fidelity Indicators.
1.3 Strength-Based
a. Therapist does an initial CANS in the intake session and it is completed every 6 months thru treatment. An initial Strengths, Needs and Culture Discovery Sheet is created in the Planning CFTM in the first month of treatment. Both documents are expanded on in monthly CFTMs and documented in The Plan of Care in the Strengths box to identify community resources to assist the family towards their goals. POLICIES–Wraparound Training Plan–Page 15, Session 4, Strengths Inventory; AND FORMS–CANS; AND Strengths, Needs and Culture Discovery Sheet.
b. Therapist does an initial CANS and every 6 months thru treatment, which is addressed in monthly CFTMs and documented in The Plan of Care in the Strengths box. POLICIES–Wraparound Training Plan–Page 15, Session 4, Strengths Inventory.
c. The team members are trained weekly thru individual or team supervisions and in department meetings in providing services which are strengths-based and solution-focused. POLICIES–Wraparound Training Plan–Pages 19 & 20, Session 5, Wraparound Department Meetings, AND Team Supervisions, AND Individual Supervisions.
d. Two clients are randomly assigned every month to each supervisor for a quality review, the TOMS and WFI-EZ are both administered biannually, and the agency facilitates a separate survey annually for all clients. This information is used by supervisors in weekly supervisions to do further coaching of staff on how to enhance their services. POLICIES–Clinical Quality Toolkit–Page 5, Quality Checks, Procedures, 1-3; AND Client Survey Protocol–Page 2, Administration, 1; AND High Fidelity Wraparound CQI Plan 07.01.26, page 3, Fidelity Indicators; AND Client Survey Protocol–Page 5, Other Programs & Services, Administration, 1; AND Wraparound Training Plan–Pages 19 & 20, Session 5, Team Supervisions, AND Individual Supervisions.
1.4 Needs Driven
a. The CANS is completed at intake and every 6 months throughout treatment, and used in monthly CFTMs to identify underlying needs causing the behaviors of the client so the team can help the family create goals to work with these behaviors. POLICIES–Wraparound Training Plan–Page 11, Session 3, Therapist Intake; AND Wraparound Training Plan–Page 15, Session 4, Strengths Inventory.
b. Staff will take the UC Davis Wraparound 101: Foundations of Fidelity training as soon as they can be enrolled as part of onboarding at C&FC, they will have an 8-session Wraparound training as part of C&FC’s second week of new hire training, and then will have ongoing training in Wrap department meetings on Wrap fidelity. POLICIES–Wraparound Training Plan–Page 20, Session 5, Wraparound Trainings; AND Wraparound Training Plan–Pages 19 & 20, Session 5, Wraparound Department Meetings; AND FORM–Wraparound Training Plan (the entire document is used in the 2nd week of new hire training).
c. Therapist does a CANS at intake and every 6 months thru treatment, which is expanded on in monthly CFTMs and documented in The Plan of Care in the Strengths box, to reevaluate client’s strengths towards the underlying needs and treatment planning toward this, with community resources discussed to assist the family towards their goals. The needs are also identified through clinical observation by each staff member in their weekly individual meetings with the client and family members, through staff input in weekly team and individual supervisions, and through discussion in monthly CFTMs. POLICIES–Wraparound Training Plan–Page 15, Session 4, Strengths Inventory; AND Wraparound Training Plan–Page 5, Session 1, Therapist; AND Wraparound Training Plan–Pages 19 & 20, Session 5, Team Supervisions, AND Individual Supervisions.
d. If the family’s goals have been met, a discharge plan is discussed and implemented in a CFTM, and a graduation celebration date is agreed upon by the family, team members, and natural supports involved. POLICIES–Service Delivery for Wraparound Service, Page 4, 13a; AND Wraparound Training Plan–Page 17, Session 4, Graduation.
1.5 Individualized
a. The CANS and PSC are open-ended tools that focus on the family’s own words, priorities, and culture, and this guides the team to set individualized ground rules in monthly CFTMs and weekly individual appointments. Family voice and choice is instrumental in creating the CFTM agenda, as well as the Plan of Care, the team can use the Strengths, Needs and Culture Discovery Sheet with the family towards this, and because the form is open-ended the team is able to individualize each plan. POLICIES–Wraparound Training Plan–Page 11, Session 3, Therapist Intake; AND Wraparound Training Plan–Page 14, Session 4, The Plan of Care; AND Wraparound Training Plan–Page 25, Session 7, Strengths, Needs and Cultural Discovery Sheet; AND Form–CFTM Agenda Demos.
b. Staff will take the UC Davis Wraparound 101: Foundations of Fidelity training as soon as they can be enrolled as part of onboarding at C&FC, and they have an 8-session Wraparound training as part of C&FC’s second week of new hire training. Staff will have case-specific coaching to support staff in implementing individualized plans of care, and this training will occur in Wrap department meetings and in weekly individual supervisions on Wrap fidelity. POLICIES–Wraparound Training Plan–Page 20, Session 5, Wraparound Trainings; AND Wraparound Training Plan–Pages 19 & 20, Session 5, Wraparound Department Meetings; AND Wraparound Training Plan–Pages 19 & 20, Session 5, Individual Supervisions; AND FORMS–Wraparound Training Plan (the entire document is used in the second week of new hire training).
c. In weekly team or individual supervision with the Facilitator and other team members the supervisor will review The Plan of Care and treatment interventions with each staff and provide real-time guidance on customizing client care, and works specifically with the Facilitator on their leadership skills. Supervisor will review the CANS and PSC with staff in weekly supervisions, attend a CFTM weekly to observe the treatment interventions being individually provided to each family, and follow up on service efficacy through random quality checks. POLICIES–Wraparound Training Plan–Page 19, Session 5, Team Supervisions; AND Wraparound Training Plan–Pages 19 & 20, Session 5, Individual Supervisions; AND Wraparound Training Plan–Page 16, Session 4, Supervisor Oversight of CFTMs and The Plan of Care; AND Clinical Quality Toolkit–Page 5, Quality Checks, Procedures, 1-3.
d. The Plan of Care is constantly evolving and reviewed in monthly CFTMs. It uses the CANS and the Strengths, Needs and Culture Discovery Sheet as the basis to build on the underlying needs of the client for the family and team to brainstorm strengths and an action plan to work with the root causes of the behaviors, and to involve natural and community supports to help the client work towards their family goals. POLICIES–Wraparound Training Plan–Page 11, Session 3, Therapist Intake; AND Wraparound Training Plan–Page 15, Session 4, Cultural Considerations, and Strengths Inventory; AND FORM–Strengths, Needs and Culture Discovery Sheet.
e. Two clients are randomly assigned every month to each supervisor for a quality review, the TOMS and WFI-EZ are both administered biannually, and the agency facilitates a separate survey annually for all clients. The Wrap Supervisor attends one CFTM weekly to engage the families and check on services provided, and staff is given feedback on fidelity of services in weekly individual and group supervisions. POLICIES–Clinical Quality Toolkit–Page 5, Quality Checks, Procedures, 1-3; AND High Fidelity Wraparound CQI Plan 07.01.26, page 3, Fidelity Indicators; AND Client Survey Protocol–Page 2, Administration, 1; AND Client Survey Protocol–Page 5, Other Programs & Services, Administration, 1; AND Wraparound Training Plan–Page 16, Session 4, Supervisor Oversight of CFTMs and The Plan of Care; AND Wraparound Training Plan–Page 19, Session 5, Team Supervisions; AND Wraparound Training Plan–Pages 19 & 20, Session 5, Individual Supervisions.
1.6 Use of Natural and Community Based Supports
a. The therapist’s initial CANS done at intake identifies natural supports who can be involved in treatment, and they are invited to monthly CFTMs to participate in planning, support and treatment with the family. These natural supports are updated ongoing in the monthly CFTMs, ensuring new supports are added as desired by the family and documented in The Plan of Care . These natural supports will continue to support the family as they work to transition out of Wraparound services so they’re able to continue their progress towards their family goals. POLICIES–Wraparound Training Plan–Page 11, Session 3, Therapist Intake; AND Wraparound Training Plan–Page 12, Session 4, CFTM; AND Service Delivery for Wraparound Service, Page 4, 13a.
b. Staff will take the UC Davis Wraparound 101: Foundations of Fidelity training as soon as they can be enrolled as part of onboarding at C&FC, and they will have an 8-session Wraparound training as part of C&FC’s second week of new hire training. Staff training will coincide with each case, will have a structured approach focusing on the four phases of Wraparound, and will occur in weekly individual and group supervisions, as well as in every-other-week department meetings. The training will focus on utilizing natural supports through treatment in preparation for eventual graduation and titration out of formal Wraparound supports. POLICIES–Wraparound Training Plan–Page 20, Session 5, Wraparound Trainings; AND Wraparound Training Plan–Page 19, Session 5, Wraparound Department Meetings; AND Wraparound Training Plan–Pages 19 & 20, Session 5, Individual Supervisions; AND Service Delivery for Wraparound Services–Page 4, 13a; AND FORM–Wraparound Training Plan (the entire document is used in the second week of new hire training).
c. The Plan of Care is consistently evolving and reviewed in monthly CFTMs for natural supports and community resources, putting a focus on strengths-based strategies and inclusion of natural supports to promote long-term interventions towards the family goals. POLICIES–Child and Family Team Protocol–Page 3, Step 2: Family Engagement, 1; AND Wraparound Training Plan–Page 11, Session 3, Therapist Intake; AND Wraparound Training Plan–Page 15, Session 4, Cultural Considerations and Strengths Inventory sections.
d. Client and family feedback regarding natural supports is regularly solicited by engaging the family in discussions in monthly CFTMs, this also occurs in weekly individual sessions of family members with the Facilitator, Parent Partner, Child & Family Specialist, and Therapist, and in the administering of the biannual TOMS and WFI-EZ. These allows the team to continually evaluate the effectiveness of each natural support’s contribution to the family goals, ensuring the support system remains culturally respectful and sustains the family progress, and this is documented on The Plan of Care . POLICIES–Child and Family Team Protocol–Page 3, Step 2: Family Engagement, 1 and 2; AND High Fidelity Wraparound CQI Plan 07.01.26, page 3, Fidelity Indicators; AND Wraparound Training Plan–Page 15, Session 4, Cultural Considerations and Strengths Inventory sections; AND Service Delivery for Wraparound Services, Page 3, 5a.
1.7 Culturally Respectful and Relevant
a. A focus of discussion in the initial CFTM (held within one month of beginning services) and documented on the planning Plan of Care is the Strengths, Needs and Culture Discovery Sheet, as this and the initial CANS are used to discuss the family’s long-term goal, family story and natural supports, cultural and spiritual beliefs, strengths, family and individual client needs for treatment to succeed. POLICIES–Wraparound Training Plan–Page 13, Session 4, The Family Story; AND FORM–Strengths, Needs and Culture Discovery Sheet.
b. Staff will take the UC Davis Wraparound 101: Foundations of Fidelity training as soon as they can be enrolled as part of onboarding at C&FC, they will have an 8-session Wraparound training as part of C&FC’s second week of new hire training, and training will continue throughout each staff’s tenure and will individually coincide with each case’s ongoing needs identified in monthly CFTMs. Ongoing training will include cultural training such as cultural humility, implicit bias, engaging clients and families within diverse populations, understanding cultural perspectives on parenting, and incorporating natural supports from within the family culture. Training will be in individual supervisions, department meetings, and as needed further training will be assigned staff through the Relias web site. POLICIES–Wraparound Training Plan–Page 20, Session 5, Wraparound Trainings; AND Wraparound Training Plan–Page 19, Session 5, Wraparound Department Meetings; AND Wraparound Training Plan–Pages 19 & 20, Session 5, Wrap Individual Supervisions; AND FORM–Wraparound Training Plan (the entire document is used in the second week of new hire training).
c. The Wrap team members will ask for feedback from the different family members and natural supports regarding services being culturally relevant and respectful for their needs. This occurs in monthly CFTMs and weekly individual staff sessions with different family members. Cultural feedback is also gathered from monthly quality checks done randomly by Supervisors, and from the Supervisor attending CFTMs for different clients weekly. POLICIES–Wraparound Training Plan–Page 15, Session 4, Cultural Considerations; AND Service Delivery for Wraparound Services–Page 2, 4b; AND Clinical Quality Toolkit–Page 5, Quality Checks, Procedures, 1-3; AND Wraparound Training Plan–Page 16, Session 4, Supervisor Oversight of CFTMs and The Plan of Care.
1.8 High-Quality Team Planning and Problem Solving
a. Team Agreements are called ground rules which address the family needs, confidentiality, and conflict resolution throughout the Wrap process. They are collaboratively discussed with the family and agreed upon in the initial CFTM the week after the therapist intake, and documented in The Plan of Care . The Wrap treatment process is evolving due to family voice and choice, so the agreements change over time to best meet the needs of the family in treatment, and team building is done so they are able to best work with each family. POLICIES–Wraparound Training Plan–Page 13, Session 4, The Family Story; AND Wraparound Training Plan–Page 19, Session 5, Wraparound Department Meetings; AND Wraparound Training Plan–Page 19, Session 5, Team Supervisions; AND Wraparound Training Plan–Page 21, Session 6, Team Building.
b. Wrap team members will ask for feedback from different family members throughout treatment regarding the ongoing engagement and collaboration with the family on services. This occurs in monthly CFTMs and weekly staff sessions with different family members, and in biannual TOM and WFI-EZ. Feedback on engagement of the family and natural supports is gathered from monthly quality checks, and from the Supervisors attending CFTMs for different clients weekly. POLICIES–High Fidelity Wraparound CQI Plan 07.01.26, page 3, Fidelity Indicators; Wraparound Training Plan–Page 15, Session 4, Cultural Considerations; AND Service Delivery for Wraparound Services–Page 2, 4b; AND Clinical Quality Toolkit–Page 5, Quality Checks, Procedures, 1-3; AND Wraparound Training Plan–Page 16, Session 4, Supervisor Oversight of CFTMs and The Plan of Care.
c. Data from quality checks and client satisfaction surveys are reviewed in weekly supervisions to do coaching and identify specific areas where staff can improve their interventions and services to better adhere to the four phases of Wraparound fidelity with each individual family. POLICIES–Wraparound Training Plan–Pages 19 & 20, Session 5, Team Supervisions AND Individual Supervisions.
d. All action steps are noted in The Plan of Care at the monthly CFTMs, and includes who on the team is responsible for working on different facets of the treatment plan (ie Wrap team members, family, and natural supports), to get buy-in and to instill teamwork towards the family goals. The Plan of Care is reviewed at every CFTM and also in bi-weekly Team Supervisions with their supervisor, and is data driven so it can be compared to the CANS and PSCs which are completed every 6 months throughout treatment to show progress towards the goals. POLICIES–Wraparound Training Plan–Page 14, Session 4, The Plan of Care; AND Wraparound Training Plan–Page 19 Session 5, Team Supervisions.
1.9 Outcomes Based Process
a. The Plan of Care documents a collaborative and evolving plan which has measurable goals with corresponding actions steps that different team members will take, with timeframes for completion in support of the family’s goals. This is discussed in the monthly CFTMs, as well as the bi-weekly team supervisions, and results can be compared from the data from the CANS and PSCs and comments from the quality checks. POLICIES–Wraparound Training Plan–Page 14, Session 4, The Plan of Care; AND Wraparound Training Plan–Page 19, Session 5, Team Supervisions; AND Clinical Quality Toolkit–Page 5, Quality Checks, Procedures, 1-3; AND FORM–Plan of Care.
b. The completion of action items is tracked by the Facilitator through The Plan of Care , which is reviewed and added to in monthly CFTMs. The Facilitator reviews the status of all assigned interventions in the CFTM, noting completion and engaging the team in brainstorming necessary adjustments to best meet the needs of the family. In between CFTMs, the Facilitator checks-in with team members in bi-weekly team consultations to monitor and motivate progress, and The Plan of Care is consistently updated and shared with all team members as a reminder of their responsibilities towards meeting the family’s shifting needs thru treatment. POLICIES–Wraparound Training Plan–Page 15, Session 4, Plan of Care Documentation; AND Wraparound Training Plan–Page 19, Session 5, Team Supervisions.
c. The Plan of Care is updated throughout treatment based on family voice and choice when their needs, strengths, or risks change. The action plans and staff/family/natural supports who are assigned to work with that part of treatment are updated in monthly CFTMs, and The Plan of Care is distributed to all team members within 48 business hours. POLICIES–Wraparound Training Plan–Page 14 Session 4, The Plan of Care; AND Wraparound Training Plan–Page 15, Session 4, Plan of Care Documentation.
d. The therapist does the CANS and administers the PSC-35 at intake, and every 6 months throughout treatment. The data from these tools inform decisions regarding changing needs and family goal tracking, and the evolving action plans are documented in The Plan of Care and discussed in team supervisions and CFTMs. POLICIES–Wraparound Training Plan–Page 5, Session 1, Therapist; AND Wraparound Training Plan–Page 15, Session 4, Strengths Inventory; AND Wraparound Training Plan–Page 19, Session 5, Team Supervisions.
e. The CANS is a tool for assessing baseline functioning, monitoring progress, and a part of informing decision-making for treatment. However, the entire treatment team, in monthly CFTMs and individual sessions with family members and weekly supervisions, will discuss the family voice and choice, monitor and discuss progress and adjust services as clinically indicated, and will work towards graduation once the family has successfully achieved their goals and can continue this work with their natural supports and not formal supports. POLICIES–Wraparound Training Plan–Page 15, Session 4, Strengths Inventory AND Wraparound Training Plan–Page 16, Session 4, Mission Statement; AND Service Delivery for Wraparound Services–Page 4, 13a; AND Wraparound Training Plan–Pages 19 & 20 Session 5, Team Supervisions, AND Individual Supervisions.
1.10 Persistence
a. The Wrap team focuses on strengths-based approaches to work with the family needs, and they are trained to be patient, persistent, and have unconditional positive regard for the families and their belief systems (both from a family systemic and a cultural perspective). The focus of the team is towards progress and graduation, overcoming obstacles, and the team works to empower the families to adjust the plan of care to achieve their goals in weekly meetings with family members and in monthly CFTMs. POLICIES–Wraparound Training Plan–Pages 16 & 17, Session 4, Managing Setbacks; AND Policy–Service Delivery for Wraparound Services–Page 4, 13a.
b. When team members face challenges (with environmental psychosocial stressors, individually, or systemically within the family or team), the team can ask the supervisor to do coaching in weekly supervisions, when the supervisor attends a CFTM, the agency can assign a Relias website training, or assistance can be asked for from the Los Angeles Country Department of Mental Health Coaching Unit. The staff can also request flex funding to help a family resolve an issue. POLICIES–Wraparound Training Plan–Page 19, Session 5, Team Supervisions AND Individual Supervisions; AND Wraparound Training Plan–Page 16, Session 4, Supervisor Oversight of CFTMs and The Plan of Care; AND Wraparound Training Plan–Page 20, Session 5, Wraparound Trainings; AND Wraparound Training Plan–Page 26, Session 7, Flex Funds.
c. Facilitators are trained in their second week of new hire with Wraparound Training Information, they take the UC Davis training Wraparound 101 Foundations of Fidelity as soon as possible upon new hire, and have ongoing training in weekly supervisions to brainstorm post‑crisis safety planning, conflict resolution, and how to continually evolve the Wrap planning thru The Plan of Care and CFTMs to support the family towards achieving their goals. Supervisors continue to monitor their performance and adaptation via observations in CFTMs and in documentation review of the matrices and progress notes. POLICIES–Wraparound Training Plan–Pages 19 & 20, Session 5, Team Supervisions, AND Individual Supervisions, AND Wraparound Trainings; AND FORM–Wraparound Training Plan (the entire document is used in the second week of new hire training).
1.11 Transitions as a part of the Fourth Phase of HFW
a. As part of the evolving monthly CFTMs and weekly meetings with team members throughout their treatment process, the families are engaged in discussing their progress towards a positive graduation, ensured that services will not end abruptly, involved in the planning for the graduation, work to brainstorm further natural and community supports for aftercare, and this gives them an appropriate transition into the next phase of their lives. POLICIES–Service Delivery for Wraparound Services, Page 4, 13a; AND Wraparound Training Plan–Pages 17 & 18, Session 4, Graduation.
b. The Wrap team celebrates the transition out of services with a graduation that is chosen by the client, using family voice and choice, in a way that addresses the family system’s culture and values towards celebrating success. The entire team is present, as are all natural and community supports the client invites, and flex funds are used to support the family in this celebration. POLICIES–Wraparound Training Plan–Pages 17 & 18, Session 4, Graduation; AND–Service Delivery for Wraparound Services–Page 4, 13a.
Expected Outcomes
2.1 Youth and Family Satisfaction
The caregivers or Tribe of two clients are randomly contacted monthly by each supervisor for a quality review, and the agency facilitates a separate survey annually for all caregivers or Tribes. Services are also evaluated throughout treatment in monthly CFTMs with the families and natural supports and documented on the Plan of Care, and in weekly individual and team supervisions with the supervisors which are documented in supervision notes. POLICIES–Clinical Quality Toolkit–Page 5, Quality Checks, Procedures, 1-3; AND Client Survey Protocol–Page 2, Administration, 1; AND Client Survey Protocol–Page 5, Other Programs & Services, Administration, 1; AND Wraparound Training Plan, Pages 5 & 6, Session 1, Program Coordinator; AND Wraparound Training Plan, Pages 19 & 20, Session 5, Team Supervisions AND Individual Supervisions; AND Child and Family Team Protocol, Page 4, Step 4: Debrief #s 1 and 2; AND FORMS–Wraparound Individual Supervision Form; AND Wraparound Team Supervision Form.
2.2 Improved School Functioning
Facilitator gets signed authorization to release PHI in the first month of treatment to collaborate with school partners to monitor the client’s attendance and educational progress. Facilitator bring updates to monthly CFTMs (ie 50% decease in absences, grades raising one level) to guide strategies that strengthen the client’s engagement with school and to link the client to services to assist with this (ie IEP/504 plan, tutoring, after-school programs, or flex funds to assist with services). For transition age youth, the focus of teamwork can be on independent living skills (ie resume writing, interview skills, securing employment), and can include flex funds for interview clothes or transportation to interviews. The data from the OMA is updated every three months throughout treatment, the CANS and PSC-35 are updated every six months throughout treatment, and these track clients’ behavioral and academic progress in school. School‑related goals are incorporated into the Plan of Care, revised when progress or barriers are identified, and Supervisors confirm that school data are documented in the Plan of Care on a monthly basis. POLICIES–Wraparound Training Plan, Page 24, Session 7, Outcome Measures Application, AND Child and Adolescent Needs and Strengths, AND Pediatric Symptom Checklist; AND Wraparound Training Plan, Pages 5 & 6, Session 1, Program Coordinator; AND Wraparound Training Plan, Page 14, Session 4, Plan of Care Details; AND FORMS–Plan of Care.
2.3 Improved Functioning in the Community
Every 6 months the CANS tracks information regarding the client’s involvement in the justice system, as well as their involvement with community activities. In monthly CFTMs, the team helps the client and families identify and work towards individualized linkage to community activities (ie sports leagues, community recreation centers, art classes, martial arts, volunteering, employment, Big Brother-Big Sister) that increase the client’s strengths and support further skill building, and this information is used to modify the strategies and assignments for each of the team members. The team pursues flex funds to pay for linkage which is documented the in the Plan of Care at monthly CFTMs, and supervisors review this. The Supervisor also review the CANS every 6 months, and look for a decrease in Special Incident Reports, so they can follow up on progress towards linkage in weekly supervisions. POLICIES–Wraparound Training Plan, Page 24, Session 7, Child and Adolescent Needs and Strengths; AND Wraparound Training Plan, Page 14, Session 4, The Plan of Care, AND Plan of Care Details; AND Wraparound Training Plan, Page 15, Session 4, Strengths Inventory; AND Page 16, Session 4, Supervisor Oversight of CFTMs and The Plan of Care; AND Wraparound Training Plan, Pages 19 & 20, Session 5, Team Supervisions, AND Individual Supervisions; AND Child and Family Team Protocol, Page 4, Step 4: Debrief #s 1 and 2.
2.4 Improved Interpersonal Functioning
Facilitators work with the client and families in monthly CFTMs, and in weekly individual meetings with the family between CFTMs, to set goals that target family and peer relationships to reduce strain in the client’s relationships, and these are documented in the Plan of Care. The Child and Family Specialists work with the clients through role play on social and communication skills, and Parent Partners work with caregivers on positive communication and listening skills using coaching and parenting support. Family and interpersonal functioning are documented in the CANS and PSC-35 every six months. Supervisors monitor progress through weekly progress notes from each team member, by attending one CFTM weekly, through a decrease in SIRs, an increase in positive family activities, successful use of the Family Safety and Crisis Plan when needed, more active family use of their natural supports, and through client and caregiver report of decreased conflicts and increased peer relationships in the community. Supervisors follow up with the progress toward goals in weekly supervisions so strategies can be adjusted to best meet the individualized needs of the family. POLICIES–Wraparound Training Plan, Pages 3-5, Session 1, Child and Family Specialist, AND Facilitator, AND Parent Partner, AND Program Coordinator; AND Wraparound Training Plan, Page 15, Session 4, Plan of Care Documentation; AND Wraparound Training Plan, Page 24, Session 7, Child and Adolescent Needs and Strengths, AND Pediatric Symptom Checklist; AND Wraparound Training Plan, Page 16, Session 4, Supervisor Oversight of CFTMs and The Plan of Care; AND Wraparound Training Plan, Pages 19 & 20, Session 5, Team Supervisions, AND Individual Supervisions; AND Child and Family Team Protocol, Page 4, Step 4: Debrief #s 1 and 2.
2.5 Increased Caregiver Confidence
Parent Partners in weekly meetings with caregivers provide parenting advice, support and mentorship which increase caregivers’ confidence in working with their child’s needs and behaviors, connecting to community resources, involving their natural supports, and navigating systems to empower them to long-term self-sufficiency. Facilitators reinforce these learned skills through coaching in monthly CFTMs while addressing their needs and wants through family voice and choice, and by addressing cultural and family systems issues. In CFTMs the team builds caregiver confidence in managing crises, communication with the client, and problem solving issues; include natural supports in the planning; and suggest flex funds to purchase items to improve family bonding (ie board games, movie tickets, a family meal). Later in treatment the team discusses with the family planning for graduation, which prepares the caregiver for the decrease in formal supports while further connecting them to sustainable, long-term natural supports and community resources. Supervisors review caregiver confidence personally when they attend weekly CFTMs, via monthly random quality checks, and via progress on the CANS and PSC-35 every 6 months. POLICIES–Wraparound Training Plan, Pages 4 & 5, Session 1, Facilitator, AND Parent Partner; AND Wraparound Training Plan, Pages 5 & 6, Session 1, Program Coordinator; AND Wraparound Training Plan, Page 17, Session 4, Graduation; AND Child and Family Team Protocol, Page 3, Step 3, #4; AND Service Delivery for Wraparound Services, Page 4, 13 a.
2.6 Stable and Least Restrictive Living Environment
Monthly CFTMs identify strategies and interventions involving community and natural supports that help the client remain safely at home and in their school, and document this in the Plan of Care. Team members track living environment changes and precipitating factors (ie crises, school disruptions, housing issues) on the KEC OMA form, review them in weekly meetings with family members, and use them to guide interventions to work with the family goals and to prevent client regression into past behaviors. Supervisors monitor placement stability through daily progress note review and monthly Plan of Care reviews, reviewing the CANS and treatment progress in weekly supervisions, and reviewing any KEC OMAs. POLICIES–Wraparound Training Plan, Page 24, Session 7, Outcome Measures Application; AND Wraparound Training Plan, Pages 14 & 15, Session 4, The Plan of Care, AND Plan of Care Documentation; AND Wraparound Training Plan, Pages 5 & 6, Session 1, Program Coordinator; AND Wraparound Training Plan, Pages 19 & 20, Session 5, Team Supervisions, AND Individual Supervisions.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
The team in monthly CFTMs develops and revises the Family Safety and Crisis Plan that identifies early warning signs and problem solves individualized proactive and reactive strategies to help families manage a crisis and avert psychiatric hospitalizations, and reinforces plan rehearsal in CFTMs and weekly meetings with the client. Following any crisis, in the CFTM the team updates the Plan of Care and Family Safety and Crisis Plan to address triggers, build skills and redirection strategies, and involve natural supports to reduce crisis recurrence. Supervisors review the SIR and Incident Report to do a post crisis evaluation to target coaching, intervention modification, and family system work that can be done to prevent future crises. POLICIES–Wraparound Training Plan, Page 22, Session 7, Family Safety and Crisis Plan; AND Wraparound Training Plan, Pages 14 & 15, Session 4, The Plan of Care; AND Wraparound Training Plan, Page 24, Session 7, Outcome Measures Application; AND Wraparound Training Plan, Pages 5 & 6, Session 1, Program Coordinator.
2.8 Reduction in Crisis Visits
All four team members teach the client and family to implement de-escalation strategies using natural supports, and the team records incidents and near misses in daily progress notes to assess the effectiveness of interventions throughout the case to achieve client stabilization. Family Safety and Crisis Plans are evolving and updated as new triggers, behaviors and risks emerge, and are distributed to all CFTM members within 48 business hours to ensure timely, coordinated interventions to address the behaviors. The Parent Partner, Child and Family Specialist, and Therapist in their individual work with the family will use role plays to practice de-escalation techniques. Supervisors review daily progress notes, monthly CFTM Matrices, and SIRs, and process them in weekly supervisions, to help the team modify the interventions used to support the needs of the individual family. POLICIES–Wraparound Training Plan, Page 22, Session 7, Family Safety and Crisis Plan; AND Wraparound Training Plan, Page 3, Session 1, Child and Family Specialist; AND Wraparound Training Plan, Page 5, Session 1, Parent Partner, AND Therapist, AND Program Coordinator; AND Wraparound Training Plan, Pages 19 & 20, Session 5, Team Supervisions, AND Individual Supervisions; AND Service Delivery for Wraparound Services, Page 4, 11b, AND 13a; AND Child and Family Team Protocol, Page 2, FREQUENCY OF CFTMs 1.
2.9 Positive Exit from HFW
The Facilitator leads the team to support the family in knowing that discharge from services is based on stabilization and sufficient progress on individualized family goals, and not an adverse event. The client’s progress is tracked every 6 months using the CANS and PSC-35. In preparation for this, the team discusses with the family progress towards goals, regression prevention, confirms transition from formal to natural supports, links to further community resources, and documents in the Plan of Care a transition plan identifying all resources to assist their family in maintaining progress. Supervisors verify completion and quality of transition documentation prior to discharge, including The Plan of Care and the Discharge Instruction Sheet. POLICIES–Wraparound Training Plan, Page 17, Session 4, Graduation; AND Service Delivery for Wraparound Services, Page 4, 13a; AND Wraparound Training Plan, Page 5, Session 1, Program Coordinator; AND Wraparound Training Plan, Page 24, Session 7, Child and Adolescent Needs and Strengths (CANS), AND Pediatric Symptom Checklist (PSC-35); FORMS–Discharge Instruction Sheet.
Engagement
3.1 Orientation
a. C&FC engages the family in HFW in the enrollment meeting and planning CFTM in the first month of treatment by establishing meaningful, trusting, individualized, and culturally responsive relationships with youth, caregivers, natural supports and Tribes, and community partners. Engagement focuses on preparing the family to collaborate by ensuring they understand the 10 principles of the model, feel welcomed, understood and respected, and have any safety needs addressed. The Facilitator works with the family to understand the 4 phases of Wrap, consent for services and confidentiality. The Facilitator explores their strengths, needs, cultural preferences, and long-term goals. The Facilitator identifies and engages team members who can support with the planning and implementation, and explains the role of each team member including the family, natural supports, and Tribes in the case of an Indian child. Engagement sets the foundation for the CFTM by ensuring families have understanding, support, and readiness to move toward plan development. POLICIES–Wraparound Training Plan, Pages 9 & 10, Session 3, Enrollment Process, AND Enrollment Meeting; AND Universal Informed Consent for Services, Pages 2 & 3, Confidentiality.
a) a) The Facilitator leads the enrollment meeting with support from the Parent Partner, Child and Family Specialist, and Therapist, to provide an explanation of the HFW process, its principles, phases, and collaborative work with the family to create and work towards their goals, including giving to and reviewing with them a handout on the 4 Phases of Wrap and 10 Wrap Standards. POLICIES–Wraparound Training Plan, Page 10, Session 3, Enrollment Meeting; AND FORM Intro to Wrap Enrollment Handout.
a) b). The Facilitator and Therapist review with families in the enrollment meeting confidentiality, client rights and responsibilities, release of information, consent for services, and mandated reporting, and documents this in the COS note. POLICIES–Wraparound Training Plan, Page 10, Session 3, Enrollment Meeting, AND COS Note; AND Wraparound Training Plan, Page 5, Session 1, Therapist; AND Universal Informed Consent for Services, Pages 2 & 3, Confidentiality, and Pages 4 & 5 Your Rights.
a) c) In the enrollment meeting the Facilitator explains the roles and responsibilities of each team member, including the family, Tribal representatives for an Indian child, natural supports, community system partners, and the Wraparound team members themselves. This helps ensure understanding before the family accepts services and begins participating in services. POLICIES–Wraparound Training Plan, Page 10, Session 3, Enrollment Meeting.
3.2 Safety and Crisis stabilization
a. The Facilitator collaborates with the youth and caregiver to discuss any immediate safety concerns in the enrollment meeting, and if needed immediately develops a Family Safety and Crisis Plan that is provided to the family and filed in EHR within 48 hours. POLICIES–Wraparound Training Plan, Page 10, Session 3, Enrollment Meeting; AND Wraparound Training Plan, Page 22, Session 7, Family Safety and Crisis Plan.
b. The initial Family Safety and Crisis Plan is designed to inform, but not replace, a more comprehensive and proactive Family Safety and Crisis Plan that will be developed during ongoing CFTMs. It will identify early warning signs and specific, actionable interventions, ensure continuity between immediate stabilization and long term planning to assist the family in working towards their individualized goals. POLICIES–Wraparound Training Plan, Page 22, Session 7, Family Safety and Crisis Plan.
c. The Facilitator gives the families written and verbal instructions how to access the Wrap team 24/7 for crisis support in the initial CFTM and ongoing thereafter, including staff phone numbers and the 24/7 therapist crisis phone, 911 and 988, and document in a progress note that this information was provided. POLICIES–Wraparound Training Plan, Page 22, Session 7, Family Safety and Crisis Plan.
3.3 Strengths, Needs, Culture and Vision Discovery
a. The Facilitator collaborates with the client and family in the enrollment meeting to create a Family Vision that reflects their hopes, values, and long-term goals, documenting it in the COS note. The Strengths, Needs and Cultural Discovery Sheet is used throughout the case as an evolving document to guide the individualized treatment towards the Family Vision, and approved by the family to emphasize their voice and choice in this process. POLICIES–Wraparound Training Plan, Page 14, Session 4, Plan of Care Details, AND Family Vision; AND FORM–Strengths, Needs and Cultural Discovery Sheet.
b. The Facilitator leads the team in creating a Strengths, Needs, and Culture Discovery sheet with the youth and family in the enrollment meeting at the start of treatment, which captures the family’s vision, culture, underlying needs, and strengths across 12 life domains. It is an evolving document that is updated at least every 90 days, and it’s shared with new team members to involve them in the treatment process. POLICIES–Wraparound Training Plan, Page 14, Session 4, Family Vision; AND Page 25, Session 7, Strengths, Needs and Cultural Discovery Sheet; AND FORM–Strengths, Needs and Cultural Discovery Sheet.
3.4 Engage All Team Members
a. In the initial enrollment meeting, the Facilitator works with the youth and family to complete a list of natural supports, trusted individuals and community connections who may participate in the CFTMs, using the Strengths, Needs, and Culture Discovery form to identify them, documenting this in a progress note in EHR. These natural supports are included in monthly CFTMs, and involved in the treatment planning and action steps towards the family goals. If natural supports are not able to attend the CFTMs, the Facilitator documents the ongoing efforts (ie calls, emails, home visits) to engage them, and the Plan of Care is sent to them within 48 business hours to ensure they are involved in the process. POLICIES–Wraparound Training Plan, Page 10, Session 3, Enrollment Meeting; AND Wraparound Training Plan, Page 12, Session 4, Initial CFTM; AND Wraparound Training Plan, Page 14, Session 4, The Plan of Care; AND Wraparound Training Plan, Page 15, Session 4, Plan of Care Documentation; AND FORM–Strengths, Needs and Cultural Discovery Sheet.
b. The Facilitator helps the family identify Children’s System of Care partners (ie Tribal representatives, DCFS CSW, probation officer, child welfare staff, school staff, or mental health workers) through outreach to ensure representation on the Wrap team, and to collaborate to integrate services into a single, individualized plan of care for the family. These partners regularly participate in monthly CFTMs to monitor progress, adjust treatment interventions, stabilize crises, and as treatment progresses the Wrap team works to transfer responsibility back to the care partners to help the family sustain progress towards graduation and beyond. POLICIES–Wraparound Training Plan, Page 10, Session 3, Enrollment Meeting; AND Wraparound Training Plan, Page 12, Session 4, CFTM; AND Wraparound Training Plan, Page 25, Session 7, Strengths, Needs and Cultural Discovery Sheet; AND Wraparound Training Plan, Page 17, Session 4, Graduation.
c. In the initial enrollment meeting, the Facilitator uses the Strengths, Needs, and Culture Discovery form to identify the client’s formal and natural supports (including the Tribe if an Indian child), documents this information in a progress note, and engages these support partners from the family’s network through outreach to ensure appropriate representation on the team. These supports help the team identify strengths and needs of the family and address safety issues, as the Facilitator explains the HFW process, principles, and role of each team member, and coordinates monthly CFTMs that fit the family’s schedule and preference of location to be able to engage the entire team in working towards the family goals. POLICIES–Wraparound Training Plan, Page 10, Session 3, Enrollment Meeting; AND FORM–Strengths, Needs and Cultural Discovery Sheet.
d. The Facilitator leads engagement and team building activities in the CFTMs that are individualized and strengths-based, such as warm introductions, shared agreements, ground rule setting, and rapport building to foster a collaborative process. This is documented in the Plan of Care, and updated thru treatment. POLICIES–Wraparound Training Plan, Page 12, Session 4, Initial CFTM; AND Wraparound Training Plan, Page 15, Session 4, Plan of Care Documentation; AND Child and Family Team Protocol, Page 3, Step 3, 1.
3.5 Arrange Meeting Logistics
a. The Facilitator offers flexible meeting times and locations aligned with the family’s needs, preferences, voice and choice, and arranges logistics such as transportation to maximize participation. POLICIES–Wraparound Training Plan, Page 3, Session 1, Core Practice Model; AND Wraparound Training Plan, Page 12, Session 4, Timing of CFTMs; AND Child and Family Team Protocol, Page 2, CFTM LOCATION, 1-5.
b. The Facilitator uses specific engagement strategies taught in their onboarding training to confirm the attendance of the family and natural supports, and to remain flexible to best meet their needs (ie offering transportation for the family, making it at a location and time that best meet their needs, and using interpretation or telehealth in the CFTM). POLICIES–Wraparound Training Plan, Page 12, Session 4, Timing of CFTMs; AND Child and Family Team Protocol, Page 2, CFTM LOCATION, 1-5.
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
a. The Facilitator leads the team in developing and documenting team ground rules and agreements based on family voice and choice, incorporating the strengths of the team to best collaborate with the family in developing a team mission statement regarding the plan to work towards the family vision. This is done during the enrollment meeting and Planning CFTM, these elements are documented in the youth’s record and incorporated into the Plan of Care, and Supervisors review documentation during weekly supervisions to ensure that team agreements, strengths, and mission statements are completed. POLICIES–Wraparound Training Plan, Page 10, Session 3, Enrollment Meeting; AND Wraparound Training Plan, Page 12, Session 4, Initial CFTM; AND Child and Family Team Protocol, Page 2, Step 1, 2.
b. The Facilitator ensures that strengths identified during engagement (from the CANS, and Strengths, Needs and Cultural Discovery Sheet) are updated and documented in the Plan of Care to reflect newly identified strengths, and the team uses these to work towards the individualized family vision. These are revisited and updated as needed during CFTMs, and Supervisors verify updates and assess how the team modifies treatment through reviewing the Plan of Care, CANS, and Strengths, Needs and Cultural Discovery Sheet. POLICIES–Wraparound Training Plan, Pages 24 & 25, Session 7, Child and Adolescent Needs and Strengths, AND Strengths, Needs and Cultural Discovery Sheet; AND Wraparound Training Plan, Page 10, Session 3, Enrollment Meeting; AND Wraparound Training Plan, Pages 5 & 6, Session 1, Program Coordinator; AND FORM–Strengths, Needs and Cultural Discovery Sheet.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
a. The Facilitator supports the team in identifying and focusing on underlying needs prior to the development of goals and treatment interventions. Underlying needs are prioritized for the family by exploring them through individualized discussion to focus on the reasons for behaviors, and they’re also identified in the initial CANS and PSC-35. These needs are documented in the Plan of Care, and Supervisors review the Plan of Careto ensure needs are identified. POLICIES–Wraparound Training Plan, Pages 12 & 13, Session 4, Initial CFTM; AND Wraparound Training Plan, Pages 24 & 25, Session 7, Pediatric Symptom Checklist, AND Strengths, Needs and Cultural Discovery Sheet; AND Wraparound Training Plan, Page 15, Session 4, Plan of Care Documentation.
b. The Facilitator uses the identification of the client’s underlying needs to ensure that needs statements are reflective of the family system. Facilitators use needs-based planning approaches during CFTMs to collaborate with the team to develop measurable goals and outcomes based on these needs, and this is done from a strengths-based perspective regarding what the client and family are capable of working on and what they want to achieve. The progress is tracked using the Plan of Care in monthly CFTMs, the OMA every 3 months, and CANS and PSC-35 every 6 months. POLICIES–Wraparound Training Plan, Page 12, Session 4, Initial CFTM; AND Wraparound Training Plan, Page 14, Session 4, The Plan of Care Details; AND Wraparound Training Plan, Page 24, Session 7, Outcome Measures Application, AND Child and Adolescent Needs and Strengths, AND Pediatric Symptom Checklist.
c. The Child and Family Team develops measurable goals and outcomes guided directly from each family’s underlying needs. Goals are created collaboratively with the client, family, and natural and formal supports, are strengths-based, aligned with the team’s mission and family vision, and interventions and action steps are tailored to the family’s culture, preferences, and needs. This teamwork towards goals is documented in the Plan of Care, and Supervisors review the Plan of Care to ensure goals are clearly connected to underlying needs and measurable. POLICIES–Wraparound Training Plan, Page 12, Session 4, Initial CFTM; AND Wraparound Training Plan, Page 15, Session 4, Plan of Care Documentation.
d. The Facilitator guides the team in brainstorming multiple individualized treatment interventions and action steps that are specific and measurable to address identified underlying needs to achieve the family goals, and works to ensure there’s a balance between formal services and natural supports. Strategies are developed in a team-based collaborative environment in monthly CFTMs and reflect the youth and family’s preferences, culture, family system, and natural and community supports to work towards the family’s vision and choices, fostering self-efficacy and problem-solving skills. Supervisors verify that multiple strategies are considered and documented through review of the Plan of Care and progress notes. POLICIES–Wraparound Training Plan, Page 12, Session 4, Initial CFTM; AND Wraparound Training Plan, Page 15, Session 4, Plan of Care Documentation.
e. For new hires, the Facilitator (and all Wraparound staff) goes thru a 1-week training in their second week on High Fidelity Wraparound Training principles, and also attend the UC Davis training Wraparound 101: Foundations of Fidelity as soon as they are able to. For existing Wraparound staff, they also attend the UC Davis training Wraparound 101: Foundations of Fidelity as soon as they are able to. This helps the Facilitators learn to prioritize and select team strategies and action steps that are most likely to be effective in working towards the individualized family goal, ensuring that these team interventions are strength-based and culturally relevant towards the Family Vision. Strategies are documented in the Plan of Care with clearly assigned responsibilities and timelines for team members, and Supervisors review the Plan of Care to ensure alignment with the needs of the client and family. POLICIES–Wraparound Training Plan, Page 3, Session 1, UC Davis Training; AND Wraparound Training Plan, Page 4, Session 1, Facilitator; AND Wraparound Training Plan, Page 15, Session 4, Plan of Care Documentation.
f. The Facilitator creates a team-based, collaborative process to develop goals, interventions, and action steps for various team members, engaging the family and team members in active participation. This process is documented during CFTMs and reflected in the initial planning Plan of Care , which is a live document that is edited in all CFTMs throughout treatment. Supervisors monitor team-based planning through review of the Plan of Care and supervision discussions. POLICIES–Wraparound Training Plan, Page 4, Session 1, Facilitator; AND Wraparound Training Plan, Page 12, Session 4, Initial CFTM; AND Wraparound Training Plan, Page 14, Session 4, The Plan of Care Details.
4.3 Develop an Individualized Child or Youth and Family Plan
a. All Facilitators participate in the UC Davis Wraparound 101: Foundations of Fidelity training, and receive ongoing training and coaching in weekly individual and team supervisions to better engage the team in a collaborative planning process that elicits perspectives from all team members, creates trust and a shared family vision, and reflects HFW principles. Facilitators apply these skills during monthly CFTMs to ensure that all voices, including youth, caregivers, and natural supports, are incorporated. Supervisors monitor implementation through CFTM observation, weekly supervision, and ongoing review of meeting documentation. POLICIES–Wraparound Training Plan, Page 4, Session 1, Facilitator; AND Wraparound Training Plan, Pages 5 & 6, Session 1, Program Coordinator, AND Program Manager.
b. The Facilitator ensures that the Plan of Care assimilates goals and objectives identified by all formal service providers, natural supports, and community-based supports to create a shared treatment vision with identified action steps and timelines for each member. The team collaborates to align system of care partner contributions with the individualized youth and family’s needs, strengths, and mission. Supervisors verify that the Plan of Care reflects collaboration among all treatment partners through weekly documentation review and weekly supervisions. POLICIES–Wraparound Training Plan, Page 4, Session 1, Facilitator; AND Wraparound Training Plan, Pages 5 & 6, Session 1, Program Coordinator, AND Program Manager.
c. The Facilitator ensures that the Plan of Care is created at the first CFTM in the first month of treatment, documented in EHR, updated at each CFTM, and distributed to all CFT members. It includes: client and family strengths; family voice and choice; individualized needs, goals, and strategies; assigned responsibilities and action timelines for all team members involved in the treatment process; integration of these natural and system of care supports; and benchmarks for transitioning to less formal services and graduation from Wrap. Supervisors review the Plan of Care for clinical accuracy and connection to the family vision and culture, and discuss it during weekly supervisions. POLICIES–Wraparound Training Plan, Pages 14 & 15, Session 4, The Plan of Care, AND Plan of Care Documentation; AND Wraparound Training Plan, Page 12, Session 4, Initial CFTM.
d. C&FC has procedures to review the ongoing Matrices as part of quality improvement, and the team adjusts the plan as needed whenever it’s clinically indicated. Supervisors review all Matrices within 48 hours, and provide feedback to staff in weekly supervisions and every-other-week department meetings to support ongoing training, coaching, and fidelity to HFW. Timely Plan of Care creation (within 30 days of referral), review (every 30-45 days), and updates (every 90 days) are monitored through the HFW Data Report which is refreshed on a monthly basis by the Data Analyst and provided to the HFW Program leadership to track findings and inform continuous program quality improvement efforts. POLICIES–Wraparound Training Plan, Page 12, Session 4, Initial CFTM; AND Wraparound Training Plan, Page 15, Session 4, Plan of Care Documentation; AND Wraparound Training Plan, Pages 19 & 20, Session 5, Individual Supervisions.
4.4 Develop a Crisis and Safety Plan
a. The Facilitator leads the team in developing an individualized family safety and crisis plan in the first month of treatment that identifies needs, cultural issues, potential risks, safety concerns, proactive and reactive interventions chosen by client and family, and which team members or natural supports should be called for 24/7 crisis support. The plan is documented in the Family Safety & Crisis Plan, with the completion of this documented in both the Plan of Care and a progress note, reflecting the client and family’s preferences. Supervisors review family safety and crisis plans to ensure appropriate level of clinical detail and individualization. POLICIES–Wraparound Training Plan, Page 22, Session 7, Family Safety and Crisis Plan; AND FORM–Family Safety & Crisis Plan.
b. The Facilitator ensures that the Family Safety & Crisis Plan is developed in a team-based, collaborative environment, and that staff receive training and coaching on collaboratively creating the safety plan with the family. The Supervisor trains staff initially at new hire and ongoing throughout their tenure in weekly supervisions, in every-other-week department meetings, and monitors safety plan development through documentation review of the plans. POLICIES–Wraparound Training Plan, Page 22, Session 7, Family Safety and Crisis Plan; AND Wraparound Training Plan, Pages 19 & 20, Session 5, Team Supervisions, AND Individual Supervisions; AND FORM–Family Safety & Crisis Plan.
c. The Facilitator reviews and updates the Family Safety & Crisis Plan monthly and as needed to reflect changes in risk, effectiveness of interventions, and evolving needs. Reviews occur during CFTMs and within 24 business hours following any crisis event. The plans are automatically submitted to the Supervisor thru the EHR, the Supervisor verifies updates and clinical appropriateness of the plan, assesses for individualized strategies, looks for proactive and reactive progression of interventions, considers family system and cultural relevancy, reviews the use of natural supports, and uses this information to provide feedback and coaching through weekly supervision. POLICIES–Wraparound Training Plan, Page 22, Session 7, Family Safety and Crisis Plan; AND Wraparound Training Plan, Pages 19 & 20, Session 5, Team Supervisions, AND Individual Supervisions; AND FORM–Family Safety & Crisis Plan.
Implementation
5.1 Implement The Plan of Care
a. The Facilitator uses the agenda to lead the monthly CFTM in reviewing strategies and action items documented in the Plan of Care that are strength-based, team-driven, and family-centered, while tracking progress towards individualized goals, confirming follow through from team members (including natural supports), and adjusting timelines and interventions to ensure fidelity. POLICIES–Wraparound Training Plan, Pages 12 & 13, Session 4, Initial CFTM, AND Ongoing CFTMs; AND Wraparound Training Plan, Pages 15 & 16 Session 4, Plan of Care Documentation; AND FORM–CFTM Agenda Demos.
b. At new hire all Wrap staff are trained in their second week using the Wraparound Training Plan on implementing the plan of care and celebrating successes in treatment, and they also take the UC Davis Training Wraparound 101: Foundations of Fidelity as soon as possible. Thru their tenure with the team, they receive ongoing coaching and clinical support for their assigned responsibilities in alignment with HFW principles through weekly supervisions and every-other-week department meetings. Fidelity to HFW is monitored through the HFW Data Report which is refreshed monthly by the Data Analyst, and provided to the HFW Program leadership to track findings and inform program quality improvement efforts. POLICIES–Wraparound Training Plan, Page 14 Session 4, The Plan of Care; AND Wraparound Training Plan, Pages 19 & 20, Session 5, Wraparound Department Meeting, AND Team Supervisions, AND Individual Supervisions.
5.2 Review and Update The Plan of Care
a. The Facilitator engages the team in a systematic review of interventions, progress, barriers to overcome, and outcomes, during monthly CFTMs to reassess whether the Plan of Care remains effective and aligned with the prioritized needs, or if it needs to be adjusted based on data to meet the family’s needs. The Facilitator recognizes the successes with action items to further motivate the team towards success, and Supervisor reviews the Plan of Care within 48 business hours to ensure that progress and barriers with action items are addressed. POLICIES–Wraparound Training Plan, Page 13, Session 4, Ongoing CFTMs; AND Wraparound Training Plan, Page 15, Session 4, Plan of Care Documentation; AND Child and Family Team Protocol, Page 2, FREQUENCY OF CFTMs, 1.
b. The Facilitator leads the team in monthly CFTMs to discuss new interventions and adjusted action items based on team member progress and barriers to problem solve, documenting these updates in the Plan of Care which the entire team signs. Supervisor reviews the Plan of Care within 48 business hours to confirm that updates reflect team decisions and are completed by assigned team members. The team focuses on new family needs using the Strengths, Needs and Culture Discovery Sheet, and track overall progress using the OMA every 3 months, and the CANS and PSC-35 every 6 months. POLICIES–Wraparound Training Plan, Page 13, Session 4, Ongoing CFTMs; AND Wraparound Training Plan, Page 15, Session 4, Plan of Care Documentation; AND Child and Family Team Protocol, Page 2, FREQUENCY OF CFTMs, 1; AND Wraparound Training Plan, Page 24, Session 7, Outcome Measures Application, AND Child and Adolescent Needs and Strengths, AND Pediatric Symptom Checklist.
c. To help the team work towards the client’s goals, the Facilitator documents: monthly CFTM member attendance; the involvement of natural and formal supports, their progress towards action steps and revisions of the team plan; and any flex funds discussed to help the family work towards their individualized goals. The Facilitator updates the Plan of Care form which all team members sign, ensuring that all team members receive a copy within 48 business hours of each CFTM. POLICIES–Wraparound Training Plan, Page 4, Session 1, Facilitator; AND Wraparound Training Plan, Page 15, Session 4, Plan of Care Documentation.
d. The Facilitator ensures the Plan of Care is a client-guided, planning form that is designed for individualized changes and updated at monthly CFTMs to meet the evolving family needs, changes in circumstances, current priorities, and shifts to the action steps and timelines for various team members. Family Safety & Crisis Plans are also designed for individualized changes when a crisis or change in client triggers occurs. The Supervisor monitors all document updates, and provides feedback through supervisions. POLICIES–Wraparound Training Plan, Page 15, Session 4, Plan of Care Documentation; AND Wraparound Training Plan, Page 14, Session 4, Plan of Care Details; AND Wraparound Training Plan, Page 22, Session 7, Family Safety and Crisis Plan.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
a. The Facilitator ensures team agreements are reviewed in monthly CFTMs and used to maintain cohesion, trust, and commitment to the family vision among all team members. POLICIES–Wraparound Training Plan, Page 13, Session 4, Ongoing CFTMs; AND Wraparound Training Plan, Page 14, Session 4, Plan of Care Details; AND Wraparound Training Plan, Page 15, Session 4, Plan of Care Documentation.
b. The Facilitator is given training and ongoing coaching to strengthen skills in building, engaging, and maintaining teams that succeed with their communication, cohesion, and teamwork with client care. POLICIES–Wraparound Training Plan, Page 4, Session 1, Facilitator.
c. The Facilitator monitors the engagement of natural supports throughout treatment, and coaching, supervision, and supervisor observation are used to help the team identify opportunities to strengthen sustainable supports who can remain with the family beyond graduation. POLICIES–Wraparound Training Plan, Page 4, Session 1, Facilitator; AND Wraparound Training Plan, Page 12, Session 4, CFTM; AND Wraparound Training Plan, Pages 19 & 20, Session 5, Team Supervisions, AND Individual Supervisions.
d. The Facilitator orients new members (such as natural and formal supports) joining the monthly CFTM by reviewing the HFW processes, current plans, interventions, and uses team building activities to help them have good communication, cohesion, and teamwork towards the family vision and goals. POLICIES–Wraparound Training Plan, Page 4, Session 1, Facilitator.
Transition
6.1 Develop a Transition Plan
a. The Facilitator initiates transition planning with the entire team in monthly CFTMs once progress has been made toward the individualized family goals, and the family demonstrates increased stability and progress thru certain benchmarks. Transition is discussed in alignment with family readiness, and Supervisors review transition readiness thru documentation and outcome measures in weekly supervisions to ensure planning is individualized. POLICIES–Wraparound Training Plan, Page 17, Session 4, Graduation; AND Wraparound Training Plan, Page 24, Session 7, Outcome Measures Application, AND Child and Adolescent Needs and Strengths, AND Pediatric Symptom Checklist; AND Service Delivery for Wraparound Services, Page 5, Section 13.
b. The Facilitator leads the team to develop a transition plan for further family progress after the Wrap graduation that outlines needs to address, strategies for sustaining progress, and identifying natural supports who will remain in place following Wrap services. This is documented in the client’s file, the Supervisor verifies that the transition plan is viable and aligned with the family’s vision through documentation review, and the plan is distributed to all team members. POLICIES–Wraparound Training Plan, Page 17, Session 4, Graduation; AND Service Delivery for Wraparound Services, Page 5, Section 13a.
c. The Facilitator receives training and coaching upon new hire and ongoing during their tenure on the transition planning process, they lead this planning with the entire team in a collaborative manner in monthly CFTMs later in treatment, ensuring that the plan reflects the family’s preferences, family vision, strengths, and cultural considerations. The Supervisor coaches of the Facilitators and team on the transition planning in weekly supervisions, and they monitor team participation and alignment with HFW principles through supervisions and documentation review. POLICIES–Wraparound Training Plan, Page 3, Session 1, Child & Family Center New Hire Training, AND UC Davis Training; Wraparound Training Plan, Page 17, Session 4, Graduation; AND Wraparound Training Plan, Pages 19 & 20, Session 5, Team Supervisions, AND Individual Supervisions.
d. The Facilitator leads the team in monthly CFTMs late in treatment on transition planning, and this includes both verifying natural supports and children’s system of care partners to continue to work with the family once HFW formal supports end, and working to ensure that the family will be able to engage in these services (including post adoption services if applicable). This is documented in the Plan of Care, which is reviewed by Supervisors to confirm the family’s needs are going to be met post-graduation. POLICIES–Wraparound Training Plan, Page 15, Session 4, Plan of Care Documentation; AND Wraparound Training Plan, Page 17, Session 4, Graduation.
6.2 Develop a Post-Transition Safety Plan
a. The Facilitator leads the team in creating the individualized Family Safety & Crisis Plan to meet the evolving needs of the family in proactive and reactive crisis management, while also planning for potential crisis situations post-graduation. This includes updating it to reflect changes in triggers or positive coping skills or natural supports chosen by the family to engage with. This is signed by the client, caregiver and the team member typing the form, the family is given copies, and it’s documented in the EHR. POLICIES–Wraparound Training Plan, Page 22, Session 7, Family Safety and Crisis Plan.
b. The Facilitator is trained on how to lead the team in collaboratively developing the revised Family Safety & Crisis Plan for the family’s proactive managing of triggers in their transition to natural supports, and the Supervisor actively coaches the team in this process through weekly supervisions and by attending monthly CFTMs. POLICIES–Wraparound Training Plan, Page 3, Session 1, Child & Family Center New Hire Training, AND UC Davis Training; AND Wraparound Training Plan, Page 22, Session 7, Family Safety and Crisis Plan; AND Wraparound Training Plan, Pages 5 & 6 Session 1, Program Coordinator, AND Program Manager.
c. The Facilitator ensures that in monthly CFTMs the team reviews the Family Safety & Crisis Plan to ensure they meet the individualized needs of the family, have interventions that are both proactive and reactive and culturally relevant for the family, and that they use their natural supports to assist them in their progress towards the family vision. The Supervisor reviews the plans within 24 business hours after they’re submitted in the EHR, and does coaching as needed on the clinical validity of the plan. POLICIES–Wraparound Training Plan, Page 22, Session 7, Family Safety and Crisis Plan.
6.3 Create a Commencement and Celebrate Success
a. The Facilitator leads the team in planning the family’s graduation from Wrap services, ensuring that the family voice and choice is utilized in choosing the date, time, and location for the celebration, while taking into account the family’s culture and values on how to best recognize their growth towards the family vision and goals. POLICIES–Wraparound Training Plan, Page 17, Session 4, Graduation.
b. The Facilitator supports the family throughout the transition process, including providing flex funds to pay for the graduation, ensuring all team members attend the graduation if possible, researching and linking the family to further natural and community supports, and ensuring there’s warm handoffs to these supports prior to the Wrap team terminating services. POLICIES–Wraparound Training Plan, Page 17, Session 4, Graduation.
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
a) Families are actively engaged in decision-making using voice and choice regarding local HFW implementation through multiple formal and informal feedback mechanisms. Wrap team members request feedback from family members throughout treatment regarding the services being provided in monthly CFTMs and weekly individual staff sessions with family members, such as the Parent Partner. Additional feedback is gathered from monthly quality checks, from Supervisors attending CFTMs, and the agency facilitates a survey annually for caregivers and clients. POLICIES–Wraparound Training Plan–Page 14, Session 4, Plan of Care; AND Clinical Quality Toolkit–Page 5, Quality Checks, Procedures, 1-3; AND Client Survey Protocol–Page 2, Administration, 1; AND Client Survey Protocol–Page 2, Other Programs & Services, Administration, 1; AND Wraparound Training Plan, Pages 5 & 6, Session 1, Program Coordinator, AND Program Manager; AND Wraparound Training Plan, Pages 19 & 20, Session 5, Wraparound Team Supervisions, AND Individual Supervisions.
b) Family feedback is gathered and used in decision making throughout treatment. Wrap team members use family feedback in the initial and ongoing monthly CFTMs to create individualized HFW plans. Feeback is also gathered from monthly quality checks, the annual agency caregivers/client survey, and the HFW Continuous Quality Improvement Plan. The information gathered is used to inform revisions to policies and procedures, improve staff training/coaching practices and improve quality of services provided. POLICIES–Wraparound Training Plan, Session 4, Page 12, CFTM; AND Wraparound Training Plan, Session 4, Page 14, Plan of Care; AND Clinical Quality Toolkit–Page 5, Quality Checks, Procedures, 1-3; AND Client Survey Protocol–Page 2, Administration, 1 and Page 2, Other Programs & Services, Administration, 1; AND HFW Continuous Quality Improvement Plan.
7.2 Community Leadership Team
a) The HFW Supervisor/Manager and/or an alternate attend all Community Leadership Team meetings. POLICIES – Wraparound Training Plan, Page 6, Session 1, Program Manager, AND Pages 5 & 6, Program Coordinator; AND FORMS–Job descriptions Program Coordinator II, AND Program Manager III.
7.3 Eligibility and Equal Access
a) Child & Family Center accepts all Wraparound clients referred to us by Los Angeles County Department of Mental Health, DCFS, County of Los Angeles Probation Department, and Post Adoption Services. We focus on strengths to have a no reject stance, tailoring services to meet their individualized needs. POLICIES–Service Delivery for Wraparound Services, Page 2, Procedures.
b) Supervisors closely monitor low caseloads to ensure staffing is adequate through a multidisciplinary team approach to support high intensity engagement and the level of services necessary to meet individualized families needs. This includes 24/7 crisis support which is on the Family Safety and Crisis Plan, and the staffing is dictated by the severity monitored through ratings in the CANS and PSC-35. The HFW team members rotate 24/7 crisis coverage and a supervisor is always available for support. POLICIES–Wraparound Training Plan, Page 6, Session 1, Our Team; AND Wraparound Training Plan, Page 7, Session 1, 24/7 On-Call Crisis Services; AND Service Delivery for Wraparound Services, Page 4, #11.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
a) Child & Family Center is a contracted provider for LA County DMH. Our budget and contracting processes prioritize program funding to ensure HFW youth and families receive timely, individualized services based on assessed strengths and needs. LA County DMH has allocated funding that is sufficient to support flexible service delivery, crisis response, care coordination, and access to flex funds that help promote stability, permanency, and well-being. POLICIES – Accounting and Administration Handbook, Page 15, IV Cost Principles; AND Child & Family Center Wrap funding FY26-27 MCA, FSP Child/TAY – High Fidelity Wrap Around.
b) Child & Family Center’s fiscal and funding structure are developed within LA County DMH contract requirements. The HFW program funds allocated are sufficient to support program quality and improvement, staff training, staff cohesion, open communication, and a clear sense of mission and compliance with HFW for all required roles and functions. POLICIES – Accounting and Administration Handbook, Page 15, IV Cost Principles; AND Child & Family Center Wrap funding FY26-27 MCA, FSP Child/TAY – High Fidelity Wrap Around.
c) The Child & Family Center Quality, Training and Compliance (QTC) Department performs data collection and analysis that is used monitor the HFW program’s quality and inform improvements to the program. QTC Department service costs are allocated to various agency programs that are supported by these functions. POLICIES – HFW CQI Plan 07.01.26, Page 4, CQI Review Process; AND Accounting and Administration Handbook, Page 15, IV Cost Principles, D. Necessary, Proper and Reasonable Allowable Costs, 3rd paragraph.
8.2 Equitable Funding Across System Partners
8.3 Cost Savings are Reinvested
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
a) LA County DMH Wraparound contract allocates a set amount the HFW program can use towards flex funds each fiscal year. POLICIES – Management of Program Funds, Page 8, Flex Funds, AND Accounting and Administration Handbook, Page 18, Flex Funds.
b)
1) When a HFW team submits a request to use flex funds, the HFW Supervisor/Manager reviews all flex funds requests within 24 hours for non-urgent requests and immediately for requests of an urgent nature. POLICIES – Management of Program Funds, Page 8, Flex Funds, 5 & 6.
2) Once a flex fund request is submitted, a supervisor reviews the request within 24 hours to ensure it meets all of the following criteria; adds value to the team mission and supports the individualized care plan, builds on family strengths, meets identified youth/family needs, culturally relevant, builds on natural support and/or community capacity, represents a good deal for the investment and includes a plan for sustainability. If all criteria are met, the flex fund is approved. POLICIES – Management of Program Funds, Page 8, Flex Funds, 5; AND Wraparound Training Plan, Page 26, Flex Funds, Process.
3) HFW team members are informed of denied flex fund requests and reason for denial. The team can submit additional information/documentation for reconsideration within one week. Appeals are reviewed by the HFW supervisor, and final decisions are communicated promptly. If the final determination is that the Flex Fund request is denied, the team will notify the family, provide the reason for the denial, and offer alternative resources and supports. POLICIES –Wraparound Training Plan, Page 26, Flex Funds, Flex fund appeal process.
8.5 Collaborative Oversight of Flex Funds
a) The HFW program maintains a transparent and collaborative process for the administration and oversight of flexible funds. All requests for flex funds are documented through a standardized review and approval process. The Flex Funds Request form captures the amount requested, intended purpose, and the recommendation of the HFW team. Funding decisions, whether approved or denied, are tracked to ensure accountability and consistency in the use of resources. Information regarding flex fund utilization and availability is communicated regularly with funders, providers, and program leadership to support shared oversight, informed decision-making, and alignment with the individualized needs identified through the Child and Family Team process. POLICIES – Management of Program Funds, Page 8, Flex Funds; AND Accounting and Administration Handbook, Page 18, Flex Funds; AND FORM–Flex Fund Request Form.
b) The HFW program utilizes a pooled flex fund approach to maximize responsiveness and equity in meeting the individualized needs of youth and families served. Flexible funds are monitored closely to ensure resources remain available to address emergent and unmet needs that support stabilization, placement preservation, permanency, and successful engagement in services. The pooled structure allows the program to allocate resources based on the unique circumstances of each family while maintaining fiscal oversight and accountability, and the agency tracks monthly spending to ensure equal resources for all families. This approach promotes timely access to supports and enhances the program’s ability to provide individualized, family-centered care across the population served. POLICIES – Wraparound Training Plan, Page 26, Flex Funds; AND Management of Program Funds, Page 8, Flex Funds; AND FORM–Flex Fund Totals by Client Report FY 2026.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
a) LA County DMH allocates flex funds for the Wraparound program. Child & Family Center has emergency funding through alternative unrestricted funding sources to ensure continuity of services and supports without disruption. POLICIES–Management of Program Funds, Page 10, Emergency Funds.
b) Historically, LA County DMH allocated funding has been sufficient to meet all flex fund requests. In the event that designated Wraparound flex funds are depleted; Child & Family Center maintains access to emergency funding through alternative unrestricted funding sources to ensure continuity of services and supports without disruption. POLICIES–Management of Program Funds, Page 10, Emergency Funds.
c) To ensure that funding source requirements do not restrict or prevent youth and families from accessing flex funds necessary to meet their individualized needs, Child & Family Center emergency funding is used to ensure flex funds remain accessible, timely, and responsive to a family’s needs. POLICIES–Management of Program Funds, Page 10, Emergency Funds.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
a) Child & Family Center’s (C&FC) Quality, Training and Compliance (QTC) Department gathers demographic data. Information collected semi annually includes race/ethnicity, culture, spiritual beliefs, and primary language. The demographic information obtained is used to assure that diverse staff who are representative of the populations served are recruited for available positions. C&FC also has 2 Spanish-speaking Wrap teams. POLICIES–Diversity, Equity Inclusion and Belonging Program & Plan, Page 5, Assessment of Needs, AND Page 6, Workforce; AND Recruitment, Hiring, Promotion or Transfer, and Staff Requirements, Page 4, Recruitment; AND Wraparound Training Plan, Page 6, Session 1, Our Team.
b) C&FC uses culturally responsive practices to ensure that the diverse needs of individual families served are met and that treatment is provided in a non-discriminatory manner in all programs and services. If the program is unable to recruit or hire staff who reflect a family’s cultural, racial, or linguistic background, we implement alternative strategies to ensure families experience meaningful cultural representation and responsiveness. The Facilitator uses the Strengths, Needs, and Culture Discovery form to help identify the client’s formal and natural supports (including the Tribe if an Indian client), the team asks questions of the family and receives training if needed, documents this in a progress note, and engages the support partners from the family’s individualized network through outreach and warm handoffs to ensure appropriate representation on the team. POLICIES– Diversity, Equity Inclusion and Belonging Program & Plan, Page 3, Culturally and Linguistically Appropriate Services; AND Wraparound Training Plan, Page 10, Session 3, Enrollment Meeting; AND Wraparound Training Plan, Page 15, Session 4, Cultural Considerations; AND FORM–Strengths, Needs and Cultural Discovery Sheet.
c) Child & Family Center promotes linguistic capacity through language assistance services such as providing bilingual staff to respond to the languages that reflect the population served and assigning the client to a program staff who speaks the client’s preferred language. If there is no program staff available for the language that is preferred, the staff will arrange for an outside interpreter. Child & Family Center contracts with TransPerfect to provide interpretation services when needed. POLICIES – Diversity, Equity Inclusion and Belonging Program & Plan, Page 10, Language Needs; AND Language Interpretation and Translation Services, Page 3, Identification of the Client’s Language of Preference, AND Page 5, Telephonic and Video Remote Language Interpretation.
9.2 Tribally Responsive Workforce
a) All HFW staff take training on tribal sovereignty, traditions, and values. All C&FC staff receive training in cultural competency, cultural humility, and diversity during new hire orientation and annually. Staff are also encouraged to attend outside trainings on diversity and cultural competency, and to learn about cultural and diversity-related issues important to families served. POLICIES–Wraparound Training Plan, Page 20, Session 5, Wraparound Trainings; AND Diversity, Equity Inclusion and Belonging Program & Plan, Page 7, Workforce Training.
b) HFW teams begin all services by building partnerships beginning with the enrollment meeting, as the Facilitator uses the Strengths, Needs, and Culture Discovery form to identify the client’s formal and natural supports (including the Tribe if an Indian child), and engages tribal representatives from the family’s network through outreach to ensure appropriate representation on the team. These natural supports are included in monthly CFTMs, involved in the treatment planning and action steps towards the family goals, and the team encourages participation in tribal traditions per the family’s voice and choice. POLICIES–Wraparound Training Plan, Page 10, Session 3, Enrollment Meeting; AND Wraparound Training Plan, Pages 12 & 13, Session 4, Initial CFTM; AND Wraparound Training Plan, Page 14, Session 4, The Plan of Care; AND FORM–Strengths, Needs and Cultural Discovery Sheet.
9.3 Flexible and Creative Work Environment
a) Child & Family Center’s Quality, Training and Compliance (QTC) Department ensures that collected data is presented to direct care staff, supervisors, and program leadership on a regular basis to help identify areas of need including staff training opportunities. The High Fidelity Wraparound Data Report is refreshed on a monthly basis by the Data Analyst and provided to HFW program leadership. Leadership reviews and shares key findings with staff on a monthly basis. Based on the data received, if a training need is identified, leadership decides who shall attend and the type of training. Training may be internal or external and may include coaching, shadowing, classroom, virtual, or independent study. Staff are also engaged in quality improvement discussions within weekly team supervisions to best address the individualized needs of each family. POLICIES–HFW Continuous Quality Improvement Plan, Page 4, CQI Review Process; AND Wraparound Training Plan, Pages 19 & 20, Session 5, Team Supervisions, AND Individual Supervisions.
b) HFW supervisors promote team communication with the family and natural supports, collaboration and cohesion in multiple ways and in varied settings. Wrap Team Department Meetings are held twice a month and include opportunities for staff to share strengths-based work with client care experiences, and positive work of their fellow team members, which help guide future individualized action plans. Wraparound supervisors plan regular team building activities for staff, minimally once a quarter. POLICIES–Wraparound Training Plan, Page 19, Session 5, Wraparound Department Meetings; AND Wraparound Training Plan, Page 20, Session 5, Wraparound Trainings; AND Wraparound Training Plan, Page 21, Session 6, Team Building; AND FORM–Wraparound Staff Meeting Minutes Template, Team Building Activity section.
c) Supervisors facilitate every-other-week department meetings where staff are encouraged to communicate program-related thoughts, ideas, and concerns to support family voice and choice toward their goals. POLICIES–Wraparound Training Plan, Page 19, Session 5, Wraparound Department Meetings; AND Wraparound Training Plan, Page 20, Session 5, Wraparound Trainings.
d) Supervisors promote HFW philosophy in every-other-week Department Meetings, and weekly supervisions, coaching on engagement using the family’s strengths, creating a plan of care that reflects the family’s vision, and action steps that involve formal and informal supports towards graduation. POLICIES–Wraparound Training Plan, Page 19, Session 5, Wraparound Department Meetings; AND Wraparound Training Plan, Page 20, Session 5, Wraparound Trainings; AND Wraparound Training Plan, Pages 19 & 20, Session 5, Team Supervisions, AND Individual Supervisions.
9.4 Hiring, Performance Evaluation, and Job Descriptions
a) The Child & Family Center HFW program has dedicated positions that met each HFW role. We currently employ Parent Partners, Child and Family Specialists (Family Specialists), and HFW Facilitators. The Program Coordinator position combines the HFW Supervisor and Fidelity Coach roles, while the Program Manager position combines the HFW Manager and Clinical Supervisor roles. We will be recruiting for the Peer Support Specialist (Youth Partner) position. Each position has a job description with clearly defined role descriptions and responsibilities. FORMS–job descriptions for: Parent Partner, Child and Family Specialist (Family Specialist), Peer Support Specialist (Youth Partner), HFW Facilitator, Program Coordinator II (HFW Supervisor/Fidelity Coach) and Program Manager III (HFW Manager/Clinical Supervisor), and Clinician.
b) The Child & Family Center HFW program job descriptions include the job purpose, essential functions and qualities that are specific to each role. FORMS–job descriptions for: Parent Partner, Child and Family Specialist (Family Specialists), Peer Support Specialist (Youth Partner), HFW Facilitator, Program Coordinator II (HFW Supervisor/Fidelity Coach), and Program Manager III (HFW Manager/Clinical Supervisor), and Clinician.
c) Each HFW program job description includes qualities, competencies and experience that are specific to each HFW role to help hiring managers identify applicants who would best fit each HFW position. FORMS–job descriptions for: Parent Partner, Child and Family Specialist (Family Specialists), Peer Support Specialist (Youth Partner), HFW Facilitator, Program Coordinator II (HFW Supervisor/Fidelity Coach), Program Manager III (HFW Manager/Clinical Supervisor), and Clinician.
d) Child & Family Center is committed to recruiting, hiring, and promoting the most qualified candidates through an equitable and inclusive process. All applicants for posted positions are carefully considered based on their qualifications, experience, attitude, and ability to successfully perform the responsibilities of the role. During the interview process, open-ended questions are used to encourage candidates to share their experiences, perspectives, and skills. This approach helps hiring managers assess how well each candidate aligns with HFW’s strength-based, family-centered, culturally responsive, and team-oriented values and practices. POLICIES–Recruitment, Hiring, Promotion or Transfer, and Staff Requirements, Page 3, POLICY, AND Page 4, Recruitment #6; AND Facilitator Interview Questions.
e) All employees review and sign their job description on date of hire. Supervisors review the HFW employee role and expectations during new hire training, and coaching in weekly supervisions. POLICIES—Employee Performance and Compensation, Page 3, POLICY, #1; AND Wraparound Training Plan, Pages 3-6, Session 1, Team Member Roles; AND Wraparound Training Plan, Pages 19 & 20, Team Supervisions, AND Individual Supervisions.
9.5 Workforce Stability
a) Child & Family Center conducts annual compensation benchmarking against comparable nonprofit behavioral health organizations in Los Angeles County to ensure wages remain competitive and responsive to the regional cost of living. Differentials are provided for Spanish-speaking staff to ensure staffing appropriately matches the population served. Differentials are also provided for Wraparound staff due to the on-call demand and nature of intensive services. The organization also considers equity adjustments and targeted increases for hard-to-fill roles to remain competitive. POLICIES—Employee Performance and Compensation, Page 3, Policy, 2, AND Page 4, Procedures, Assignment & Tracking, 2; AND Language Translation and Interpretation Services 08.26.25, Page 4, Provision of Services in a Language Other than English, 2.
b) The Agency prioritizes manageable workloads to support quality service delivery and staff well-being. Caseload guidelines are established by program and are regularly reviewed based on number of service hours provided weekly. Supervisors monitor workload capacity, acuity levels, administrative demands, adjusting as needed to prevent burnout, and monitor caseloads to ensure staffing is adequate to support the level of services necessary to meet families needs, including 24/7 crisis support. POLICIES–Wraparound Training Plan, Page 6, Session 1, Our Team; AND Wraparound Training Plan, Page 7, Session 1, 24/7 On-Call Crisis Services.
c) Child & Family Center maintains transparent and inclusive career pathways that are communicated through job descriptions, internal recruitment processes, and ongoing performance and development conversations. Advancement opportunities are accessible to all staff, including those with lived experience, and minimum qualifications are evaluated to ensure they are not unnecessarily restrictive. The organization actively promotes from within and supports staff through training, conferences, and professional development opportunities. POLICIES—Recruitment, Hiring, Promotion or Transfer, and Staff Requirements, Page 3, Policy, 1st paragraph; AND Page 5, Promotion or Transfer, Promotion or Transfer within Same or Different Department (Existing Position), 1, 2; AND Employee Professional Development: Training and Licensure, Page 2, Policy 1.
d) The organization provides multiple avenues for professional and financial growth that do not require a formal change in position. These include annual merit-based salary increases, stipends for taking on additional responsibilities (such as leading projects, facilitating groups or training, or participating in committees), and participation in leadership development initiatives including the Mentorship Program. This approach allows staff to expand their skills, contribute at a higher level, and increase earnings while maintaining continuity in their roles. POLICIES—Employee Performance and Compensation, Pages 3 & 4, Policy, 5, 6; AND Additional Job Duties; AND Mentorship Program Description.
9.6 High Fidelity Training Plan
a) HFW staff will take the UC Davis Wraparound 101: Foundations of Fidelity training as soon as they can be enrolled as part of onboarding at C&FC, they will have an 8-session Wraparound training as part of C&FC’s second week of new hire training, and then will have ongoing training in Wrap department meetings on Wrap fidelity. POLICIES–Wraparound Training Plan–Page 20, Session 5, Wraparound Trainings; AND Wraparound Training Plan–Pages 19, Session 5, Wraparound Department Meetings; AND FORM–Wraparound Training Plan (the entire document is used in the 2nd week of new hire training).
b) HFW staff will have role specific coaching to support staff in implementing individualized plans of care, and this training will occur in Wrap department meetings and in weekly individual supervisions on Wrap fidelity. POLICIES–Wraparound Training Plan–Page 20, Session 5, Wrap Trainings; AND Wraparound Training Plan–Page 19, Session 5, Wraparound Department Meetings; AND Wraparound Training Plan–Pages 19 & 20, Session 5, Wrap Individual Supervisions; AND FORMS–Wraparound Training Plan (the entire document is used in the second week of new hire training).
c) HFW staff will receive annual booster trainings on Wraparound and their specific roles. This training will occur in Wrap department meetings and in weekly individual supervisions on Wrap fidelity. POLICIES–Wraparound Training Plan–Page 20, Session 5, Wrap Trainings; AND Wraparound Training Plan–Page 19, Session 5, Wraparound Department Meetings; AND Wraparound Training Plan–Pages 19 & 20, Session 5, Wrap Individual Supervisions.
d) HFW supervisors/managers will have role specific coaching to support staff in implementing individualized plans of care, and this training will occur in Wrap department meetings and in weekly individual supervisions on Wrap fidelity. POLICIES–Wraparound Training Plan–Page 20, Session 5, Wraparound Trainings; AND Wraparound Training Plan–Page 19, Session 5, Wraparound Department Meetings; AND Wraparound Training Plan–Pages 19 & 20, Session 5, Wrap Individual Supervisions; AND FORMS–Wraparound Training Plan (the entire document is used in the second week of new hire training).
e) All HFW staff take a training on ICWA and tribal sovereignty. In addition, staff are also encouraged to attend outside trainings on diversity and cultural competency, and to learn about cultural and diversity-related issues important to persons served. POLICIES–Wraparound Training Plan–Page 20, Session 5, Wraparound Trainings; AND Diversity, Equity Inclusion and Belonging Program & Plan, Page 7, Workforce Training.
9.7 Community-based Training Program
a) Child & Family Center send staff to external training providers, such as the Parent Partner Training Academy and UC Davis RCFFP. These trainings incorporate youth, family members, and parent partners with lived experience into their training. Staff are encouraged to share information and resources learned in these trainings that incorporate those with lived experience with staff and supervisors in Department/Team meetings and Individual Supervision. POLICIES–Wraparound Training Plan–Page 20, Session 5, Wraparound Trainings.
b) Child & Family Center does not offer formal wrap trainings for community partners, but the HFW teams work to education all community partners (school personnel, after-school program staff, relatives, friends, neighbors, coaches, church/spiritual leaders, and other agencies/service providers) who become part of the HFW team, by ensuring they understand the HFW process, including the 10 principles and 4 phases of Wrap. Child & Family Center refers community partners who want more formalized HFW training to external Wraparound training providers, such as UC Davis RCFFP and LA County DMH. POLICIES–Wraparound Training Plan, Page 9, Session 3, Enrollment Process; AND Wraparound Training Plan, Page 10, Session 3, Enrollment Meeting.
9.8 Coaching and Supervision
a) All HFW staff take the UC Davis Wraparound 101: Foundations of Fidelity training as soon as they can be enrolled as part of onboarding at C&FC, and they have an 8-session Wraparound training as part of C&FC’s second week of new hire training that covers HFW principles, phases and activities, and the effective use of flex funds. Staff will have case-specific coaching to support staff in implementing individualized plans of care, and this training will occur in Wrap department meetings and in weekly individual supervisions on Wrap fidelity. POLICIES–Wraparound Training Plan–Page 20, Session 5, Wraparound Trainings; AND Wraparound Training Plan–Page 19, Session 5, Wraparound Department Meetings; AND Wraparound Training Plan–Pages 19 & 20, Session 5, Wrap Individual Supervisions; AND FORMS–Wraparound Training Plan (the entire document is used in the second week of new hire training).
b) A supervisor is available to staff 24/7 for supervision or coaching. POLICIES–Wraparound Training Plan, Page 7, Session 1, 24/7 On-Call Crisis Services; AND Wraparound Training Plan, Page 6, Session 1, Program Manager; AND Wraparound Training Plan, Pages 5 & 6, Session 1, Program Coordinator; AND Service Delivery for Wraparound Services, Page 4, #11.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
a. C&FC ensures that collected data is presented to direct care staff, supervisors, and program leadership on a monthly basis to identify areas of need including staff training opportunities. The HFW Data Report is refreshed on a monthly basis by the Data Analyst and provided to HFW program leadership, who reviews and shares key findings with staff. Based on the data received, if a training need is identified, leadership decides who shall attend and the type of training (i.e. internal or external, coaching, in supervision, shadowing, classroom, virtual, or independent study). POLICIES–HFW Continuous Quality Improvement Plan, page 4-5, CQI Review Process.
b. C&FC HFW leadership reviews the monthly HFW Data Report to determine progress toward CQI Plan goals. If goals are lacking progress, interventions for individual families are identified and implemented, and results after implementation are reviewed for effectiveness. POLICIES–HFW Continuous Quality Improvement Plan, page 4-5, CQI Review Process; AND HFW Continuous Quality Improvement Plan, page 5, CQI Plan Evaluation; AND Wraparound Training Plan, pages 19 & 20, Session 5, Team Supervisions, AND Individual Supervisions.
c. C&FC utilizes data from the HFW Continuous Quality Improvement Plan to identify and share barriers and challenges encountered during the implementation of HFW to the Community Leadership Team. C&FC HFW leadership participates in opportunities to collaborate at the system level to help improve HFW implementation. POLICIES–HFW Continuous Quality Improvement Plan, page 4-5, CQI Review Process.
Fidelity Indicators
1.1 Timely Engagement and Planning
Olive Crest ensures timely engagement and planning through clearly defined timelines embedded in policy, staff training, and system tracking within OLIVER.
Upon referral, a Wraparound team is assigned within 24 hours, and initial contact with the family is attempted within 48 hours, ensuring engagement well within the required 10-day standard.
The first face-to-face meeting is scheduled promptly, and all engagement activities are tracked in OLIVER, allowing supervisors to monitor timeliness and follow up on any delays. Staff are trained to use flexible and persistent engagement strategies, including alternative outreach methods when families are difficult to reach.
The initial Plan of Care is developed during the first Child and Family Team (CFT) meeting and is completed within 30 days of the first face-to-face contact.
CFT meetings are held at minimum every 30–45 days to review progress, assess needs, and adjust strategies. Plans of Care are formally updated and redistributed at least every 90 days, or more frequently based on family need.
Supervisors utilize OLIVER and fidelity tools (e.g., DART) to monitor compliance with timelines and provide ongoing feedback through supervision and CQI processes. Timeliness data is reviewed regularly to identify trends, inform coaching, and improve practice.
Supporting Documentation
a. Wraparound Enrollment Procedures (310.02) – pgs. 1–4, referral, intake, engagement, and initial family contact expectations; FirstF2FPacket_English.pdf – pgs. 1–3, initial engagement and first face-to-face contact process; County of Orange Wraparound Contract – pg. 23 section 5.4.1, engagement and timely service initiation requirements; Riverside DPSS Wraparound Services Executed Contract – pgs. 4–6, referral response and engagement expectations.
b. Wraparound Enrollment Procedures (310.02) – pg. 2 section 3.3, timelines related to Plan of Care completion and service initiation; Wraparound Plan of Care Policy (310.04) – pgs. 1–3, development and implementation of individualized Plans of Care; IE_Wrap POC Template 2026 – pgs. 1–5, individualized planning structure and required planning components; Riverside DPSS Wraparound Services Executed Contract – pg. 32, Plan of Care requirements and documentation timelines.
c. County of Orange Wraparound Contract – pg. 23 section 5.4.2, Child and Family Team meeting and review expectations; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, frequency and purpose of Child and Family Team meetings and collaborative review of Plans of Care; IE_Wrap POC Template 2026 – pgs. 3–5, review of goals, strategies, action items, and progress updates during team meetings.
d. Wraparound Plan of Care Policy (310.04) – pgs. 2–3 section 5.0, ongoing updating, review, and distribution of Plans of Care; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, collaborative review and communication of updated plans during Child and Family Team meetings; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, centralized documentation, updating, sharing, and storage of Plans of Care and meeting records across assigned team members ; Riverside DPSS Wraparound Services Executed Contract – pg. 32, documentation and transition planning expectations.
e. Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, review, coaching, and performance feedback expectations; Olive Crest TOM Experience for Learning Community – pgs. 1–5, fidelity review, supervision debriefing, coaching feedback loops, and CQI monitoring processes ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, responsibilities related to supervision, coaching, documentation review, CQI, and implementation oversight ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, reporting, supervision review, service monitoring, and CQI tracking processes supporting accountability and timely documentation .
f. OC Wrap Training Plan – pgs. 1–2, training related to engagement, outreach, collaboration, and family-centered practice; FirstF2FPacket_English.pdf – pgs. 1–2, strengths discovery and engagement strategies used during initial family contact; Wraparound Enrollment Procedures (310.02) – pgs. 1–4, engagement expectations and family-centered outreach processes; Facilitator: Role and Functions – pg. 1, facilitators engage families using individualized approaches and coordinate outreach and engagement activities based on family needs and barriers ; Parent Partner: Role and Functions – pg. 1, parent partners assist with engagement, advocacy, relationship-building, and reducing barriers to participation .
1.2 Led by Youth and Families
Olive Crest ensures that the Wraparound process is led by youth and family voice and choice, with their perspectives serving as the foundation for all planning and decision-making.
During the Engagement Phase, staff intentionally elicit the family’s values, culture, strengths, preferences, and lived experience through structured conversations and ongoing relationship-building. This information is used to develop the Family Vision and Team Mission, which guide all strategies and supports.
The Plan of Care is developed collaboratively during Child and Family Team (CFT) meetings, where youth and family voice drive priority setting, strategy selection, and decision-making.
Family culture, identity, and natural supports are actively incorporated into planning and documented within the case record. Teams also ensure inclusion of culturally relevant supports and, when applicable, Tribal representatives as equal partners in the process.
Supervisors and coaches reinforce this practice by reviewing documentation, observing team meetings, and providing feedback to staff to strengthen family-driven facilitation and engagement.
Family feedback is routinely collected through formal and informal mechanisms, including participation in team meetings, ongoing check-ins, and fidelity tools such as the Team Observation Measure (TOM). This feedback is used to inform supervision, improve practice, and ensure services remain aligned with family preferences and needs.
Supporting Documentation
a. Wraparound Plan of Care Policy (310.04) – pgs. 1–3, family voice, strengths, vision, mission, and individualized planning process; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, family participation and shared team decision-making expectations; Wraparound Enrollment Procedures (310.02) – pgs. 2–4, engagement and information gathering process used to elicit family voice and preferences; FirstF2FPacket_English.pdf – pgs. 1–3, engagement and strengths discovery process.
b. Wraparound Plan of Care Policy (310.04) – pgs. 2–4, documentation of family strengths, culture, preferences, and individualized supports; Wraparound Enrollment Procedures (310.02) – pgs. 2–4, engagement and information gathering process used to elicit family voice and preferences; FirstF2FPacket_English.pdf – pgs. 1–2, strengths discovery and family engagement process. Interagency Family Plan of Care Review – pgs. 1–3, indicators related to culturally relevant planning, functional strengths, multiple perspectives, and individualized plans .
c. Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, expectations regarding Child and Family Team meeting facilitation and documentation review; A DMH MH122219 Contract.pdf – pg. 33, Quality Improvement requirements. Olive Crest TOM Experience for Learning Community.pdf – pg. 3, TOM observation process including scheduling observations, scoring, feedback timelines, supervision debriefing, and action items ; Interagency Family Plan of Care Review – pgs. 1–4, structured review process for evaluating family-centered language, culturally relevant planning, individualized planning, underlying needs, collaboration, functional strengths, and outcome-based planning ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 2–4, supervisors utilize data to monitor service delivery, identify gaps, guide reflective supervision, coaching, and CQI review .
d. Feedback from families is routinely elicited to share their experience of the Wraparound process: A DMH MH122219 Contract.pdf – pg. 33, Quality Improvement requirements; fidelity monitoring and implementation requirements; Wraparound Plan of Care Policy (310.04) – pg. 3 section 5.0, ongoing review and update process.
1.3 Strength-Based
Olive Crest ensures that the Wraparound process is led by youth and family voice and choice, with their perspectives serving as the foundation for all planning and decision-making.
During the Engagement Phase, staff intentionally elicit the family’s values, culture, strengths, preferences, and lived experience through structured conversations and ongoing relationship-building. This information is used to develop the Family Vision and Team Mission, which guide all strategies and supports.
The Plan of Care is developed collaboratively during Child and Family Team (CFT) meetings, where youth and family voice drive priority setting, strategy selection, and decision-making.
Family culture, identity, and natural supports are actively incorporated into planning and documented within the case record. Teams also ensure inclusion of culturally relevant supports and, when applicable, Tribal representatives as equal partners in the process.
Supervisors and coaches reinforce this practice by reviewing documentation, observing team meetings, and providing feedback to staff to strengthen family-driven facilitation and engagement.
Family feedback is routinely collected through formal and informal mechanisms, including participation in team meetings, ongoing check-ins, and fidelity tools such as the Team Observation Measure (TOM). This feedback is used to inform supervision, improve practice, and ensure services remain aligned with family preferences and needs.
Supporting Documentation
a. Wraparound Plan of Care Policy (310.04) – pgs. 1–3, information gathering, strengths, culture, values, potential resources, Family Vision/Team Mission, and Plan of Care development; Wraparound Family Team Development Procedures (310.11) – pgs. 1–2, identification of formal, informal, tribal, natural, and community supports; IE_Wrap POC Template 2026 – pg. 3, Strengths & Needs Summary including youth strengths, family strengths, team member strengths/resources, and life domains; Strengths-Needs Summary Template – pgs. 1–2, family vision, family story, strengths, needs, and review updates; Riverside DPSS Wraparound Services Executed Contract – pg. 4, definition of CFT and case planning including strengths, needs, community involvement, team meetings, and transition planning.
b. Wraparound Outcome Reporting Policy (310.03) – pgs. 1–2, completion and review of CANS/IP-CANS within required intervals and use of outcome measures to assess progress; Wraparound Plan of Care Policy (310.04) – pgs. 2–3, identification of strengths, interests, skills, values, cultural considerations, expertise, capabilities, unmet needs, and Plan of Care development; IE_Wrap POC Template 2026 – pg. 5, CANS Item with Rating(s), need statement, goal/outcome statement, selected strategies, action items, and related strengths; Wraparound Clinician Role and Functions – pg. 1, use of CANS for prioritization, assessment of needs and strengths, and tracking progress.
c. Family Preservation Personnel Policy (300.09) – pgs. 1–2, staff knowledge and skills related to identifying needs, strengths, protective factors, family voice and choice, community resources, team-based planning, outcome measurement, and supervision; Staff Supervision Policy (402.2) – pg. 1, supervisors provide consultation, support, review of work practices, problem-solving, and reinforcement of effective service delivery; OC Wrap Training Plan – pgs. 1–2, initial and ongoing Wraparound training including Core Training, Facilitator Training, Meeting Facilitation Training, Wraparound Institute, and role-specific professional development; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, field observation, coaching, documentation review, role play, feedback, CQI-informed skill development, and use of CANS, WFI-EZ, and TOMS; County of Orange Wraparound Contract – Attachment A, Section 18 Training, pgs. 76–79.
d. Wraparound Outcome Reporting Policy (310.03) – pgs. 1–2, family feedback, family satisfaction surveys, WFI-EZ, outcome measures, quality improvement reviews, and use of outcome data for CQI; WFI-EZ Caregiver Form – pgs. 1–4, caregiver survey regarding family experience in Wraparound; TOM 2.0 Form – pg. 3, “Driven by Strengths and Families” indicators assessing parent/caregiver and youth contribution, functional strengths, and solution-focused practice; Olive Crest TOM Experience for Learning Community – pgs. 1–5, TOM implementation, coaching feedback loops, supervision debriefing, and program improvement; OLIVER Data System Description – pgs. 3–4, use of engagement data, service trends, supervision review, coaching, and CQI at individual, program, and system levels; LA DMH MH122219 Contract – Quality Assurance/Quality Improvement requirements.
1.4 Needs Driven
Olive Crest ensures that all Wraparound services are needs-driven, with a clear focus on identifying and addressing the underlying needs of youth and families rather than behaviors alone.
During the Engagement and Planning phases, staff gather information to identify strengths and underlying needs through structured conversations and formal assessment tools, including the IP-CANS.
Facilitators support the team in developing clear needs statements that reflect the underlying reasons for behaviors, which are then prioritized before goals and strategies are developed within the Plan of Care.
The Plan of Care is structured around these prioritized needs, ensuring that all interventions, supports, and action steps are directly linked to meeting those needs. Progress toward needs is reviewed regularly in Child and Family Team (CFT) meetings and adjusted as necessary.
Staff receive ongoing training and coaching on needs-based planning, including how to differentiate between behaviors and underlying needs, and how to develop effective needs statements. Supervisors reinforce this practice through documentation review, observation, and reflective supervision.
Transition planning occurs when the team, including the youth and family, determines that priority needs have been sufficiently met, and natural supports are in place to sustain progress.
Supporting Documentation
a. Wraparound Plan of Care Policy (310.04) – pgs. 1–3, development of individualized Plans of Care based on prioritized underlying needs before development of goals and strategies; IE_Wrap POC Template 2026 – pg. 5, identification of underlying need statements prior to goals, strategies, and action items; Strengths-Needs Summary Template – pgs. 1–2, documentation of family story, strengths, needs, barriers, and individualized planning; Interagency Family Plan of Care Review – pg. 2, review indicators requiring needs statements to reflect underlying reasons, root causes, and functional needs rather than services or behaviors ; Facilitator: Role and Functions – pg. 1, prioritization of family needs and preferences to guide planning and strategy development .
b. Family Preservation Personnel Policy (300.09) – pgs. 1–2, staff knowledge and skills related to identifying needs, strengths, protective factors, and individualized planning; Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, support, coaching, and review of work practices; OC Wrap Training Plan – pgs. 1–2, initial and ongoing training requirements related to Wraparound planning, facilitation, and fidelity practice; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, field-based coaching, role play, documentation review, and CQI-informed skill development related to high-fidelity Wraparound practice ; Interagency Family Plan of Care Review – pg. 2, structured review indicators differentiating behavioral/service-focused statements from underlying need statements ; Olive Crest TOM Experience for Learning Community – pgs. 1–5, use of TOM observations, coaching feedback loops, supervision debriefing, and fidelity improvement strategies .
c. Wraparound Outcome Reporting Policy (310.03) – pgs. 1–2, completion and review of IP-CANS/CANS to support assessment, outcome tracking, and service planning; Wraparound Clinician Role and Functions – pg. 1, use of CANS for assessment, prioritization of needs and strengths, and tracking of progress ; IE_Wrap POC Template 2026 – pg. 5, linkage between CANS items, identified needs, goals, and selected strategies; Wraparound Plan of Care Policy (310.04) – pgs. 2–3, integration of individualized needs into goals, interventions, and action planning.
d. Wraparound Transition Policy (310.18) – pgs. 1–2, transition planning process based on family readiness, achievement of goals, and team agreement regarding stabilization of needs; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, ongoing review of progress, team planning, and transition discussions during Child and Family Team meetings; Riverside DPSS Wraparound Services Executed Contract – pg. 32, discharge and transition planning expectations; Facilitator: Role and Functions – pg. 1, facilitators introduce and plan for transitions from the beginning of care and revise plans based on team learning and progress
1.5 Individualized
Olive Crest ensures that Wraparound services are highly individualized, with each Plan of Care tailored to reflect the unique strengths, needs, culture, values, and preferences of the youth and family.
The Plan of Care is developed through a collaborative team process and is designed to be flexible, allowing for creative and individualized strategies that align with the family’s vision and priorities.
Facilitators guide teams to identify and incorporate natural supports, community resources, and culturally relevant strategies, ensuring that plans are not standardized but instead reflect the specific context of each family.
Documentation templates support flexibility and individualized planning, allowing teams to develop customized goals, strategies, and action steps based on identified needs and strengths. Plans are routinely reviewed during Child and Family Team (CFT) meetings to ensure strategies remain relevant, effective, and aligned with the family’s evolving needs.
Staff receive ongoing training and coaching in individualized service delivery, including how to design creative, strength-based interventions and avoid one-size-fits-all approaches. Supervisors reinforce this practice through documentation review, observation, and reflective supervision.
Family feedback is routinely gathered through team meetings, ongoing engagement, and fidelity tools such as the Team Observation Measure (TOM), and is used to ensure services remain responsive and individualized while informing continuous quality improvement efforts.
Supporting Documentation
a. Wraparound Plan of Care Policy (310.04) – pgs. 1–3, individualized planning process based on family strengths, needs, culture, values, preferences, and prioritized outcomes; IE_Wrap POC Template 2026 – pgs. 1–5, customizable planning structure including individualized strengths, needs, goals, strategies, action items, cultural considerations, and team member responsibilities; Strengths-Needs Summary Template – pgs. 1–2, individualized family story, vision, strengths, barriers, and needs identification; Interagency Family Plan of Care Review – pgs. 1–3, review indicators assessing individualized planning, culturally relevant planning, family language, multiple perspectives, and customized strategies ; Wraparound Flex Funds Updates – pg. 1, individualized expenditures aligned with identified family goals and Plans of Care .
b. Family Preservation Personnel Policy (300.09) – pgs. 1–2, staff competencies related to individualized planning, family voice and choice, strengths-based practice, and community resource integration; Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, coaching, problem-solving, and reinforcement of effective service delivery practices; OC Wrap Training Plan – pgs. 1–2, ongoing Wraparound training and professional development requirements; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, field-based coaching, documentation review, modeling, role play, and CQI-informed staff development ; Olive Crest TOM Experience for Learning Community – pgs. 1–5, use of TOM observations, coaching feedback loops, and supervision debriefing to improve individualized practice and fidelity .
c. Facilitator: Role and Functions – pg. 1, facilitators coordinate individualized plans based on family priorities, strengths, culture, interests, and preferences and revise plans based on team learning and progress ; Staff Supervision Policy (402.2) – pg. 1, ongoing supervision, consultation, and support for direct service staff; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, individualized coaching and skill development related to high-fidelity Wraparound facilitation ; OC Wrap Training Plan – pgs. 1–2, facilitator-specific training and ongoing Wraparound professional development; Olive Crest TOM Experience for Learning Community – pg. 3, TOM observation, scoring, coaching feedback, supervision debriefing, and action planning process .
d. Interagency Family Plan of Care Review – pgs. 1–4, structured review indicators assessing individualized plans, culturally relevant planning, functional strengths, underlying needs, collaboration with natural/community supports, outcome-based planning, and integration of community resources throughout the Plan of Care ; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, ongoing review and updating of team plans, strategies, supports, and action items during Child and Family Team meetings; Wraparound Plan of Care Policy (310.04) – pgs. 2–3, ongoing review and modification of goals, strategies, outcomes, and supports; Olive Crest TOM Experience for Learning Community – pg. 5, improvement in outcome-based planning, use of natural supports, teamwork, and skilled facilitation through fidelity review processes .
e. Wraparound Outcome Reporting Policy (310.03) – pgs. 1–2 use of family feedback, satisfaction surveys, WFI-EZ, and outcome measures to support CQI and program improvement; WFI-EZ Caregiver Form – pgs. 1–4, caregiver feedback regarding family experience and Wraparound process; TOM 2.0 Form – pg. 3, fidelity indicators related to family-driven, strengths-based, and individualized practice; Olive Crest TOM Experience for Learning Community – pgs. 1–5, use of TOM observations, coaching feedback loops, supervision debriefing, and fidelity outcome review to improve practice and family experience ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, use of engagement trends, supervision review, coaching, outcome monitoring, and CQI review processes at the individual, program, and system level ; LA DMH MH122219 Contract – Quality Assurance/Quality Improvement requirements.
1.6 Use of Natural and Community Based Supports
Olive Crest prioritizes the identification, engagement, and integration of natural and community-based supports as essential members of the Wraparound team.
During the Engagement Phase, staff work collaboratively with families to identify natural supports through structured tools and conversations, including the Strengths, Needs, and Culture Discovery and initial face-to-face engagement process.
Natural supports—such as extended family members, friends, and community connections—are documented and incorporated into the Child and Family Team (CFT) and are actively engaged in planning and implementation.
CFT meeting structures explicitly prompt teams to identify and utilize both formal and informal supports, ensuring that strategies are community-based and sustainable over time.
Plans of Care prioritize the use of natural supports in action steps and interventions, with the goal of reducing reliance on formal services and strengthening long-term support systems within the family’s community.
Staff receive ongoing training and coaching on how to identify, engage, and integrate natural supports into the Wraparound process. Supervisors reinforce this practice through documentation review, fidelity observation (TOM), and reflective supervision.
Family feedback regarding the inclusion and effectiveness of natural supports is routinely gathered through team meetings and formal feedback mechanisms such as the Wrap Line, allowing families to share their experience and inform continuous quality improvement.
Supporting Documentation
a. Wraparound Family Team Development Procedures (310.11) – pgs. 1–2, identification and engagement of formal, informal, tribal, natural, and community supports during team development; Ecomap – pg. 1, mapping of family relationships, supports, and community connections; Connections & Support Map – pg. 1, identification of supportive individuals and community resources connected to the family; IE_Wrap POC Template 2026 – pgs. 1–5, documentation of natural supports, team member strengths/resources, and individualized planning; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–2, tracking of assigned team members, natural supports, Plans of Care, and ongoing service coordination .
b. Family Preservation Personnel Policy (300.09) – pgs. 1–2, staff competencies related to family voice and choice, community resources, and team-based planning; Staff Supervision Policy (402.2) – pg. 1, consultation, coaching, support, and review of work practices; OC Wrap Training Plan – pgs. 1–2, initial and ongoing Wraparound training requirements; Parent Partner: Role and Functions – pg. 1, helping families identify and connect with extended family and supportive individuals to build permanent supportive connections ; Youth Partner: Role and Functions – pg. 1, supporting youth connection to extended family and supportive individuals to strengthen long-term supports ; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, field observation, coaching, documentation review, and fidelity-informed staff development related to high-fidelity Wraparound practice .
c. Interagency Family Plan of Care Review – pg. 2, review indicators assessing inclusion of natural/community supports in strategies, action items, and collaboration beyond Wraparound staff ; IE_Wrap POC Template 2026 – pgs. 3–5, integration of natural supports, team member responsibilities, community resources, goals, strategies, and action items; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, review and updating of supports, strategies, and team participation during Child and Family Team meetings; Olive Crest TOM Experience for Learning Community – pg. 5, improvement in “Use of Natural Supports,” teamwork, and outcome-based planning through fidelity review processes ; TOM 2.0 Form – indicators related to natural support attendance, participation, and integration into team process and planning.
d. Wraparound Outcome Reporting Policy (310.03) – pgs. 1–2, use of family feedback, WFI-EZ, satisfaction surveys, and outcome measures to support CQI and program improvement; WFI-EZ Caregiver Form – pgs. 1–4, caregiver feedback regarding team participation, support, and Wraparound experience; Olive Crest TOM Experience for Learning Community – pgs. 1–5, use of TOM observations, coaching feedback loops, supervision debriefing, and fidelity outcome review to improve family-centered team practices ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, use of engagement trends, supervision review, coaching, and CQI review processes to improve practice and outcomes ; LA DMH MH122219 Contract – Quality Assurance/Quality Improvement requirements.
1.7 Culturally Respectful and Relevant
Olive Crest ensures that Wraparound services are culturally respectful and relevant by intentionally integrating each family’s values, traditions, language, and cultural identity into all phases of the Wraparound process.
During the Engagement Phase, staff complete a Strengths, Needs, and Culture Discovery process to gather information about the family’s background, beliefs, traditions, and preferences prior to development of the Plan of Care. This information is documented and used to guide all planning and service delivery.
Facilitators support the Child and Family Team (CFT) in incorporating culturally relevant strategies, including the use of natural supports, community connections, and services that align with the family’s cultural identity and language preferences.
Services are delivered in the family’s preferred language whenever possible, and teams actively work to ensure accessibility and cultural responsiveness across all interactions.
Staff receive ongoing training and coaching on cultural humility, engagement across differences, and the integration of culture into needs-driven planning. Supervisors reinforce this practice through documentation review, observation of team meetings, and reflective supervision.
Family feedback regarding culturally respectful and relevant services is routinely gathered through team discussions, outcome measures, and feedback tools such as the FACI-8 and Wrap Line. This feedback is used to inform continuous quality improvement and guide staff development.
Supporting Documentation
a. Wraparound Enrollment Procedures (310.02) – pgs. 2–4, engagement, information gathering, and initial assessment process prior to Plan of Care development; FirstF2FPacket_English.pdf – pgs. 1–3, engagement, strengths discovery, family story, and information gathering process; Strengths-Needs Summary Template – pgs. 1–2, documentation of family story, strengths, needs, barriers, cultural considerations, and individualized planning; Culture Discovery Tool – pg. 1, exploration and documentation of family culture, traditions, values, language, and identity; Wraparound Plan of Care Policy (310.04) – pgs. 1–3, development of individualized Plans of Care based on identified strengths, needs, culture, values, and family preferences; Interagency Family Plan of Care Review – pgs. 1–2, review indicators related to family language, culturally relevant planning, individualized planning, and integration of multiple perspectives throughout the Plan of Care .
b. Family Preservation Personnel Policy (300.09) – pgs. 1–2, staff competencies related to family voice and choice, cultural responsiveness, community resources, and individualized planning; OC Wrap Training Plan – pgs. 1–2, initial and ongoing Wraparound training requirements related to engagement, planning, facilitation, and fidelity practice; Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, support, coaching, and review of work practices; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, field observation, documentation review, modeling, coaching, and CQI-informed staff development related to high-fidelity Wraparound practice ; Parent Partner: Role and Functions – pg. 1, ensuring family voice, culture, interests, and preferences are honored within plans and strategies ; Youth Partner: Role and Functions – pg. 1, ensuring youth culture, interests, and preferences are incorporated into planning and service delivery ; Interagency Family Plan of Care Review – pg. 1, indicators assessing culturally relevant planning and integration of family culture throughout the Plan of Care .
c. Wraparound Outcome Reporting Policy (310.03) – pgs. 1–2, use of family feedback, WFI-EZ, satisfaction surveys, and outcome measures to support CQI and program improvement; WFI-EZ Caregiver Form – pgs. 1–4, caregiver feedback regarding family experience, participation, and Wraparound process; TOM 2.0 Form – pg. 3, fidelity indicators related to strengths-based, family-driven, and culturally responsive practice; Olive Crest TOM Experience for Learning Community – pgs. 1–5, use of TOM observations, coaching feedback loops, supervision debriefing, and fidelity outcome review to improve family-centered and culturally responsive services ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, use of engagement trends, supervision review, coaching, and CQI review processes to improve service delivery and outcomes ; LA DMH MH122219 Contract – Quality Assurance/Quality Improvement requirements.
1.8 High-Quality Team Planning and Problem Solving
Olive Crest ensures high-quality team planning and problem solving through structured Child and Family Team (CFT) meetings where formal and natural supports collaborate to develop, implement, and monitor the individualized Plan of Care.
Family Team Meetings are the primary structure for shared decision-making, where all team members—including family, natural supports, and system partners—actively participate in identifying needs, developing strategies, and assigning action steps.
Team agreements and expectations are established early in the process to promote respectful communication, shared ownership, and accountability among all team members.
Facilitators guide the team in structured problem-solving, ensuring that all voices are heard and that decisions are made collaboratively and aligned with the family’s vision and priorities. Plans of Care and meeting minutes clearly document assigned responsibilities and action steps, reinforcing shared ownership and follow-through.
Supervisors and fidelity coaches routinely review Plans of Care and meeting documentation, and may observe team meetings to assess collaboration, engagement, and effectiveness of facilitation. Tools such as the Team Observation Measure (TOM) are used to evaluate team functioning and guide coaching.
Feedback from families and team members is routinely gathered through team discussions, observation, and feedback tools, and is used to inform supervision, staff development, and continuous quality improvement.
Additionally, OLIVER supports team coordination by documenting team membership, tracking assigned tasks, and providing visibility into service delivery and follow-through, allowing supervisors to monitor engagement and address gaps in real time.
Supporting Documentation
a. Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, Child and Family Team meeting structure, participation expectations, and collaborative team process; Facilitator: Role and Functions – pg. 1, facilitators support development and implementation of shared team agreements and coordination of team responsibilities ; IE_Wrap POC Template 2026 – pgs. 1–5, documentation of team members, assigned responsibilities, strategies, and action items; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–2, centralized storage of Plans of Care, meeting minutes, team member participation, and shared team documentation .
b. Wraparound Outcome Reporting Policy (310.03) – pgs. 1–2, use of WFI-EZ, satisfaction surveys, and outcome measures to gather family feedback and support CQI; WFI-EZ Caregiver Form – pgs. 1–4, caregiver feedback regarding participation, teamwork, and Wraparound experience; TOM 2.0 Form – indicators related to effective teamwork, meeting participation, engagement, and collaboration; Olive Crest TOM Experience for Learning Community – pgs. 1–5, use of TOM observations, direct observation of team process, coaching feedback loops, and fidelity review to improve collaboration and engagement ; Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, collaborative review of Plans of Care, fidelity review discussions, cross-system problem-solving, and shared feedback processes .
c. Olive Crest TOM Experience for Learning Community – pg. 3, TOM scoring, supervision debriefing, coaching feedback timelines, and action item process ; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, use of observation, documentation review, WFI-EZ, TOMS, and CQI-informed coaching to improve staff performance and fidelity ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, CQI activities, employee development, coaching, supervision, and data-informed practice improvement ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, use of supervision review, service trends, coaching, and CQI monitoring at the individual, program, and system level ; LA DMH MH122219 Contract – Quality Assurance/Quality Improvement requirements.
d. Interagency Family Plan of Care Review – pgs. 1–4, review indicators assessing collaboration, multiple perspectives, outcome-based planning, natural supports, action items, and team accountability throughout the Plan of Care ; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, review and updating of plans, strategies, supports, and assigned action items during Child and Family Team meetings; IE_Wrap POC Template 2026 – pgs. 3–5, documentation of team responsibilities, action items, goals, and strategies; Riverside County Wraparound Collaborative Meeting Minutes – pg. 3, collaborative review of Plans of Care and feedback regarding improvement opportunities and fidelity review ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, centralized documentation, service tracking, meeting records, and supervisory review of plans and team activities .
1.9 Outcomes Based Process
Olive Crest ensures that Wraparound services are outcomes-based through structured monitoring of progress toward identified needs, goals, and action steps, with data used to inform ongoing decision-making.
The Plan of Care includes clearly defined needs statements linked to measurable outcomes, with specific strategies, action steps, assigned team members, and timeframes.
Facilitators are responsible for tracking completion of action items and progress toward outcomes, which are reviewed and updated during Child and Family Team (CFT) meetings held at least every 30–45 days. Adjustments to strategies and action steps are made collaboratively based on progress and shared with all team members.
Standardized outcome measures, including the IP-CANS, are integrated into the Wraparound process. The IP-CANS is completed by trained staff (Facilitators and/or Clinicians, depending on program requirements) within 30 days of enrollment and updated at minimum every 90 days.
IP-CANS data is used to inform identification and prioritization of needs, track progress over time, and guide team decision-making. This data is reviewed alongside ongoing tracking of needs, goal progress, and action step completion to ensure a comprehensive understanding of family progress and to inform planning for transition.
OLIVER supports this process by tracking service delivery, documentation, and completion of action steps, allowing supervisors and teams to monitor progress in real time and address gaps as needed.
Supervisors reinforce outcomes-based practice through documentation review, supervision, and use of fidelity tools, ensuring that plans remain measurable, data-informed, and responsive to family progress.
Supporting Documentation
a. IE_Wrap POC Template 2026 – pgs. 3–5, measurable goals, identified strategies, assigned action items, responsible parties, and target dates/timeframes; Interagency Family Plan of Care Review – pgs. 2–3, review indicators related to measurable goals, outcome-based planning, individualized strategies, and action item alignment ; Facilitator: Role and Functions – pg. 1, facilitators coordinate implementation of plans and ensure team accountability for identified activities and strategies .
b. Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, ongoing review of progress, action items, strategies, and team follow-through during Child and Family Team meetings; IE_Wrap POC Template 2026 – pgs. 3–5, tracking of assigned action items, responsibilities, and progress updates; Facilitator: Role and Functions – pg. 1, facilitators ensure coordination of activities, accountability of team members, and ongoing review and revision of plans ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, tracking of meetings, contacts, documentation updates, service activity, and follow-up actions to support ongoing monitoring of team progress .
c. Wraparound Plan of Care Policy (310.04) – pgs. 2–3 section 5.0, ongoing review and modification of strategies, goals, supports, and action items; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, collaborative review and updating of team plans and strategies during Child and Family Team meetings; Facilitator: Role and Functions – pg. 1, facilitators revise plans based on what is learned and ensure communication among team members regarding changes and team decisions ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–2, shared team access to case updates, documentation, schedules, and communication across assigned team members .
d. Wraparound Outcome Reporting Policy (310.03) – pgs. 1–2, procedures for completion, review, and use of the IP-CANS/CANS within required timeframes to support planning and outcome tracking; Facilitator: Role and Functions – pg. 1, facilitators gather information from multiple sources and use information to inform consensus-developed CANS scoring ; Wraparound Clinician: Role and Functions – pg. 1, clinicians participate in assessment of needs and strengths utilizing the CANS for prioritization and tracking progress ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–2, centralized documentation and shared team access to Plans of Care, assessments, meeting records, and service information .
e. Wraparound Outcome Reporting Policy (310.03) – pgs. 1–2, use of CANS/IP-CANS and additional outcome measures to support service planning, tracking progress, and informing decision-making; IE_Wrap POC Template 2026 – pgs. 3–5, ongoing tracking of needs, measurable goals, strategies, action items, and progress updates; Interagency Family Plan of Care Review – pgs. 2–3, review indicators related to underlying needs, measurable goals, outcome-based planning, and progress tracking ; Wraparound Transition Policy (310.18) – pgs. 1–2, transition planning based on team agreement, goal achievement, stabilization of needs, and family readiness; Facilitator: Role and Functions – pg. 1, facilitators lead review of plans, evaluate effectiveness of strategies, and update plans and CANS scores based on progress and ongoing team learning .
1.10 Persistence
Olive Crest ensures persistence in the Wraparound process by supporting teams to remain engaged with youth and families through challenges, setbacks, and limited progress, with a continued focus on revising the Plan of Care rather than disengaging services.
Wraparound services continue until the team—guided by youth and family voice and choice—determines that needs have been sufficiently met. Setbacks are addressed through ongoing team problem-solving, revision of strategies, and reinforcement of strengths-based approaches.
Facilitators lead teams in revisiting and adapting the Plan of Care during Child and Family Team (CFT) meetings, ensuring that strategies remain responsive and effective. Conflict and challenges within the team are addressed through structured facilitation and conflict resolution practices that maintain collaboration and family-centered decision-making.
Teams have access to multiple layers of support when challenges arise, including supervision, coaching, and system resources. Supervisors provide ongoing consultation, problem-solving support, and guidance to staff, ensuring that barriers are addressed and services remain aligned with Wraparound principles.
Flexible funding (Flex Funds) is available to support creative, individualized solutions when traditional resources are insufficient, allowing teams to address unmet needs and prevent disruption in placement or services.
Staff receive ongoing training and coaching in crisis planning, safety planning, conflict resolution, and adaptive problem-solving. Safety Plans are developed proactively and revised as needed to respond to crises and maintain stability within the family.
Supporting Documentation
a. Wraparound Phases and Activities Policy (310.05) – pgs. 1–3, expectations related to persistence, ongoing team engagement, transition readiness, and continuation of services through setbacks and crises; Facilitator: Role and Functions – pgs. 1–2, facilitators revise plans based on team learning, address crises, maintain hope during difficult periods, and continue supporting teams toward identified goals ; Parent Partner: Role and Functions – pgs. 1–2, ongoing parent support, advocacy, crisis support, and reinforcement of family voice and perseverance throughout the Wraparound process ; Youth Partner: Role and Functions – pgs. 1–2, engagement and support of youth through challenges while reinforcing voice, hope, and connection .
b. Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, support, problem-solving assistance, and review of work practices; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, supervisors provide consultation, coaching, coordination support, problem-solving assistance, and access to resources when teams are facing barriers ; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, field-based coaching, modeling, documentation review, and CQI-informed support to improve team functioning and fidelity ; Wraparound Flex Funds Updates – pg. 1, process for requesting flex funds, supervisory approval expectations, documentation requirements, and alignment with Plans of Care ; Wraparound Flex Fund Expenditure Form – pg. 1, documentation and approval process for flexible funding expenditures ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, communication, shared documentation, incident reporting, supervisory oversight, and tracking of supports and service coordination .
c. Wraparound Conflict Management Procedures (310.10) – pgs. 1–2, conflict resolution and collaborative problem-solving expectations within Child and Family Team meetings; OC Wrap Training Plan – pgs. 1–2, initial and ongoing Wraparound training requirements including facilitation and crisis-related skill development; Facilitator: Role and Functions – pg. 1, facilitators mediate differing perspectives, revise plans based on team learning, coordinate safety planning, and lead ongoing planning discussions ; Olive Crest TOM Experience for Learning Community – pg. 3, TOM feedback, supervision debriefing, action planning, and coaching processes used to strengthen facilitation and planning practices ; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, field observation, role play, coaching, and documentation review to improve Wraparound facilitation skills and fidelity .
1.11 Transitions as a part of the Fourth Phase of HFW
Olive Crest ensures that transitions are intentional, gradual, and driven by youth and family readiness, consistent with the Transition Phase of the High Fidelity Wraparound model.
Transition planning begins early in the Wraparound process and is continuously discussed during Child and Family Team (CFT) meetings to ensure that supports, resources, and natural supports are in place prior to discharge. Services do not end due to administrative requirements or adverse events, but rather when the team, guided by youth and family voice, determines that needs have been sufficiently met.
The Plan of Care is used to guide transition planning, including identifying ongoing supports, community connections, and strategies to maintain stability after formal services end.
A structured Transition Checklist is utilized to ensure that key elements of transition are addressed, including linkage to community resources, natural supports, and aftercare planning.
Transitions are celebrated in a manner that reflects the family’s culture, values, and preferences. Teams may utilize flexible funding and community partnerships to support meaningful celebrations and recognition of progress.
Staff are supported by supervisors and program structures to dedicate time to transition planning, coordination of community resources, and participation in transition celebrations, ensuring a positive and supported closure to services.
Supporting Documentation
a. Wraparound Phases and Activities Policy (310.05) – pgs. 2–3, transition phase activities focused on sustainability, transition readiness, and maintaining supports following Wraparound discharge; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, ongoing review of progress, planning, transition readiness, and coordination of supports during Child and Family Team meetings; Facilitator: Role and Functions – pg. 1, facilitators introduce transition planning early, revise plans based on team learning, and coordinate continuity of supports throughout the Wraparound process ; OLIVER – DATA SYSTEM DESCRIPTION – pg. 3, aftercare follow-up tracking and continuity of care processes following discharge ; Riverside DPSS Wraparound Services Executed Contract – pg. 32, discharge and transition planning expectations.
b. Parent Partner: Role and Functions – pg. 2, assisting families in strengthening long-term supports and celebrating progress and success throughout the Wraparound process ; Youth Partner: Role and Functions – pg. 2, reinforcing youth voice, accomplishments, and supportive relationships throughout transitions ; Wraparound Flex Funds Updates – pg. 1, flex fund approval and use processes supporting individualized family needs and transition-related supports ; Wraparound Flex Fund Expenditure Form – pg. 1, documentation and approval process for individualized expenditures aligned with Plans of Care and transition needs ; Family Preservation Personnel Policy (300.09) – pgs. 1–2, staff expectations related to family-centered practice, community collaboration, engagement of supports, and individualized service delivery; Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, collaborative discussions regarding community partnerships, resource coordination, transition planning, and support of family-centered Wraparound practices .
Expected Outcomes
2.1 Youth and Family Satisfaction
Olive Crest ensures that youth and family satisfaction is routinely measured, evaluated, and used to inform continuous quality improvement.
Youth and families are provided multiple opportunities to share feedback regarding their experience in Wraparound services, including their level of satisfaction, engagement, and perceived progress. Formal feedback is collected through standardized tools such as the Family Attachment and Changeability Index (FACI-8), which captures family functioning, communication, and satisfaction with the Wraparound process.
In addition, families are encouraged to provide ongoing feedback through team meetings, direct communication with staff, and through program feedback mechanisms such as the Wrap Line, allowing for real-time input on service experience.
Outcome and satisfaction data are reviewed as part of the program’s outcome monitoring process and are used to assess service effectiveness, inform case planning, and guide program-level improvements.
Supervisors and leadership review satisfaction data to identify trends, address concerns, and provide targeted coaching and training to staff. Feedback is integrated into supervision, team discussions, and CQI processes to ensure services remain responsive, family-driven, and aligned with Wraparound principles.
OLIVER supports the documentation and tracking of family feedback, follow-up contacts, and aftercare engagement, allowing the program to monitor satisfaction over time and maintain connection with families post-discharge.
Supporting Documentation
Wraparound Outcomes Monitoring and Reporting (Policy 310.03), pp. 1–2 – Collection and use of outcome and satisfaction data
Family Attachment & Changeability Index (FACI-8), p. 1 – Standardized tool to assess family experience and functioning
Educational Outcomes Measure, p. 1 – Example of ongoing outcome and satisfaction-related tracking
OLIVER Data System Description, pp. 3–4 – Tracking of family engagement, feedback, and aftercare follow-up
Wraparound Service Philosophy (Policy 310.15), p. 1 – Commitment to family voice and feedback in service delivery
2.2 Improved School Functioning
Olive Crest ensures that youth experience improved school functioning through intentional monitoring of educational outcomes and integration of school-related goals into the Wraparound process.
Educational needs are identified during the Engagement and Planning phases and incorporated into the Plan of Care, with specific goals and strategies related to attendance, academic performance, behavior, and school engagement.
Youth progress is tracked using formal tools such as the Educational Outcomes Measure, which captures key indicators including attendance, suspensions, expulsions, and progress toward graduation.
Educational functioning is also assessed through standardized tools such as the CANS/IP-CANS, which are completed at intake and updated at regular intervals to monitor progress across life domains, including education.
School performance and progress are reviewed regularly during Child and Family Team (CFT) meetings, where school personnel (when appropriate) and team members collaborate to address barriers and adjust strategies to support academic success.
In school-based Wraparound and collaborative cases, staff maintain ongoing communication with educational partners to monitor attendance, behavior, and progress toward Individualized Education Plan (IEP) goals.
OLIVER supports documentation and tracking of school-related services, progress notes, and outcome data, allowing teams and supervisors to monitor educational progress and respond to emerging needs.
Supporting Documentation
Educational Outcomes Measure, p. 1 – Tracking of attendance, performance, and school engagement
Wraparound Outcomes Monitoring and Reporting (Policy 310.03), pp. 1–2 – Use of CANS/IP-CANS to track functioning across domains, including education
Wraparound Plan of Care Policy (310.04), pp. 2–4 – Inclusion of education-related goals and strategies
Wraparound Family Team Meeting Procedures (Policy 310.12), pp. 1–2 – Ongoing review of progress and collaboration with team members
Inland Wraparound Orientation, p. 8 – Expectation to track educational outcomes and coordinate with school systems
OLIVER Data System Description, pp. 2–3 – Tracking of service delivery, progress notes, and outcomes
2.3 Improved Functioning in the Community
Olive Crest ensures that youth experience improved functioning in the community through ongoing monitoring of community engagement, behavioral functioning, and involvement with formal systems, including juvenile justice when applicable.
Community functioning is identified and addressed within the Plan of Care, with specific goals and strategies designed to increase participation in prosocial activities, strengthen natural supports, and reduce system involvement.
Youth progress is measured using standardized tools such as the CANS/IP-CANS, which assess functioning across multiple life domains, including community involvement, risk behaviors, and system interaction.
Additional outcome measures, such as the FACI-8, provide insight into family functioning and engagement, which are directly connected to youth success in community settings.
Progress toward community-based goals, including participation in activities, reduction in risky behaviors, and improved engagement with natural and community supports, is reviewed regularly during Child and Family Team (CFT) meetings. Team members collaborate to adjust strategies and address barriers to community involvement.
When applicable, collaboration with system partners such as probation, education, and community-based organizations is incorporated into planning and monitored through ongoing team communication and documentation.
OLIVER supports the tracking of service delivery, community-based interventions, and system involvement, allowing teams and supervisors to monitor progress and identify areas for improvement in real time.
Supporting Documentation
Wraparound Outcomes Monitoring and Reporting (Policy 310.03), pp. 1–2 – Use of CANS/IP-CANS to track functioning across domains, including community and system involvement
Wraparound Plan of Care Policy (310.04), pp. 2–4 – Inclusion of community-based goals, strategies, and supports
Family Attachment & Changeability Index (FACI-8), p. 1 – Measurement of family functioning and engagement
Wraparound Family Team Development (Policy 310.11), pp. 1–2 – Inclusion of community and natural supports
Wraparound Family Team Meeting Procedures (Policy 310.12), pp. 1–2 – Ongoing review of progress and collaboration with system partners
OLIVER Data System Description, pp. 2–3 – Tracking of service delivery, system involvement, and community-based activities
2.4 Improved Interpersonal Functioning
Olive Crest ensures that youth and families experience improved interpersonal functioning through ongoing assessment, team-based planning, and monitoring of family relationships, communication, and overall functioning.
Interpersonal functioning is identified and addressed within the Plan of Care through needs statements and goals related to family relationships, communication, conflict resolution, and social connections.
Family functioning and interpersonal relationships are measured using standardized tools such as the Family Attachment and Changeability Index (FACI-8), which assesses communication, problem-solving, shared decision-making, and overall family dynamics.
In addition, the CANS/IP-CANS is used to assess and monitor functioning across domains, including family relationships, emotional functioning, and behavioral needs.
Progress is reviewed regularly during Child and Family Team (CFT) meetings, where team members—including family and natural supports—collaborate to address interpersonal challenges, reinforce strengths, and adjust strategies to improve relationships and reduce family stress.
Staff are trained to support families in developing healthy communication, conflict resolution skills, and strengthening connections with natural supports. Supervisors reinforce this practice through documentation review, coaching, and observation.
OLIVER supports the documentation of family interactions, progress notes, and outcome data, allowing teams to track improvements in interpersonal functioning and respond to emerging needs.
Supporting Documentation
Family Attachment & Changeability Index (FACI-8), p. 1 – Measurement of family communication, relationships, and functioning
Wraparound Outcomes Monitoring and Reporting (Policy 310.03), pp. 1–2 – Use of CANS/IP-CANS to assess family and emotional functioning
Wraparound Plan of Care Policy (310.04), pp. 2–4 – Development of goals and strategies related to family functioning and relationships
Wraparound Family Team Meeting Procedures (Policy 310.12), pp. 1–2 – Ongoing review of family progress and team-based problem solving
Wraparound Conflict Management (Policy 310.10), pp. 1–2 – Support for conflict resolution and strengthening relationships
OLIVER Data System Description, pp. 2–3 – Documentation and tracking of progress and family interactions
2.5 Increased Caregiver Confidence
Olive Crest ensures that caregivers develop increased confidence in their ability to manage future challenges through skill-building, connection to resources, and ongoing support throughout the Wraparound process.
Caregiver confidence and capacity are developed through participation in the Child and Family Team (CFT), where caregivers are supported in decision-making, problem-solving, and implementation of strategies aligned with their family’s needs and goals.
The Plan of Care includes strategies that build caregiver skills, strengthen natural supports, and connect families to community-based resources, ensuring that caregivers have the tools and relationships needed to sustain progress beyond formal services.
Caregiver confidence and family functioning are measured using standardized tools such as the Family Attachment and Changeability Index (FACI-8), which assesses communication, shared decision-making, and the family’s ability to manage challenges.
Additional assessment through the CANS/IP-CANS captures caregiver needs, strengths, and resource connections, allowing teams to monitor progress over time and adjust supports as needed.
Caregivers are also supported through access to flexible resources, including community-based services and Flex Funds, which help address immediate needs and reduce barriers to stability.
Transition planning ensures that caregivers are connected to ongoing supports and understand how to access resources and respond to future challenges, reinforcing long-term confidence and independence.
OLIVER supports documentation and tracking of caregiver engagement, service utilization, and follow-up contacts, including aftercare, allowing the program to monitor sustained caregiver confidence and connection to resources.
Supporting Documentation
Family Attachment & Changeability Index (FACI-8), p. 1 – Measurement of caregiver confidence, communication, and family functioning
Wraparound Outcomes Monitoring and Reporting (Policy 310.03), pp. 1–2 – Use of CANS/IP-CANS to assess caregiver needs and strengths
Wraparound Plan of Care Policy (310.04), pp. 2–4 – Development of strategies to build caregiver capacity and resource connection
Wraparound Family Team Meeting Procedures (Policy 310.12), pp. 1–2 – Caregiver participation in decision-making and planning
Wraparound Phases and Principles (Policy 310.05), pp. 1–2 – Transition planning and sustainability of supports
Flex Funds & Fidelity Training, pp. 5–6 – Access to flexible resources to support caregiver needs
OLIVER Data System Description, pp. 3–4 – Tracking of engagement, services, and aftercare follow-up
2.6 Stable and Least Restrictive Living Environment
Olive Crest ensures that youth maintain stable, least restrictive living environments through proactive planning, ongoing monitoring, and use of individualized supports to prevent placement disruption.
Placement stability is a primary focus of the Wraparound process and is addressed through the Plan of Care, which includes strategies to maintain youth safely in their home and community.
Progress toward stability is monitored through standardized outcome measures, including the CANS/IP-CANS and CAFAS, which assess risk behaviors, functioning, and factors that may contribute to placement instability.
Child and Family Team (CFT) meetings are used to regularly review risk factors, identify potential threats to placement, and adjust strategies to maintain stability and prevent escalation to more restrictive settings.
Crisis and Safety Plans are developed proactively with the family and team to address potential destabilizing events and provide clear, coordinated responses that reduce the likelihood of placement disruption.
Flexible funding (Flex Funds) is utilized to address immediate needs and remove barriers that could lead to placement instability, allowing teams to implement timely, individualized interventions.
OLIVER supports the tracking of placement information, service delivery, and critical incidents, allowing teams and supervisors to monitor placement stability, identify trends, and respond quickly to risks or changes in living environment.
When placement changes do occur, they are documented, reviewed, and analyzed through supervision and CQI processes to inform practice improvements and prevent future disruptions.
Supporting Documentation
Wraparound Plan of Care Policy (310.04), pp. 2–4 – Strategies to support stability and prevent placement disruption
Wraparound Outcomes Monitoring and Reporting (Policy 310.03), pp. 1–2 – Use of CANS/IP-CANS and CAFAS to monitor risk and functioning
Wraparound Family Team Meeting Procedures (Policy 310.12), pp. 1–2 – Ongoing review of risks and team-based problem solving
Wraparound Family Safety Plan/Crisis Procedures (Policy 310.06), pp. 1–2 – Proactive crisis planning to maintain stability
Flex Funds & Fidelity Training, pp. 5–6 – Use of flexible funds to prevent placement disruption
OLIVER Data System Description, pp. 2–3 – Tracking of placement, incidents, and service data
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Olive Crest ensures reduction in inpatient and emergency behavioral health utilization through proactive crisis planning, ongoing monitoring of behavioral health needs, and timely intervention through the Wraparound process.
Behavioral health stability is addressed within the Plan of Care through needs-driven strategies that target emotional regulation, crisis prevention, and access to appropriate supports.
Youth behavioral health functioning is monitored using standardized tools such as the CANS/IP-CANS and CAFAS, which assess emotional and behavioral needs and are updated at regular intervals to track progress and identify risk factors that may lead to hospitalization.
A comprehensive Safety/Crisis Plan is developed with the youth, family, and team to proactively identify potential triggers, early warning signs, and coordinated response strategies to prevent escalation and reduce the need for emergency or inpatient services.
Child and Family Team (CFT) meetings are used to regularly review behavioral health status, monitor incidents, and adjust strategies to maintain stability and prevent crisis escalation.
OLIVER supports the tracking of critical incidents, crisis responses, and service utilization, including documentation of behavioral health events and follow-up actions. This allows supervisors and teams to monitor trends in hospital utilization and respond proactively.
When hospitalizations or emergency visits occur, they are reviewed through supervision and CQI processes to identify contributing factors and inform revisions to the Plan of Care and crisis response strategies.
Supporting Documentation
Wraparound Plan of Care Policy (310.04), pp. 2–4 – Behavioral health needs and strategies within the Plan of Care
Wraparound Outcomes Monitoring and Reporting (Policy 310.03), pp. 1–2 – Use of CANS/IP-CANS and CAFAS to monitor behavioral health functioning
Wraparound Family Safety Plan/Crisis Procedures (Policy 310.06), pp. 1–2 – Development of proactive crisis and safety plans
Wraparound Family Team Meeting Procedures (Policy 310.12), pp. 1–2 – Ongoing review of behavioral health and team-based problem solving
Inland Wraparound Orientation, pp. 17–18 – Crisis response procedures and reporting expectations
OLIVER Data System Description, pp. 3–4 – Tracking of incidents, crisis responses, and service utilization
2.8 Reduction in Crisis Visits
Olive Crest ensures a reduction in crisis visits by strengthening the capacity of youth and their natural supports to anticipate, prevent, and manage crises with decreasing reliance on formal services.
Crisis prevention is addressed through the development of individualized Family Safety Plans, which identify triggers, early warning signs, and step-by-step response strategies that prioritize the use of family strengths and natural supports.
These plans are developed collaboratively with the youth, family, and team and are reviewed and updated regularly during Child and Family Team (CFT) meetings to ensure they remain relevant and effective.
The Plan of Care includes strategies that build the skills of caregivers and natural supports to respond to challenges independently, including problem-solving, communication, and crisis de-escalation.
Staff receive ongoing training and coaching in crisis prevention, de-escalation, and safety planning, ensuring that teams are equipped to support families in managing crises without escalation to higher levels of care.
Crisis events and responses are documented and tracked in OLIVER, including level of involvement of professional supports. This allows supervisors and teams to monitor frequency of crises, identify trends, and adjust strategies to further reduce reliance on formal interventions.
When crises do occur, they are reviewed through supervision and CQI processes to strengthen prevention strategies and improve future responses.
Supporting Documentation
Wraparound Family Safety Plan/Crisis Procedures (Policy 310.06), pp. 1–2 – Development and use of crisis prevention and response plans
Wraparound Plan of Care Policy (310.04), pp. 2–4 – Strategies to build caregiver and natural support capacity
Wraparound Family Team Meeting Procedures (Policy 310.12), pp. 1–2 – Ongoing review and updating of safety plans and strategies
Wraparound Training Plan, p. 1 – Training in crisis prevention and de-escalation strategies
Inland Wraparound Orientation, pp. 17–18 – Crisis response procedures and staff expectations
OLIVER Data System Description, pp. 3–4 – Tracking of crisis events, responses, and service involvement
2.9 Positive Exit from HFW
Olive Crest ensures that youth and families exit Wraparound services based on stabilization and successful progress toward meeting identified needs, rather than as a result of adverse events or administrative requirements.
Transition planning is an ongoing process embedded throughout the Wraparound phases and is formally addressed during Child and Family Team (CFT) meetings to assess readiness for discharge. Teams determine readiness based on progress toward needs, achievement of goals, and the presence of sustainable natural and community supports.
The Plan of Care is used to guide this process, with measurable outcomes and progress indicators informing decisions about transition and discharge.
Standardized outcome measures, including CANS/IP-CANS and CAFAS, are completed at discharge to evaluate overall progress and stability.
A structured Transition Checklist is utilized to ensure that all key elements of a successful transition are addressed, including connection to ongoing supports and aftercare planning.
OLIVER supports the documentation of discharge reasons, transition planning activities, and aftercare follow-up, allowing the program to track when and why families exit services and to monitor post-discharge stability.
Post-discharge follow-up contacts are conducted to assess continued stability and provide additional support if needed, reinforcing a positive and supported exit from services.
Supporting Documentation
Wraparound Phases and Principles (Policy 310.05), pp. 1–2 – Transition Phase and criteria for discharge
Wraparound Plan of Care Policy (310.04), pp. 2–4 – Use of outcomes and progress to guide transition decisions
Wraparound Outcomes Monitoring and Reporting (Policy 310.03), pp. 1–2 – Discharge outcome measures (CANS/IP-CANS, CAFAS)
Transition Checklist, p. 1 – Structured transition and discharge planning process
Wraparound Family Team Meeting Procedures (Policy 310.12), pp. 1–2 – Ongoing team review of readiness for transition
OLIVER Data System Description, pp. 3–4 – Tracking of discharge, transition, and aftercare follow-up
Engagement
3.1 Orientation
Olive Crest ensures that all youth and families receive a comprehensive orientation to the Wraparound process at the time of engagement, establishing a clear understanding of expectations, roles, and the structure of services.
During initial contact and the first face-to-face meeting, staff provide an overview of the Wraparound process, including the purpose of services, voluntary participation, and next steps.
Families are formally oriented to the principles and phases of High Fidelity Wraparound, including Engagement, Planning, Implementation, and Transition, and how these guide the development and implementation of the Plan of Care.
Orientation includes a clear explanation of team roles, including the responsibilities of the Facilitator, Parent Partner, Behavior Specialist, Clinician, Supervisor, as well as the critical role of the youth, family, and natural supports as active decision-makers in the process.
Legal and ethical considerations are reviewed with families, including confidentiality, mandated reporting requirements, and the “no secrets” approach used to support transparency and team collaboration.
The Inland Wraparound Orientation training materials provide a structured and consistent approach to orienting families, ensuring that all required elements—including principles, phases, team roles, and expectations—are clearly communicated and understood.
Staff reinforce orientation throughout the Engagement Phase and early team meetings, ensuring that families feel informed, empowered, and prepared to participate fully in the Wraparound process.
Supporting Documentation
a. Wraparound Enrollment Procedures (310.02) – pgs. 1–4, initial engagement process, informed participation, explanation of Wraparound services, and orientation to the Wraparound process; Inland Wrap Orientation – pgs. 1–4, overview of High Fidelity Wraparound principles, phases, family voice and choice, team roles, engagement expectations, and individualized planning processes; Wraparound Phases and Activities Policy (310.05) – pgs. 1–3, overview of Wraparound phases, team process, transition activities, and family-centered planning expectations; Wraparound Service Philosophy (310.15) – pgs. 1–2, guiding principles including family voice and choice, cultural responsiveness, strengths-based practice, natural supports, and persistence; Wraparound Family Team Development Procedures (310.11) – pgs. 1–2, explanation of team member roles including family members, natural supports, formal supports, and community participation in Child and Family Team development; Family Preservation Personnel Policy (300.09) – pgs. 1–2, expectations regarding confidentiality, ethics, collaboration, family-centered practice, and team responsibilities; Facilitator: Role and Functions – pg. 1, facilitator responsibilities related to explaining Wraparound, coordinating team development, supporting informed participation, and engaging family and natural supports ; Parent Partner: Role and Functions – pg. 1, supporting family understanding of the Wraparound process, team participation, advocacy, and family voice and choice ; Youth Partner: Role and Functions – pg. 1, supporting youth engagement, participation, and understanding of the Wraparound process and team planning .
3.2 Safety and Crisis stabilization
Olive Crest ensures that immediate safety and crisis stabilization needs are addressed during the Engagement Phase so that families can fully participate in the Wraparound process.
Initial safety concerns are identified and discussed during first contact and the initial face-to-face meeting. When urgent needs are identified, the team develops an immediate response to stabilize the situation and ensure safety.
A formal Family Safety Plan/Crisis Plan is developed collaboratively with the youth, family, and team to address potential crisis situations, identify triggers, and outline clear response strategies. This plan is documented in the case record and shared with all team members.
The crisis plan developed during engagement informs the more comprehensive Safety Plan created during the Planning Phase and is updated regularly as part of the ongoing Wraparound process.
Families are provided with clear information on how to access 24/7 crisis response services, including contact information and guidance on when and how to seek immediate support.
Crisis and safety planning are reviewed and updated during Child and Family Team (CFT) meetings to ensure continued relevance and effectiveness, allowing the team to proactively respond to emerging risks.
Staff receive training and supervision in crisis identification, safety planning, and stabilization to ensure consistent and effective response across all cases.
Supporting Documentation
a. Wraparound Enrollment Procedures (310.02) – pgs. 2–4, engagement, initial assessment, and identification of immediate safety and crisis concerns during intake and enrollment; FirstF2FPacket_English.pdf – pgs. 1–3, engagement process including strengths discovery, crisis discussion, and identification of immediate family concerns; Wraparound Safety Plan Procedures (310.06) – pgs. 1–3, development and documentation of safety plans and immediate crisis response planning; Facilitator: Role and Functions – pg. 1, facilitators coordinate crisis planning, assess family needs, and ensure team responsiveness to identified concerns ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–2, documentation of plans, incident reports, meeting records, and shared access to crisis-related information .
b. Wraparound Safety Plan Procedures (310.06) – pgs. 1–3, distinction between immediate crisis response planning and ongoing individualized HFW Safety Planning; Wraparound Plan of Care Policy (310.04) – pgs. 2–3, incorporation of safety planning into individualized team planning and ongoing Plan of Care review; IE_Wrap POC Template 2026 – pgs. 3–5, individualized planning structure incorporating identified risks, needs, strategies, and action planning; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, review and updating of plans, supports, and safety-related strategies during Child and Family Team meetings.
c. Wraparound Enrollment Procedures (310.02) – pgs. 2–4, orientation and provision of service information and emergency contact processes during enrollment; Wraparound Safety Plan Procedures (310.06) – pgs. 1–3, documentation and communication of crisis response and emergency contact procedures; Facilitator: Role and Functions – pg. 1, facilitators ensure families understand available supports, crisis response processes, and team communication expectations ; Riverside DPSS Wraparound Services Executed Contract – crisis response and service accessibility requirements; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–2, communication systems, incident reporting, and coordination of urgent response activities across assigned team members .
3.3 Strengths, Needs, Culture and Vision Discovery
Olive Crest ensures that strengths, needs, culture, and family vision are identified early and continuously updated to guide the Wraparound process.
During the Engagement Phase, facilitators lead structured conversations and activities with the youth and family to identify strengths, underlying needs, cultural values, and the family’s vision for the future. This information is documented in a Strengths, Needs, and Culture Discovery Tool, which serves as a foundational document for planning and is shared with all team members.
A Family Vision statement is developed with each family and documented in the case record, providing a clear, family-driven direction for the Plan of Care and team decision-making.
Additional information is gathered during the First Face-to-Face/Intake process, ensuring comprehensive understanding of the family’s strengths, preferences, and supports.
Identified needs are further clarified and refined using structured tools such as the Needs Worksheet, ensuring that planning is based on underlying needs rather than behaviors.
The Strengths, Needs, and Culture Discovery document is updated throughout the Wraparound process, including at least every 90 days, and is used to orient new team members and inform ongoing Plan of Care development.
Supervisors reinforce this practice through documentation review and coaching, ensuring that discovery remains current, meaningful, and integrated into team planning and service delivery.
Supporting Documentation
a. Wraparound Enrollment Procedures (310.02) – pgs. 2–4, engagement and information gathering activities completed prior to Plan of Care development; FirstF2FPacket_English.pdf – pgs. 1–3, engagement, strengths discovery, family story, and family visioning process; Strengths-Needs Summary Template – pg. 1, documentation of Family Vision, family story, strengths, barriers, and identified needs; Wraparound Plan of Care Policy (310.04) – pgs. 1–2, Family Vision and Team Mission incorporated into individualized planning and service delivery; IE_Wrap POC Template 2026 – pgs. 1–2, Family Vision and Team Mission sections included within the Plan of Care; Facilitator: Role and Functions – pg. 1, facilitators engage families in identifying priorities, goals, strengths, and desired outcomes to guide planning .
b. Strengths-Needs Summary Template – pgs. 1–2, documentation of strengths, needs, barriers, culture, family story, and ongoing updates; Culture Discovery Tool – pg. 1, documentation of cultural identity, values, language, traditions, supports, and preferences; Wraparound Plan of Care Policy (310.04) – pgs. 2–3 section 5.0, ongoing review and updating of plans, strengths, needs, goals, and supports; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, ongoing review and updating of team information, strategies, and supports during Child and Family Team meetings; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–2, centralized documentation and shared access to Plans of Care, team documents, meeting records, and updated family information for assigned team members ; Interagency Family Plan of Care Review – pgs. 1–3, review indicators assessing culturally relevant planning, individualized strengths, multiple perspectives, and ongoing integration of updated information throughout the Plan of Care .
3.4 Engage All Team Members
Olive Crest ensures active engagement of all team members by intentionally identifying, inviting, and supporting participation of formal and natural supports throughout the Wraparound process.
During the Engagement Phase, facilitators work collaboratively with youth and families to identify potential team members using structured tools and conversations, including the Strengths, Needs, and Culture Discovery and initial intake process. This includes both formal system partners and natural supports who play a meaningful role in the family’s life.
A natural supports inventory is developed and maintained, ensuring that informal supports are actively considered and incorporated into the Child and Family Team (CFT).
Facilitators engage Children’s System of Care partners (e.g., education, probation, mental health providers) and ensure their inclusion in planning and service coordination. Roles and responsibilities of each team member are clearly defined and reinforced during team meetings.
Facilitators intentionally promote a positive and collaborative team culture by guiding structured team-building activities, encouraging participation, and ensuring all voices are heard during meetings.
Engagement efforts, team participation, and assigned roles are documented in meeting minutes and case notes, ensuring accountability and continuity as team membership evolves.
OLIVER supports tracking of team members, communication, and participation, allowing supervisors and teams to monitor engagement and address gaps in team involvement.
Supporting Documentation
a. Wraparound Family Team Development Procedures (310.11) – pgs. 1–2, identification and engagement of formal, informal, tribal, natural, and community supports during team development; Ecomap – pg. 1, identification and mapping of family relationships and support systems; Connections & Support Map – pg. 1, documentation of supportive individuals and community resources connected to the youth and family; IE_Wrap POC Template 2026 – pgs. 1–5, documentation of natural supports, team member strengths/resources, and individualized planning; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–2, centralized documentation and tracking of team members, natural supports, Plans of Care, and service coordination .
b. Wraparound Family Team Development Procedures (310.11) – pgs. 1–2, identification and engagement of formal supports, service providers, schools, community partners, and natural supports; Facilitator: Role and Functions – pg. 1, facilitators coordinate multidisciplinary teaming and engage formal and informal supports identified by the family ; Riverside DPSS Wraparound Services Executed Contract – pg. 4, Child and Family Team composition and coordination expectations involving family, community partners, and service providers; Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, collaboration and coordination with Children’s System of Care partners, community providers, and multidisciplinary stakeholders .
c. Wraparound Family Team Development Procedures (310.11) – pgs. 1–2, collaborative identification of team members and clarification of team member roles and responsibilities; Parent Partner: Role and Functions – pg. 1, assisting families in identifying supportive individuals, extended family, and permanent connections ; Youth Partner: Role and Functions – pg. 1, supporting youth in identifying meaningful supports and relationships to strengthen team engagement ; Facilitator: Role and Functions – pg. 1, facilitators engage youth and families in identifying important people, supports, and team participants based on family voice and choice ; IE_Wrap POC Template 2026 – pgs. 1–3, documentation of team members, natural supports, and assigned team roles/responsibilities.
d. Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, documentation of Child and Family Team meetings, participation, planning activities, and ongoing review of supports and strategies; Facilitator: Role and Functions – pg. 1, facilitators coordinate engagement activities, team meetings, and ongoing team communication and planning ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, tracking and documentation of meetings, contacts, case notes, service coordination, and team communication ; Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, documented collaboration, planning discussions, fidelity review, and coordination activities across teams and partners .
3.5 Arrange Meeting Logistics
Olive Crest ensures that Child and Family Team (CFT) meetings are scheduled and conducted in a manner that prioritizes family voice and choice, accessibility, and full team participation.
Facilitators work collaboratively with youth and families to identify meeting times, locations, and formats that accommodate family schedules, preferences, cultural considerations, and any barriers to participation. Meetings are scheduled with flexibility, including evenings, virtual options, or community-based locations as needed to support engagement.
Staff are trained to prioritize family-centered scheduling and to coordinate with all team members to maximize attendance and participation.
Meeting logistics—including transportation needs, interpretation services, and telehealth options—are considered and arranged in advance to ensure equitable access for all participants.
Facilitators utilize OLIVER to coordinate scheduling, send meeting invitations, and share agendas with team members, ensuring clear communication and preparation for meetings.
CFT agendas and meeting documentation reflect participation and engagement, reinforcing accountability and ensuring that meetings are inclusive, accessible, and responsive to family needs.
Supervisors reinforce this practice through coaching and review of documentation, ensuring that meeting logistics consistently align with Wraparound principles of family voice, accessibility, and collaboration.
Supporting Documentation
a. Family Preservation Personnel Policy (300.09) – pgs. 1–2, expectations related to flexible, family-centered service delivery and responsiveness to family needs; Facilitator: Role and Functions – pg. 1, facilitators coordinate meetings and services based on family availability, preferences, and team participation needs ; Parent Partner: Role and Functions – pg. 1, engagement and support activities provided in alignment with family needs, preferences, and participation barriers ; Youth Partner: Role and Functions – pg. 1, flexible youth engagement and support activities designed to maximize participation and relationship-building ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–2, tracking of meetings, schedules, team coordination, communication, and service activities across staff and team members ; County of Orange Wraparound Contract – pgs. 23–24, expectations regarding family engagement, meeting participation, and responsiveness to family needs and scheduling considerations.
b. OC Wrap Training Plan – pgs. 1–2, initial and ongoing Wraparound training related to engagement, facilitation, collaboration, and team-based planning; Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, support, and reinforcement of effective engagement and collaboration practices; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, collaborative meeting planning, team participation expectations, and facilitation processes; Facilitator: Role and Functions – pg. 1, facilitators coordinate multidisciplinary teams and engage youth, families, natural supports, and providers to maximize participation and collaboration ; Parent Partner: Role and Functions – pg. 1, supporting family participation, engagement, advocacy, and collaborative planning within Child and Family Team meetings ; Olive Crest TOM Experience for Learning Community – pgs. 1–5, use of TOM observations and coaching feedback to strengthen team participation, engagement, and collaborative practice .
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
Description of Practice
Olive Crest ensures that, prior to development of the Plan of Care, facilitators lead the Child and Family Team (CFT) in establishing foundational elements that guide team functioning and planning.
During early CFT meetings, facilitators guide the team in developing team agreements that define expectations for participation, communication, and decision-making, ensuring a respectful and collaborative team environment.
Building on the Engagement Phase, facilitators support the team in identifying and documenting additional strengths of the youth, family, team members, and community. These strengths are continuously updated and incorporated into planning.
A Team Mission Statement is developed collaboratively with the youth, family, and team, aligning with the Family Vision and establishing a shared purpose that guides all planning and service delivery.
These elements—team agreements, strengths, and mission—are documented and maintained within the case record prior to and throughout the development of the Plan of Care.
Facilitators ensure that newly identified strengths are regularly updated through ongoing team discussions and documentation, reinforcing a strengths-based and evolving planning process.
Supporting Documentation
a. Wraparound Enrollment Procedures (310.02) – pgs. 2–4, engagement, information gathering, and initial team development activities completed prior to Plan of Care development; Wraparound Family Team Development Procedures (310.11) – pgs. 1–2, development of team membership, identification of strengths and supports, and clarification of team roles and agreements; Strengths-Needs Summary Template – pgs. 1–2, documentation of Family Vision, strengths, needs, barriers, and individualized family information; IE_Wrap POC Template 2026 – pgs. 1–3, inclusion of Family Vision, Team Mission, team members, strengths, and individualized planning information; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, collaborative development of team processes, team participation expectations, and planning activities during Child and Family Team meetings; Facilitator: Role and Functions – pg. 1, facilitators engage families in identifying strengths, priorities, supports, and team members to guide development of the individualized team process and planning .
b. Wraparound Plan of Care Policy (310.04) – pgs. 2–3 section 5.0, ongoing review and updating of strengths, needs, goals, supports, and strategies throughout the Wraparound process; Strengths-Needs Summary Template – pgs. 1–2, ongoing documentation and updating of strengths, needs, barriers, and family information; IE_Wrap POC Template 2026 – pgs. 3–5, ongoing revision of strengths, strategies, action items, and progress updates; Interagency Family Plan of Care Review – pgs. 1–3, review indicators assessing individualized strengths, multiple perspectives, culturally relevant planning, and incorporation of updated information throughout the Plan of Care ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, centralized documentation and updating of Plans of Care, case information, meeting records, and ongoing team communication .
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
Olive Crest ensures that needs-driven, team-based planning is the foundation of the Wraparound process, with all goals and strategies directly tied to prioritized underlying needs.
During the Planning Phase, facilitators guide the Child and Family Team (CFT) in reviewing needs identified during engagement and adding any newly identified needs. These needs are clarified and prioritized using structured tools and team discussion, ensuring focus on underlying causes rather than behaviors.
Prioritized needs are used to develop specific, measurable goals and outcomes, which are documented in the Plan of Care and reflect the family’s vision and priorities.
Goals and outcomes are developed collaboratively with the youth, family, and team members, ensuring shared ownership and alignment with family voice and choice.
Facilitators lead the team in brainstorming multiple individualized strategies to address each prioritized need before selecting the most appropriate interventions. These strategies are documented in the Plan of Care, meeting minutes, and/or progress notes and are available for ongoing review and adjustment.
Selected strategies are assigned to specific team members as action items with defined responsibilities and timelines, reinforcing accountability and follow-through.
Facilitators receive ongoing training and coaching in needs-based planning, goal development, and team facilitation to ensure consistency with High Fidelity Wraparound practices.
These steps collectively guide the development of the individualized Plan of Care within a collaborative, team-based environment.
Supporting Documentation
a. Wraparound Enrollment Procedures (310.02) – pgs. 2–4, engagement, assessment, and identification of family strengths, needs, and priorities prior to Plan of Care development; Strengths-Needs Summary Template – pgs. 1–2, documentation of family story, underlying needs, barriers, strengths, and priorities; IE_Wrap POC Template 2026 – pg. 5, identification of underlying needs linked to goals, strategies, and action items; Interagency Family Plan of Care Review – pg. 2, review indicators requiring underlying needs to reflect root causes and functional needs rather than behaviors or services ; Facilitator: Role and Functions – pg. 1, facilitators identify and prioritize family needs, strengths, and preferences through engagement and team development .
b. Wraparound Plan of Care Policy (310.04) – pgs. 2–3, development of measurable goals, individualized outcomes, and strategies linked to identified needs; IE_Wrap POC Template 2026 – pgs. 3–5, measurable goals, outcome statements, identified needs, strategies, and action planning; Interagency Family Plan of Care Review – pgs. 2–3, review indicators assessing measurable goals, outcome-based planning, individualized needs statements, and avoidance of deficit-focused planning ; Wraparound Clinician: Role and Functions – pg. 1, clinicians utilize CANS and individualized assessment information to support goal development and progress tracking .
c. Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, collaborative Child and Family Team meeting process and shared planning expectations; Facilitator: Role and Functions – pg. 1, facilitators engage youth, family members, natural supports, and providers in collaborative planning and decision-making ; Parent Partner: Role and Functions – pg. 1, support of family voice, advocacy, and participation in collaborative team planning ; Youth Partner: Role and Functions – pg. 1, support of youth participation, voice, and individualized engagement within planning and service delivery ; IE_Wrap POC Template 2026 – pgs. 1–5, team-based documentation of goals, strategies, supports, and assigned responsibilities.
d. IE_Wrap POC Template 2026 – pgs. 3–5, documentation of multiple individualized strategies, interventions, action items, responsible parties, and timelines; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, collaborative review and updating of strategies and action items during Child and Family Team meetings; Interagency Family Plan of Care Review – pgs. 2–3, review indicators assessing individualized strategies, multiple perspectives, culturally relevant planning, and outcome-based interventions ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, documentation of meeting records, plans, action items, progress notes, and ongoing updates to team planning .
e. OC Wrap Training Plan – pgs. 1–2, initial and ongoing training requirements related to facilitation, planning, engagement, and Wraparound implementation; Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, coaching, support, and reinforcement of effective facilitation and planning practices; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, field observation, modeling, role play, documentation review, and CQI-informed coaching related to facilitation and planning skills ; Olive Crest TOM Experience for Learning Community – pg. 3, TOM observation, scoring, supervision debriefing, coaching feedback, and action planning process used to strengthen facilitation and planning practices ; Facilitator: Role and Functions – pg. 1, facilitators coordinate brainstorming, collaborative planning, implementation of strategies, and ongoing revision of plans based on team learning .
f. Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, Child and Family Team collaboration, participation, and planning expectations; IE_Wrap POC Template 2026 – pgs. 1–5, team-based documentation of individualized goals, strategies, action items, strengths, supports, and responsibilities; Interagency Family Plan of Care Review – pgs. 1–4, review indicators assessing individualized planning, collaboration, family language, natural supports, culturally relevant planning, measurable goals, and outcome-based interventions ; Riverside DPSS Wraparound Services Executed Contract – pg. 4, Child and Family Team planning, strengths-based planning, and collaborative Wraparound service expectations.
4.3 Develop an Individualized Child or Youth and Family Plan
Olive Crest ensures that each youth and family has a comprehensive, individualized Plan of Care developed through a high-quality, team-based process that reflects High Fidelity Wraparound principles.
Facilitators lead the Child and Family Team (CFT) in developing the Plan of Care based on prioritized needs, goals, and strategies identified collaboratively during the Planning Phase. The Plan aligns with the Family Vision and Team Mission and reflects the strengths, needs, and culture of the youth and family.
The Plan of Care addresses needs across multiple life domains and integrates input from all Children’s System of Care partners, including education, mental health, and other involved systems, ensuring coordinated and comprehensive service delivery.
Strategies and action items are clearly documented within the Plan, including assigned team members, defined responsibilities, and timelines. Strategies reflect a balance of formal services, natural supports, and community resources, with an emphasis on increasing reliance on natural supports over time.
Services and supports are tailored to the individual needs of the youth and family and are delivered in community-based settings that are accessible and responsive to family preferences, schedules, and cultural considerations.
Natural supports and sustainable community resources are incorporated into the Plan, or strategies are developed to build these supports to ensure long-term sustainability beyond formal services.
The Plan of Care also includes benchmarks and progression toward less restrictive and less formal supports, guiding a gradual transition process based on family readiness.
Plans of Care are documented in OLIVER, distributed to all team members, and reviewed regularly during CFT meetings to monitor progress and make adjustments.
Supervisors and fidelity coaches review Plans of Care using structured tools to ensure quality, adherence to Wraparound principles, and continuous improvement, providing feedback to staff through supervision and coaching processes.
Facilitators receive ongoing training and coaching in team-based planning, engagement, and facilitation to ensure consistent implementation of high-quality, individualized planning practices.
Supporting Documentation
a. OC Wrap Training Plan – pgs. 1–2, initial and ongoing Wraparound training related to facilitation, engagement, collaborative planning, and fidelity practice; Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, support, coaching, and reinforcement of effective team facilitation and engagement practices; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, field observation, role play, modeling, documentation review, and CQI-informed coaching related to facilitation and team process ; Olive Crest TOM Experience for Learning Community – pgs. 1–5, TOM implementation process including direct observation, coaching feedback loops, supervision debriefing, and fidelity improvement strategies focused on teamwork, family voice and choice, and skilled facilitation ; Facilitator: Role and Functions – pg. 1, facilitators engage youth, family members, natural supports, and providers in collaborative planning, shared decision-making, and individualized team development .
b. Wraparound Plan of Care Policy (310.04) – pgs. 1–3, development of individualized and collaborative Plans of Care integrating team priorities, goals, strategies, and supports; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, collaborative team process involving youth, family, formal supports, natural supports, and community partners; IE_Wrap POC Template 2026 – pgs. 1–5, documentation of multidisciplinary goals, strategies, assigned responsibilities, and team participation; Riverside DPSS Wraparound Services Executed Contract – pg. 4, Child and Family Team planning expectations including integration of strengths, needs, community supports, and multidisciplinary collaboration; Interagency Family Plan of Care Review – pgs. 1–4, review indicators assessing collaboration, multiple perspectives, natural/community supports, individualized planning, and coordinated outcome-based strategies across systems .
c. Wraparound Plan of Care Policy (310.04) – pgs. 1–3, documentation, review, updating, and distribution expectations related to Plans of Care; IE_Wrap POC Template 2026 – pgs. 1–5, individualized Plan of Care structure including Family Vision, Team Mission, strengths, needs, goals, strategies, action items, timelines, and assigned responsibilities; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–2, centralized documentation system supporting storage, sharing, updating, and access to Plans of Care, meeting records, and team documentation across assigned team members ; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, ongoing review and communication of plans, strategies, and updates during Child and Family Team meetings; Riverside DPSS Wraparound Services Executed Contract – pg. 32, Plan of Care and documentation expectations.
d. Interagency Family Plan of Care Review – pgs. 1–4, structured review indicators assessing individualized planning, family language, culturally relevant planning, measurable goals, collaboration, natural supports, outcome-based planning, and fidelity to HFW principles ; Olive Crest TOM Experience for Learning Community – pg. 3, TOM scoring, supervision debriefing, coaching feedback timelines, and action planning process ; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, documentation review, observation, coaching, and CQI-informed staff development ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, CQI activities, employee development, supervision, coaching, and fidelity review responsibilities ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, use of supervision review, service trends, coaching, and CQI monitoring at the individual, program, and system level ; LA DMH MH122219 Contract – Quality Assurance/Quality Improvement requirements.
4.4 Develop a Crisis and Safety Plan
Olive Crest ensures that each youth and family has an individualized, team-developed Crisis and Safety Plan that proactively and reactively addresses potential risks and crisis situations.
Facilitators lead the Child and Family Team (CFT) in identifying safety concerns, triggers, and high-risk situations, and in developing proactive and reactive strategies that are tailored to the youth and family. These strategies are selected collaboratively with the family and prioritize cultural relevance, family voice and choice, and the use of natural supports whenever possible.
The Crisis and Safety Plan clearly outlines step-by-step responses to potential crises, including who to contact for support, available natural supports, and access to 24/7 crisis resources. The plan is documented in the youth’s case file and shared with all team members.
Development of the plan occurs within a team-based, collaborative environment, typically during CFT meetings, ensuring input from all relevant team members and alignment with the overall Plan of Care.
Crisis and Safety Plans are reviewed and updated regularly to ensure they remain individualized, effective, and responsive to changing needs. Supervisors and fidelity processes support ongoing review of plans to ensure inclusion of proactive and reactive strategies, cultural relevance, and appropriate use of natural supports.
Facilitators receive ongoing training and coaching in crisis planning, safety planning, and team-based facilitation to ensure consistent, high-quality implementation.
OLIVER supports the documentation, updating, and accessibility of Crisis and Safety Plans, ensuring that all team members have access to current information and that updates are tracked over time.
Supporting Documentation
a. Wraparound Safety Plan Procedures (310.06) – pgs. 1–3, individualized safety planning process including identification of triggers, crisis situations, proactive and reactive strategies, natural supports, emergency contacts, and 24/7 crisis response information; IE_Wrap POC Template 2026 – pgs. 3–5, individualized strategies, supports, action items, and safety-related planning integrated into the Plan of Care; Wraparound Plan of Care Policy (310.04) – pgs. 2–3, incorporation of individualized strategies, crisis response considerations, and ongoing review of supports and interventions; Facilitator: Role and Functions – pg. 1, facilitators coordinate crisis planning, assess safety concerns, and ensure plans reflect family voice, needs, and preferences ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–2, centralized documentation and access to safety plans, incident reports, team communication, and crisis-related information ; Riverside DPSS Wraparound Services Executed Contract – crisis response and safety planning requirements.
b. Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, collaborative Child and Family Team planning process involving youth, family, natural supports, and formal supports; OC Wrap Training Plan – pgs. 1–2, ongoing training related to facilitation, crisis planning, collaborative engagement, and Wraparound implementation; Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, coaching, support, and review of facilitation and planning practices; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, field observation, role play, documentation review, and CQI-informed coaching related to facilitation and safety planning ; Facilitator: Role and Functions – pg. 1, facilitators coordinate team planning, mediate differing perspectives, revise plans based on team learning, and support collaborative crisis planning ; Olive Crest TOM Experience for Learning Community – pg. 3, TOM observation, coaching feedback, supervision debriefing, and action planning processes used to strengthen collaborative team planning and facilitation .
c. Wraparound Safety Plan Procedures (310.06) – pgs. 1–3, review and updating of individualized safety strategies, crisis progression planning, natural supports, and team response expectations; Interagency Family Plan of Care Review – pgs. 1–4, review indicators assessing individualized planning, culturally relevant planning, natural/community supports, collaboration, and outcome-based strategies ; Olive Crest TOM Experience for Learning Community – pgs. 1–5, fidelity review, coaching feedback loops, supervision debriefing, and CQI processes used to strengthen planning and team practice ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, responsibilities related to CQI, documentation review, employee development, coaching, and fidelity monitoring ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, use of supervision review, service trends, coaching, and CQI monitoring at the individual, program, and system level .
Implementation
5.1 Implement The Plan of Care
Olive Crest ensures that the Plan of Care is actively implemented, monitored, and adjusted through a structured, team-based process consistent with High Fidelity Wraparound principles.
Facilitators lead the Child and Family Team (CFT) in implementing the Plan of Care by regularly reviewing strategies, action items, and assigned responsibilities during team meetings. Progress toward completion of action items and outcomes is tracked, and adjustments are made collaboratively to ensure strategies remain effective and aligned with family needs.
Meeting agendas and documentation support consistent tracking of action items, timelines, and team accountability, ensuring that all team members understand their roles and follow through on assigned tasks.
OLIVER is used to document service delivery, track completion of action items, and monitor progress in real time, allowing facilitators and supervisors to identify gaps, support staff, and ensure timely follow-through.
Staff receive ongoing training and coaching in implementing Plans of Care, including maintaining fidelity to Wraparound principles, adapting strategies as needed, and engaging families and teams in the process.
Teams intentionally recognize and celebrate progress and successes as they occur, reinforcing strengths, building motivation, and supporting continued engagement of youth, families, and team members.
Supervisors reinforce implementation through documentation review, coaching, and fidelity tools to ensure that Plans of Care are carried out effectively and consistently.
Supporting Documentation
a. Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, ongoing review of progress, strategies, action items, timelines, and team responsibilities during Child and Family Team meetings; IE_Wrap POC Template 2026 – pgs. 3–5, documentation of measurable goals, strategies, action items, responsible parties, timelines, and progress updates; Facilitator: Role and Functions – pg. 1, facilitators coordinate implementation of strategies, monitor progress, revise plans based on team learning, and ensure accountability for identified activities and supports ; Interagency Family Plan of Care Review – pgs. 2–3, review indicators assessing measurable goals, individualized strategies, action items, collaboration, and outcome-based planning ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, tracking of meetings, documentation updates, action items, service coordination, timelines, and team communication .
b. OC Wrap Training Plan – pgs. 1–2, initial and ongoing training related to Wraparound implementation, facilitation, engagement, and fidelity practice; Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, support, coaching, and reinforcement of effective service delivery practices; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, field observation, coaching, modeling, role play, documentation review, and CQI-informed staff development related to high-fidelity Wraparound implementation ; Olive Crest TOM Experience for Learning Community – pgs. 1–5, use of TOM observations, supervision debriefing, coaching feedback loops, and fidelity review to improve implementation of HFW principles and team practice ; Parent Partner: Role and Functions – pg. 2, supporting recognition of family progress, successes, and development of long-term supports throughout the Wraparound process ; Youth Partner: Role and Functions – pg. 2, reinforcing youth accomplishments, engagement, and positive progress throughout service delivery ; Wraparound Phases and Activities Policy (310.05) – pgs. 2–3, transition and maintenance activities focused on reinforcing progress, sustaining gains, and recognizing family success.
5.2 Review and Update The Plan of Care
Olive Crest ensures that the Plan of Care is continuously reviewed and updated through an ongoing, team-based process that reflects progress, evolving needs, and effectiveness of strategies.
Facilitators lead the Child and Family Team (CFT) in regularly reviewing strategies, action items, and progress toward outcomes during team meetings. These reviews occur at minimum every 30–45 days, with formal updates to the Plan of Care completed and distributed at least every 90 days, or more frequently as needed.
During these meetings, the team assesses the effectiveness of current strategies, celebrates successes, identifies new or changing needs, and collaboratively adjusts goals, strategies, and action steps to ensure continued alignment with family priorities.
Facilitators document and communicate updates through meeting minutes and case documentation, including completion of tasks, new assignments, team attendance, involvement of formal and natural supports, and use of flexible funding.
Plans of Care are updated in real time within OLIVER, allowing for individualized modifications and ensuring that all team members have access to the most current version of the plan.
Documentation tools and forms are flexible and allow for ongoing updates and customization based on the youth and family’s changing needs.
Supervisors and fidelity processes support review of Plans of Care to ensure quality, accuracy, and alignment with Wraparound principles, providing feedback to staff for continuous improvement.
Supporting Documentation
a. Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, Child and Family Team meeting process including review of goals, strategies, action items, progress, barriers, and ongoing planning; IE_Wrap POC Template 2026 – pgs. 3–5, documentation of goals, strategies, action items, responsible parties, timelines, and progress updates; Facilitator: Role and Functions – pg. 1, facilitators coordinate meetings, monitor implementation of strategies, and review progress with the team ; Interagency Family Plan of Care Review – pgs. 2–3, review indicators related to measurable goals, individualized strategies, collaboration, and outcome-based planning .
b. Wraparound Plan of Care Policy (310.04) – pgs. 2–3 section 5.0, ongoing review and modification of goals, strategies, supports, and action items; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, collaborative review and updating of team plans and strategies during Child and Family Team meetings; Facilitator: Role and Functions – pg. 1, facilitators revise plans based on team learning, progress, identified needs, and changing family circumstances ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, ongoing updates to Plans of Care, meeting records, progress notes, and team communication .
c. Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, documentation of team participation, action items, assigned responsibilities, and progress updates during Child and Family Team meetings; IE_Wrap POC Template 2026 – pgs. 3–5, documentation of assigned tasks, strategies, responsible parties, and timelines; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, centralized documentation of meetings, contacts, plans, action items, team communication, natural supports, and service coordination ; Wraparound Flex Funds Updates – pg. 1, documentation and approval requirements related to flex fund utilization and linkage to Plans of Care ; Wraparound Flex Fund Expenditure Form – pg. 1, documentation of individualized expenditures, approvals, and alignment with identified needs and team planning .
d. IE_Wrap POC Template 2026 – pgs. 1–5, customizable and individualized planning structure reflecting changing strengths, needs, goals, strategies, and team responsibilities; Strengths-Needs Summary Template – pgs. 1–2, ongoing updating of family strengths, needs, barriers, and cultural information; Interagency Family Plan of Care Review – pgs. 1–4, review indicators assessing individualized planning, culturally relevant planning, multiple perspectives, and updated information throughout the Plan of Care ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, centralized system supporting ongoing documentation updates, revisions, communication, and access to current planning information across the Wraparound team .
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
Olive Crest ensures that Child and Family Teams (CFTs) remain cohesive, collaborative, and effective by intentionally building trust, maintaining team agreements, and continuously strengthening both formal and natural supports.
Facilitators establish and reinforce team agreements that guide communication, participation, and decision-making. These agreements are reviewed regularly during team meetings to maintain a respectful, collaborative environment and address any challenges that arise.
Facilitators actively monitor team dynamics and engagement, using structured facilitation and team-building strategies to promote trust, shared ownership, and commitment among team members.
Natural supports are continually identified, developed, and integrated into the team throughout the Wraparound process. Their involvement is monitored over time, with an intentional focus on increasing reliance on informal supports and strengthening sustainable networks.
When new team members are added, facilitators provide orientation to the Wraparound process, including review of the Plan of Care, team roles, expectations, and current strategies. Team-building activities are used to integrate new members and maintain cohesion.
Staff receive ongoing training and coaching in team facilitation, engagement, and conflict resolution to support effective team functioning. Supervisors reinforce these practices through observation, documentation review, and reflective supervision.
OLIVER supports tracking of team membership, participation, and communication, allowing teams and supervisors to monitor engagement and ensure continuity as team composition evolves.
Supporting Documentation
a. Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, Child and Family Team meeting process including team participation expectations, collaborative review, and ongoing discussion of team functioning and responsibilities; Wraparound Family Team Development Procedures (310.11) – pgs. 1–2, development of team membership, team roles, collaboration expectations, and engagement of formal, informal, and natural supports; IE_Wrap POC Template 2026 – pgs. 1–3, documentation of team members, roles, responsibilities, and collaborative planning activities; Facilitator: Role and Functions – pg. 1, facilitators coordinate collaborative team processes and support shared ownership and accountability across team members ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–2, centralized documentation of meetings, team participation, plans, and ongoing team communication .
b. Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, support, coaching, and reinforcement of effective facilitation and engagement practices; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, field observation, role play, modeling, documentation review, and CQI-informed coaching related to facilitation and team development ; Olive Crest TOM Experience for Learning Community – pgs. 1–5, use of TOM observations, coaching feedback loops, supervision debriefing, and fidelity review processes focused on teamwork, engagement, and skilled facilitation ; Facilitator: Role and Functions – pg. 1, facilitators engage youth, family members, natural supports, and formal supports in collaborative planning and shared decision-making .
c. Interagency Family Plan of Care Review – pg. 2, review indicators assessing use of natural/community supports in strategies, action items, and collaborative planning ; Olive Crest TOM Experience for Learning Community – pg. 5, monitoring and improvement of “Use of Natural Supports” through fidelity review, coaching, and CQI processes ; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, use of observation, documentation review, WFI-EZ, and TOMS to provide coaching and improve team functioning and fidelity ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, CQI activities, documentation review, coaching, supervision, and fidelity monitoring responsibilities ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, use of supervision review, engagement trends, coaching, and CQI monitoring at the individual, program, and system level
d. Wraparound Enrollment Procedures (310.02) – pgs. 1–4, orientation to Wraparound services, team process, and family engagement expectations; Inland Wrap Orientation – pgs. 1–4, overview of HFW principles, phases, team roles, family voice and choice, and collaborative planning expectations; Wraparound Family Team Development Procedures (310.11) – pgs. 1–2, engagement and orientation of formal supports, natural supports, and team participants; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, collaborative team process, review of current plans and strategies, and ongoing team participation expectations; Facilitator: Role and Functions – pg. 1, facilitators support engagement, orientation, coordination, and communication among all team members ; Parent Partner: Role and Functions – pg. 1, assisting families and supports in understanding the Wraparound process and strengthening engagement within the team .
Transition
6.1 Develop a Transition Plan
Olive Crest ensures that transition planning is intentional, individualized, and driven by youth and family readiness, with a focus on sustaining progress beyond formal Wraparound services.
Facilitators lead the Child and Family Team (CFT) in identifying readiness for transition based on progress toward needs, goals, and team mission benchmarks that have been monitored throughout the Wraparound process.
Once readiness is determined, the facilitator guides the team in developing a formal individualized Transition Plan that outlines ongoing needs, services, and supports that will remain in place after discharge. This includes strategies to transfer responsibilities from Wraparound staff to natural supports and community-based resources.
Transition planning occurs in a collaborative team setting, ensuring that youth, family, natural supports, and system partners are actively involved in identifying and confirming ongoing supports.
The team verifies that all identified supports are accessible and sustainable, and that the family understands how to utilize these resources. For adoptive families, staff provide education and linkage to post-adoption services (AAP) to support continued stability and success after transition.
The Transition Plan is documented in the case record, distributed to all team members, and reinforced through ongoing discussion and preparation prior to discharge.
Facilitators receive ongoing training and coaching in transition planning and team facilitation to ensure consistent, high-quality implementation of this process.
Supporting Documentation
a. Wraparound Transition Policy (310.18) – pgs. 1–2, transition readiness process based on progress toward goals, stabilization of needs, sustainability of supports, and team agreement; Wraparound Phases and Activities Policy (310.05) – pgs. 2–3, transition phase activities focused on monitoring progress, evaluating readiness, and sustaining gains achieved during Wraparound; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, ongoing review of goals, strategies, progress, and transition readiness during Child and Family Team meetings; Facilitator: Role and Functions – pg. 1, facilitators monitor progress, revise plans based on team learning, and guide transition planning throughout the Wraparound process ; Interagency Family Plan of Care Review – pgs. 2–3, review indicators assessing measurable goals, outcome-based planning, and progress toward identified outcomes .
b. Wraparound Transition Policy (310.18) – pgs. 1–2, development of individualized transition plans identifying ongoing needs, services, supports, and sustainability planning; IE_Wrap POC Template 2026 – pgs. 3–5, documentation of goals, supports, action items, responsible parties, and transition-related planning; Wraparound Plan of Care Policy (310.04) – pgs. 2–3, ongoing updating and communication of individualized planning documents; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, collaborative review and communication of transition planning activities and supports during Child and Family Team meetings; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, centralized documentation, storage, updating, and communication of Plans of Care, transition information, and team records ; Riverside DPSS Wraparound Services Executed Contract – pg. 32, discharge and transition planning expectations.
c. OC Wrap Training Plan – pgs. 1–2, initial and ongoing training related to facilitation, collaborative planning, Wraparound implementation, and transition processes; Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, support, coaching, and reinforcement of effective facilitation and planning practices; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, field observation, coaching, role play, documentation review, and CQI-informed support related to facilitation and transition planning ; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, collaborative Child and Family Team meeting process involving youth, family, natural supports, and formal supports in ongoing planning and decision-making; Facilitator: Role and Functions – pg. 1, facilitators engage team members in collaborative planning, shared decision-making, and ongoing plan revision throughout the Wraparound process ; Olive Crest TOM Experience for Learning Community – pg. 3, TOM observation, supervision debriefing, coaching feedback, and action planning process used to strengthen facilitation and collaborative planning practices .
d. Wraparound Transition Policy (310.18) – pgs. 1–2, transition planning focused on sustainability of supports, continued access to services, and long-term stability following discharge; Wraparound Phases and Activities Policy (310.05) – pgs. 2–3, transition and maintenance activities supporting continuity of care and ongoing connection to formal and natural supports; Parent Partner: Role and Functions – pg. 2, assisting families in strengthening permanent supports, community connections, and long-term sustainability beyond formal services ; Youth Partner: Role and Functions – pg. 2, reinforcing youth connections to supportive relationships and ongoing community supports during transition ; OLIVER – DATA SYSTEM DESCRIPTION – pg. 3, aftercare follow-up tracking and continuity of care monitoring following discharge ; Riverside DPSS Wraparound Services Executed Contract – pg. 32, discharge and transition planning expectations including continuity of services and supports.
6.2 Develop a Post-Transition Safety Plan
Olive Crest ensures that youth and families transition from Wraparound services with an updated, individualized Crisis and Safety Plan that prepares them to effectively manage potential future crises using sustainable supports.
Facilitators lead the Child and Family Team (CFT) in reviewing and updating the existing Crisis and Safety Plan—or developing a transition-specific plan—to reflect anticipated risks and needs following discharge from formal Wraparound services. These plans identify potential post-transition crisis situations and include proactive and reactive strategies tailored to the youth and family.
Youth and families play a central role in identifying strategies, ensuring that the plan reflects their preferences, cultural values, and strengths. Plans emphasize the use of natural supports and community-based resources that will remain in place after Wraparound services end.
Development of the post-transition safety plan occurs in a team-based, collaborative environment, ensuring that ongoing supports are clearly identified, engaged, and prepared to respond as needed.
The updated Crisis and Safety Plan is documented in the case file, shared with all team members, and aligned with the overall Transition Plan to ensure continuity of care and support beyond formal services.
Supervisors and fidelity processes support the review of safety plans to ensure inclusion of individualized strategies, progression of proactive and reactive responses, cultural relevance, and appropriate integration of natural supports for continuous quality improvement.
Facilitators receive ongoing training and coaching in safety planning, crisis response, and transition planning to ensure consistent, high-quality implementation of this process.
This process is further reinforced through county contract requirements that mandate crisis planning, safety planning, and continuity of care as part of service delivery expectations and transition processes.
Supporting Documentation
a. Wraparound Safety Plan Procedures (310.06) – pgs. 1–3, individualized safety planning including proactive and reactive crisis strategies, identification of supports, crisis response planning, and ongoing review/update of safety plans; Wraparound Phases and Activities Policy (310.05) – pgs. 2–3, transition phase activities supporting continuity of care, maintenance of gains, and strengthening of natural supports; IE_Wrap POC Template 2026 – pgs. 3–5, individualized goals, strategies, supports, and action planning that can be updated throughout transition planning; Parent Partner: Role and Functions – pg. 2, strengthening family and natural supports to sustain progress beyond formal services ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, centralized documentation and updating of safety plans, Plans of Care, transition records, and team communication .
b. Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, collaborative Child and Family Team process involving youth, family, natural supports, and formal supports in planning and review activities; OC Wrap Training Plan – pgs. 1–2, ongoing training related to facilitation, crisis planning, collaborative planning, and Wraparound implementation; Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, support, coaching, and reinforcement of effective facilitation and planning practices; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, field observation, modeling, role play, documentation review, and CQI-informed coaching related to facilitation and safety planning ; Facilitator: Role and Functions – pg. 1, facilitators coordinate collaborative planning, mediate differing perspectives, revise plans based on team learning, and support ongoing crisis and safety planning ; Olive Crest TOM Experience for Learning Community – pg. 3, TOM observation, supervision debriefing, coaching feedback, and action planning process used to strengthen collaborative facilitation and planning practices .
c. Wraparound Safety Plan Procedures (310.06) – pgs. 1–3, review and updating of individualized safety strategies, progression of crisis response planning, natural supports, and team response expectations; Interagency Family Plan of Care Review – pgs. 1–4, review indicators assessing individualized planning, culturally relevant planning, collaboration, natural/community supports, and outcome-based strategies ; Olive Crest TOM Experience for Learning Community – pgs. 1–5, fidelity review, coaching feedback loops, supervision debriefing, and CQI processes used to strengthen team planning and implementation practices ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, responsibilities related to CQI, documentation review, coaching, supervision, and fidelity monitoring ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, use of supervision review, service trends, coaching, and CQI monitoring at the individual, program, and system level .
6.3 Create a Commencement and Celebrate Success
Olive Crest ensures that the conclusion of Wraparound services is recognized as a meaningful and positive milestone through intentional celebration of the youth and family’s progress and success.
Facilitators lead the Child and Family Team (CFT) in planning and implementing a transition celebration that reflects the youth and family’s culture, values, and preferences. Celebrations are individualized and may include recognition of accomplishments, sharing of progress, and acknowledgment of the strengths and relationships developed throughout the Wraparound process.
Celebrations are planned collaboratively with the family and team, ensuring that the experience is meaningful, culturally relevant, and aligned with family voice and choice.
Olive Crest supports this practice through administrative structures that allow staff the flexibility and resources to participate in transition celebrations. This includes the use of Flex Funds, staff time for planning and attending celebrations, and connection to community-based supports that may continue involvement beyond Wraparound services.
Child and Family Team meetings and documentation reflect recognition of progress and accomplishments, reinforcing a strengths-based and success-oriented approach throughout the transition process.
Facilitators receive training and coaching on maintaining a strengths-based approach and celebrating successes as part of the Wraparound model, ensuring consistency in practice.
This process is further supported through contractual expectations that emphasize family-centered, community-based service delivery and transition planning that promotes positive outcomes and sustained success.
Supporting Documentation
a. Wraparound Phases and Activities Policy (310.05) – pgs. 2–3, transition phase activities emphasizing celebration of progress, maintenance of gains, and strengthening natural supports; Parent Partner: Role and Functions – pg. 2, supporting families in recognizing accomplishments, strengthening long-term supports, and reinforcing family voice and choice throughout transition ; Youth Partner: Role and Functions – pg. 2, reinforcing youth accomplishments, engagement, supportive relationships, and individualized transition experiences ; Interagency Family Plan of Care Review – pg. 1, review indicators assessing culturally relevant planning and individualized family-centered practice throughout the Wraparound process .
b. Wraparound Flex Funds Updates – pg. 1, flex fund approval and utilization process supporting individualized family needs and transition-related supports ; Wraparound Flex Fund Expenditure Form – pg. 1, documentation and approval process for individualized expenditures aligned with family needs and Plans of Care ; Family Preservation Personnel Policy (300.09) – pgs. 1–2, expectations related to individualized, family-centered service delivery, community collaboration, and engagement of natural/community supports; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, responsibilities related to supporting staff, coordination of resources, coaching, and oversight of individualized service delivery ; Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, collaboration regarding community partnerships, resource coordination, flex fund discussions, and support of family-centered Wraparound practices ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, tracking of flex funds, service coordination, team communication, and community resource linkage activities .
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
Olive Crest ensures that youth and family voice is central to decision-making at all levels of the Wraparound program, including service planning, implementation, workforce development, and continuous quality improvement.
At the practice level, youth and families are active decision-makers within the Child and Family Team (CFT), where they guide the development and implementation of the Plan of Care, ensuring that services reflect their needs, preferences, and goals.
At the program level, Olive Crest utilizes formal feedback mechanisms including the Wraparound Fidelity Index (WFI-EZ) and Family Attachment and Changeability Index (FACI-8) to gather youth and family perspectives on their experience, engagement, and outcomes.
This feedback is reviewed through supervision and CQI processes and is used to inform:
Service planning and delivery practices
Staff training and workforce development
Program improvements and operational decision-making
Additionally, informal feedback is gathered through ongoing communication with families, quality assurance follow-up, and team interactions, allowing for real-time adjustments to services and supports.
Family voice is also incorporated into broader program development through leadership review of outcome data, feedback trends, and service delivery patterns, ensuring that policies, procedures, and program design reflect the needs and experiences of the families served.
OLIVER supports the tracking and integration of family feedback, outcome data, and service trends, allowing leadership and supervisors to use data-informed decision-making to improve practice and outcomes.
These processes are further reinforced through county contract requirements that emphasize family-centered practice, outcome monitoring, and continuous quality improvement.
Supporting Documentation
a. Parent Partner: Role and Functions – pgs. 1–2, parent partners support advocacy, family voice and choice, participation in program improvement activities, and collaboration regarding service delivery and Wraparound implementation ; Youth Partner: Role and Functions – pgs. 1–2, youth voice, participation, and feedback are incorporated into planning and program improvement activities ; Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, collaborative discussions regarding Wraparound implementation, service coordination, quality improvement activities, and system planning involving multidisciplinary stakeholders ; Wraparound Service Philosophy (310.15) – pgs. 1–2, organizational commitment to family voice and choice, collaboration, and individualized family-centered planning; Olive Crest TOM Experience for Learning Community – pgs. 1–5, implementation of fidelity review, coaching feedback loops, and CQI activities informed by team and family experience .
b. Wraparound Outcome Reporting Policy (310.03) – pgs. 1–2, collection and use of family feedback, WFI-EZ results, satisfaction surveys, and outcome measures to support CQI and program improvement; WFI-EZ Caregiver Form – pgs. 1–4, caregiver feedback regarding Wraparound experience, participation, teamwork, and service effectiveness; Olive Crest TOM Experience for Learning Community – pgs. 1–5, use of TOM observations, fidelity review, coaching feedback loops, supervision debriefing, and program improvement activities informed by family and team experience ; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, use of WFI-EZ, TOMS, documentation review, and CQI-informed coaching to improve staff development and fidelity practice ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, responsibilities related to CQI activities, workforce development, supervision, coaching, and implementation oversight ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, use of engagement trends, supervision review, coaching, service monitoring, and CQI processes at the individual, program, and system level ; LA DMH MH122219 Contract – Quality Assurance/Quality Improvement requirements.
7.2 Community Leadership Team
Olive Crest actively participates in county-led Community Leadership Team (CLT) structures to support system-level collaboration, alignment with California Wraparound Standards, and continuous quality improvement.
Program leadership, including the Program Director and designated representatives, participate in regional and county-level meetings and collaboratives, contributing provider perspective, sharing program data, and supporting cross-system coordination efforts.
Through this participation, Olive Crest collaborates with county partners, system stakeholders, and other providers to:
Identify and address system-level barriers impacting youth and families
Support alignment with High Fidelity Wraparound principles and practices
Contribute to discussions related to service delivery, access, and outcomes
Participate in cross-agency training and community collaboration efforts
Olive Crest also shares program-level data, trends, and feedback from youth and families to inform system-level decision-making and CQI efforts.
Formal communication between Olive Crest and county partners occurs through regular meetings, reporting processes, and contract monitoring activities, ensuring alignment between program operations and broader system expectations.
Participation in these structures is further reinforced through contractual expectations requiring collaboration with county agencies, engagement in system-level coordination, and adherence to Wraparound service delivery standards.
Supporting Documentation
a. Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, participation in multidisciplinary collaborative meetings focused on Wraparound implementation, service coordination, quality improvement, and community partnership development ; Riverside County Wraparound Collaborative Agenda – pg. 1, collaborative review of implementation activities, fidelity processes, resource coordination, and systems collaboration .
7.3 Eligibility and Equal Access
Olive Crest ensures equitable access to Wraparound services by accepting referrals based on county-established eligibility criteria and serving youth and families with complex and high-acuity needs without exclusion based on severity or presentation.
All referrals are received through county partners and community referral sources, and once eligibility is confirmed, services are initiated in alignment with required timelines. Olive Crest does not exclude families based on the intensity of their needs and is structured to support youth with complex behavioral, emotional, and system-involved challenges.
Staffing structures and caseload assignments are intentionally designed to ensure that families receive the frequency and intensity of services required, including the ability to respond to crises and provide 24/7 support when needed.
Program capacity, including staffing levels, supervision, and service coordination, is aligned with contractual expectations to ensure that families have access to a full array of Wraparound services and supports.
Olive Crest collaborates with county partners, schools, and community organizations to ensure that Wraparound services are accessible and known to referral sources. Outreach efforts include ongoing communication with system partners and participation in community-based collaborations to increase awareness and access to services.
OLIVER supports tracking of referrals, enrollment timelines, service delivery, and demographic data, allowing the program to monitor access, engagement, and service utilization to ensure equitable service delivery.
Contractual requirements further reinforce equitable access, staffing expectations, service capacity, and the provision of crisis response and Wraparound services to eligible youth and families.
Supporting Documentation
a. Wraparound Enrollment Procedures (310.02) – pgs. 1–4, referral, screening, engagement, and enrollment procedures for eligible youth and families; Riverside DPSS Wraparound Services Executed Contract – pgs. 4–6, eligibility criteria, referral requirements, and expectations for serving youth with complex behavioral, emotional, and placement stability needs; Family Preservation Personnel Policy (300.09) – pgs. 1–2, expectations related to individualized, family-centered, strengths-based service delivery for youth and families with complex needs; Wraparound Service Philosophy (310.15) – pgs. 1–2, commitment to family voice and choice, persistence, individualized planning, and serving youth with intensive and complex needs; Facilitator: Role and Functions – pg. 1, facilitators support individualized planning and service coordination for youth and families with multiple and complex needs .
b. Family Preservation Personnel Policy (300.09) – pgs. 1–2, staffing qualifications, competency expectations, and service delivery requirements supporting intensive family-centered services; Staff Supervision Policy (402.2) – pg. 1, supervisory oversight, consultation, support, and review of service delivery practices; Riverside DPSS Wraparound Services Executed Contract – pgs. 23–24 and pg. 32, expectations regarding staffing capacity, service intensity, crisis response accessibility, Child and Family Team participation, and continuity of care; Wraparound Safety Plan Procedures (310.16) – pgs. 1–3, crisis response planning, emergency response coordination, and 24/7 support processes; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, tracking of staffing assignments, service activity, crisis response coordination, documentation, and supervisory oversight ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
Olive Crest ensures that fiscal practices, contracts, and program operations are aligned with the California High Fidelity Wraparound (HFW) model and support full implementation of Wraparound principles and standards.
Funding for Wraparound services is established through county contracts that define service expectations, staffing structures, and required components of high-fidelity service delivery. These contracts support the provision of individualized, intensive, community-based services designed to meet the complex needs of youth and families.
Contracts include funding for required staffing roles, including Facilitators, Behavior Specialists, Parent Partners, and Clinicians, ensuring that teams are adequately resourced to deliver high-quality, team-based services.
Workforce development is supported through funding for ongoing training, coaching, and supervision to maintain fidelity to the Wraparound model and ensure staff competency in engagement, planning, implementation, and transition practices.
Funding also supports the use of data collection and management systems, including OLIVER, which is used to track referrals, service delivery, outcomes, documentation, and quality improvement efforts. This ensures that data-informed decision-making and CQI processes are fully integrated into program operations.
Additionally, contracts and program structures allow for the use of flexible funding to address individualized family needs, further supporting the Wraparound principle of individualized, needs-driven care.
Through these combined fiscal practices, Olive Crest ensures that funding supports not only service delivery, but also the infrastructure required to sustain high-fidelity Wraparound implementation, including staffing, training, data systems, and individualized supports.
Supporting Documentation
a. Riverside DPSS Wraparound Services Executed Contract – pgs. 4–6, description of Wraparound services, individualized planning, Child and Family Team expectations, crisis response, and intensive community-based supports; County of Orange Wraparound Contract – pg. 23 section 5.4.1 and section 5.4.2, expectations related to engagement, Child and Family Team meetings, individualized planning, and high-fidelity Wraparound implementation; Wraparound Service Philosophy (310.15) – pgs. 1–2, commitment to individualized, family-driven, strengths-based, and community-based services; Wraparound Plan of Care Policy (310.04) – pgs. 1–3, individualized Plans of Care developed to address identified strengths, needs, culture, and family preferences.
b. Family Preservation Personnel Policy (300.09) – pgs. 1–2, staffing qualifications, competencies, and workforce expectations related to Wraparound implementation; Staff Supervision Policy (402.2) – pg. 1, supervisory oversight, coaching, consultation, and workforce support expectations; OC Wrap Training Plan – pgs. 1–2, initial and ongoing workforce development and training requirements for Wraparound staff; Facilitator: Role and Functions – pgs. 1–2, responsibilities related to facilitation, engagement, planning, coordination, and implementation of HFW services ; Parent Partner: Role and Functions – pgs. 1–2, peer support, advocacy, engagement, and family voice responsibilities ; Youth Partner: Role and Functions – pgs. 1–2, youth engagement, advocacy, and supportive relationship responsibilities ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, supervision, coaching, CQI, and staffing oversight responsibilities ; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, fidelity coaching, observation, documentation review, and workforce development responsibilities ; Riverside DPSS Wraparound Services Executed Contract – pgs. 23–24, staffing, supervision, crisis response, and service delivery expectations.
c. Wraparound Outcome Reporting Policy (310.03) – pgs. 1–2, collection and review of outcome measures, WFI-EZ, IP-CANS/CANS, and CQI-related data; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–4, centralized electronic documentation system supporting Plans of Care, case notes, assessments, meeting records, service tracking, reporting, supervision review, and CQI monitoring ; Olive Crest TOM Experience for Learning Community – pgs. 1–5, use of TOM observations, fidelity review, coaching feedback loops, and data-informed CQI processes ; LA DMH MH122219 Contract – Quality Assurance/Quality Improvement and documentation requirements; Riverside DPSS Wraparound Services Executed Contract – documentation, reporting, and outcome tracking requirements pg. 32.
8.2 Equitable Funding Across System Partners
Olive Crest supports equitable funding across system partners by collaborating with county agencies and community partners to maximize available resources and ensure that youth and families receive comprehensive, coordinated services.
As a contracted Wraparound provider, Olive Crest operates within funding structures established by county partners, including Child Welfare and Behavioral Health, and aligns service delivery with these systems to ensure that available resources are effectively utilized to meet family needs.
Olive Crest leverages multiple funding streams across its program initiatives, including Child Welfare (DPSS), Behavioral Health (Medi-Cal eligible services), and Adoption Assistance Program (AAP) funding, to support a wide range of services and ensure access for diverse populations.
Through collaboration with system partners, the program coordinates services across agencies, ensuring that funding sources are used appropriately and that services are not duplicated. This includes coordination with mental health providers, schools, probation (when applicable), and community-based organizations to align services and supports.
Olive Crest also ensures that Medi-Cal services are integrated into care when youth are eligible, allowing for clinical services to be funded through Behavioral Health while Wraparound services provide coordination and support.
Contractual agreements define service expectations, funding structures, and coordination requirements, reinforcing shared responsibility across system partners and supporting equitable access to services.
Internally, Olive Crest utilizes OLIVER to track services, funding-related activities, and coordination efforts, supporting transparency and accountability in how services are delivered across systems.
Supporting Documentation
a. Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, collaborative review of community resources, service coordination, funding discussions, and cross-system partnership activities involving Child Welfare, Behavioral Health, schools, and community partners ; Riverside County Wraparound Collaborative Agenda – pg. 1, multidisciplinary collaboration regarding Wraparound implementation, resource coordination, and systems planning ; Family Preservation Personnel Policy (300.09) – pgs. 1–2, expectations related to community collaboration, resource identification, and linkage to supports and services; Wraparound Service Philosophy (310.15) – pgs. 1–2, emphasis on collaboration, individualized planning, and use of community-based and natural supports.
b. Riverside DPSS Wraparound Services Executed Contract – pgs. 23–24 and pg. 32, service funding expectations, staffing requirements, reporting, crisis response, and individualized service coordination; Wraparound Flex Funds Updates – pg. 1, procedures for use, approval, and tracking of individualized flex fund expenditures aligned with Plans of Care ; Wraparound Flex Fund Expenditure Form – pg. 1, documentation and approval process for individualized expenditures and resource utilization ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, tracking and review of service utilization, supervision review, reporting, and CQI processes related to program operations and resource management .
c. Riverside DPSS Wraparound Services Executed Contract – pgs. 4–6 and pgs. 23–24, collaborative service delivery expectations and coordination among Child Welfare, Behavioral Health, schools, and community-based partners; LA DMH MH122219 Contract – Behavioral Health service and Quality Improvement requirements; Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, multidisciplinary collaboration and coordinated planning across Children’s System of Care partners including Behavioral Health and Child Welfare .
d. Riverside DPSS Wraparound Services Executed Contract – pgs. 4–6 and pg. 32, funding and service delivery expectations supporting individualized Wraparound services; County of Orange Wraparound Contract – pgs. 23–24 and pgs. 76–79, expectations related to staffing, training, and service implementation; LA DMH MH122219 Contract – Quality Assurance/Quality Improvement and Behavioral Health service requirements; Wraparound Flex Funds Updates – pg. 1, flex funding processes supporting individualized family needs and reduction of service barriers ; Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, collaborative resource coordination and systems partnership discussions to support access to services and supports across the Children’s System of Care
8.3 Cost Savings are Reinvested
Description of Practice
N/A – Provider Role
As a contracted Wraparound provider, Olive Crest does not directly manage or control system-level cost savings or reinvestment decisions across the Children’s System of Care, as these processes are administered at the county level.
However, Olive Crest ensures that all allocated funding is utilized in alignment with contract requirements to support high-fidelity Wraparound service delivery, including staffing, training, supervision, and service coordination.
Internally, Olive Crest prioritizes reinvestment of program resources to strengthen service delivery and outcomes for youth and families. This includes ongoing investment in:
Workforce development (training, coaching, supervision)
Data systems and reporting infrastructure (OLIVER)
Program expansion and service enhancements when feasible
Olive Crest maintains fiscal accountability through contract compliance, monitoring processes, and reporting requirements, ensuring that funds are used effectively to meet the needs of youth and families.
Contractual agreements reinforce expectations for responsible use of funds, service delivery, and program performance, ensuring alignment with system goals and Wraparound standards.
Supporting Documentation
a. Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, collaborative discussions regarding Wraparound implementation, resource coordination, program operations, and community/system partnership activities ; Riverside County Wraparound Collaborative Agenda – pg. 1, review of implementation activities, systems collaboration, and program planning with community stakeholders ; Wraparound Flex Funds Updates – pg. 1, documented process for use, approval, tracking, and accountability of individualized flex fund expenditures aligned with family needs and Plans of Care ; Wraparound Flex Fund Expenditure Form – pg. 1, tracking and approval documentation for individualized expenditures and resource utilization ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, reporting, supervision review, tracking of service utilization, documentation practices, and CQI monitoring processes used to support program oversight and accountability ; LA DMH MH122219 Contract – Quality Assurance/Quality Improvement and reporting requirements.
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied., (c) N/A (AAP funded Wraparound)
Olive Crest ensures that youth and families have timely access to flexible funds to meet urgent and individualized needs that cannot be addressed through traditional funding sources.
Flexible funds are integrated into the Wraparound model and are available to support the Plan of Care and team mission, allowing teams to address barriers and stabilize families in real time.
Facilitators and Child and Family Teams (CFTs) identify potential flex fund requests during team meetings, ensuring that requests are team-based and aligned with family voice and choice.
A defined approval process is in place to evaluate requests based on established criteria, including whether the request:
Supports the team mission and Plan of Care
Builds on family strengths
Meets identified needs
Is culturally relevant
Strengthens natural supports and/or community capacity
Represents a reasonable and appropriate use of funds
Includes consideration for sustainability
Requests are reviewed and approved through supervisory and/or administrative processes to ensure accountability and alignment with program expectations.
Olive Crest prioritizes timely access to flexible funds, particularly for urgent needs, ensuring that families receive support when it is most impactful.
All flex fund requests, approvals, and expenditures are documented and tracked within OLIVER, including details on purpose, amount, and alignment with the Plan of Care. This allows for monitoring, reporting, and quality improvement.
Processes are in place to communicate decisions to teams and families, including rationale when requests are not approved, allowing for transparency and team discussion.
Supervisors and program leadership review flex fund utilization as part of CQI processes to ensure alignment with Wraparound principles and to evaluate effectiveness in supporting family outcomes.
Contractual requirements further support the availability and appropriate use of flexible funds as part of individualized, family-centered service delivery.
Supporting Documentation
a. Wraparound Flex Funds Updates – pg. 1, flex fund approval, utilization, accountability, and individualized funding expectations aligned with youth and family needs ; Wraparound Flex Fund Expenditure Form – pg. 1, documentation and approval process for individualized expenditures and resource utilization ; Riverside DPSS Wraparound Services Executed Contract – pgs. 4–6 and pg. 32, individualized service planning and resource coordination expectations supporting youth and family needs; Wraparound Service Philosophy (310.15) – pgs. 1–2, commitment to individualized, family-centered, culturally responsive, and community-based supports.
b. Wraparound Flex Funds Updates – pg. 1, procedures related to requesting, reviewing, approving, documenting, and communicating flex fund decisions; evaluation of requests based on individualized need, family voice and choice, team recommendations, sustainability, cultural relevance, and alignment with Plans of Care ; Wraparound Flex Fund Expenditure Form – pg. 1, documentation of requests, justification, supervisory approval, and alignment with identified needs and team planning ; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, collaborative Child and Family Team process including review of individualized needs, strategies, supports, and resource coordination; Facilitator: Role and Functions – pg. 1, facilitators coordinate team planning, identify barriers, and support individualized strategies and resource access based on family voice and team recommendations ; Parent Partner: Role and Functions – pg. 1, assisting families in advocacy, resource access, and identification of individualized supports and barriers ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, documentation, communication, and supervisory review processes related to plans, supports, service coordination, and individualized resource utilization
8.5 Collaborative Oversight of Flex Funds
Olive Crest ensures collaborative oversight and transparent management of flexible funds through structured processes that involve both internal leadership and alignment with county funding partners.
Flexible fund requests are initiated and discussed within the Child and Family Team (CFT), ensuring that recommendations are team-based and aligned with the Plan of Care and family needs.
All flex fund requests—whether approved or denied—are documented with detailed information including the amount requested, purpose of the request, and team recommendation, ensuring full transparency and accountability.
Olive Crest maintains a centralized tracking process for flexible funds through OLIVER and administrative oversight, allowing program leadership to monitor utilization, identify trends, and ensure equitable access across families served.
Flexible funds are managed in a manner that ensures availability to meet the needs of all families, with oversight processes in place to prioritize urgent and high-impact requests and maintain sustainability of available funds.
Information regarding flex fund use is shared through reporting, supervision, and contract monitoring processes with county partners, supporting collaborative oversight between providers and funders and ensuring alignment with funding expectations.
Supervisors and program leadership review flex fund utilization as part of continuous quality improvement efforts to ensure that funds are used effectively, equitably, and in alignment with Wraparound principles.
Supporting Documentation
a. Wraparound Flex Funds Updates – pg. 1, procedures related to flex fund requests, approval review, documentation, supervisory oversight, communication, and accountability processes including individualized justification and alignment with team planning ; Wraparound Flex Fund Expenditure Form – pg. 1, documentation of request amount, identified need, purpose, approval process, and linkage to the individualized Plan of Care and team recommendations ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, centralized documentation and tracking of service coordination, team planning, individualized supports, supervisory review, and reporting processes ; Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, collaborative discussions regarding resource coordination, program implementation, and systems partnership activities involving providers and system partners .
b. Wraparound Flex Funds Updates – pg. 1, flex fund management and allocation process supporting individualized family needs across the Wraparound program ; Riverside DPSS Wraparound Services Executed Contract – pgs. 4–6 and pg. 32, expectations regarding individualized service delivery, resource coordination, and support of youth and families with complex needs; Family Preservation Personnel Policy (300.09) – pgs. 1–2, expectations related to family-centered planning, individualized service delivery, and community resource coordination; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, monitoring, supervisory review, reporting, and CQI processes supporting accountability and program oversight of individualized supports and services .
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
Olive Crest ensures that flexible funding and program resources are utilized in a manner that prioritizes the individualized needs of youth and families, rather than being limited by the restrictions of any single funding source.
Wraparound services are delivered within a blended funding structure, including Child Welfare (DPSS), Behavioral Health (including Medi-Cal where applicable), and other program-specific funding streams. This allows the program to coordinate services and resources across systems to meet the full range of family needs.
Flexible funds are used to address needs that cannot be met through traditional funding sources, ensuring that families have access to timely and individualized supports regardless of funding limitations tied to specific programs.
When limitations exist within a particular funding source, Olive Crest works collaboratively with system partners to identify alternative funding options, community resources, or internal program supports to meet the identified need. This ensures that services remain needs-driven and aligned with Wraparound principles rather than constrained by funding restrictions.
Flex fund requests are evaluated based on their alignment with the Plan of Care, team mission, and family needs—not based on the limitations of a specific funding stream—ensuring equitable access for all families served.
Contracts and program structures support this approach by emphasizing individualized, family-centered service delivery and coordination across systems, allowing for flexibility in how resources are utilized.
OLIVER supports tracking of flex fund usage, service coordination, and funding-related activities, allowing the program to monitor how resources are utilized across funding streams and to ensure that family needs are being met effectively.
Supporting Documentation
a. Riverside DPSS Wraparound Services Executed Contract – pgs. 4–6 and pg. 32, individualized service delivery, resource coordination, and funding expectations supporting youth and families with complex needs; LA DMH MH122219 Contract – Behavioral Health and Quality Improvement service requirements supporting coordinated system involvement; County of Orange Wraparound Contract – pgs. 23–24 and pgs. 76–79, staffing, service delivery, and training expectations supporting Wraparound implementation; Wraparound Flex Funds Updates – pg. 1, flex fund utilization and approval processes supporting individualized youth and family needs across the Wraparound program ; Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, collaborative coordination among system partners regarding implementation, resources, and supports across the Children’s System of Care .
b. Wraparound Flex Funds Updates – pg. 1, individualized review and approval processes supporting access to flexible supports aligned with identified needs and Plans of Care ; Family Preservation Personnel Policy (300.09) – pgs. 1–2, expectations related to community resource coordination, individualized service planning, and family-centered support; Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, collaborative problem-solving, resource coordination, and systems partnership activities to support service access and reduce barriers ; Facilitator: Role and Functions – pg. 1, facilitators coordinate supports, address barriers, and assist teams in identifying individualized resources and strategies to meet family needs ; Parent Partner: Role and Functions – pg. 1, assisting families in accessing supports, resources, and advocacy to address identified barriers and needs .
c. Wraparound Service Philosophy (310.15) – pgs. 1–2, commitment to individualized, family-driven, culturally responsive, and strengths-based service delivery; Wraparound Flex Funds Updates – pg. 1, flex fund review and approval processes based on individualized need, team recommendation, family voice and choice, and alignment with Plans of Care rather than a single funding source limitation ; Wraparound Flex Fund Expenditure Form – pg. 1, documentation of individualized requests, identified needs, and approval review processes ; Riverside DPSS Wraparound Services Executed Contract – pgs. 4–6, individualized planning and coordinated service expectations supporting access to resources for youth and families with complex needs; Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, collaborative coordination and systems partnership activities supporting access to individualized services and supports across the Children’s System of Care .
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
Olive Crest ensures a culturally responsive workforce by aligning hiring practices, service delivery, and team composition with the cultural, racial, and linguistic needs of the youth, families, and communities served.
The program monitors demographic trends of the population served and uses this information to inform recruitment and hiring practices, prioritizing candidates who reflect the cultural and linguistic diversity of the community, including bilingual staff.
Olive Crest actively recruits staff with lived experience and cultural competence, including Parent Partners and team members who can authentically connect with families and support engagement.
When a direct cultural or linguistic match is not available, facilitators work with the Child and Family Team (CFT) to identify and engage natural supports or culturally relevant community members who can support the family and enhance cultural responsiveness.
For families who prefer services in a language other than English, Olive Crest ensures access to interpreters, bilingual staff, or natural supports to support effective communication and engagement.
Staff receive ongoing training in cultural humility, cultural responsiveness, and engagement practices to ensure services are respectful, relevant, and aligned with family values and cultural context.
These practices ensure that services remain accessible, inclusive, and responsive to the diverse needs of youth and families served by the program.
Supporting Documentation
a. Family Preservation Personnel Policy (300.09) – pgs. 1–2, staffing qualifications, workforce competencies, and expectations related to culturally responsive and family-centered service delivery; Wraparound Service Philosophy (310.15) – pgs. 1–2, commitment to culturally responsive, individualized, and family-driven practice; OC Wrap Training Plan – pgs. 1–2, workforce development and training requirements related to engagement, collaboration, and culturally responsive practice; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, collection and review of service trends, demographic information, supervision review, and CQI monitoring processes supporting program oversight and workforce planning ; Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, collaborative discussions regarding community needs, service delivery, and system planning activities .
b. Wraparound Family Team Development Procedures (310.11) – pgs. 1–2, engagement of formal supports, informal supports, natural supports, and community resources identified by the family; Culture Discovery Tool – pg. 1, identification of family culture, traditions, language, identity, supports, and preferences; Parent Partner: Role and Functions – pg. 1, assisting families in identifying supportive individuals, advocacy, and culturally responsive engagement within the Wraparound process ; Youth Partner: Role and Functions – pg. 1, supporting culturally relevant youth engagement and strengthening meaningful support connections ; Wraparound Service Philosophy (310.15) – pgs. 1–2, commitment to cultural responsiveness, family voice and choice, and individualized planning.
c. Culture Discovery Tool – pg. 1, identification of preferred language, communication needs, and cultural considerations; Wraparound Enrollment Procedures (310.02) – pgs. 2–4, engagement and information gathering processes addressing family communication and participation needs; Wraparound Family Team Development Procedures (310.11) – pgs. 1–2, engagement of formal supports, informal supports, natural supports, and community resources to support family participation and team functioning; Parent Partner: Role and Functions – pg. 1, assisting families in engagement, communication, advocacy, and access to supports and resources ; Wraparound Service Philosophy (310.15) – pgs. 1–2, commitment to culturally responsive and individualized service delivery practices.
9.2 Tribally Responsive Workforce
Olive Crest ensures that services for Indian children are delivered in a manner that respects tribal sovereignty, cultural traditions, and the unique role of tribes in supporting youth and families.
Staff receive training on culturally responsive practices, including awareness of tribal sovereignty, traditions, and values, and are guided to approach engagement with respect, humility, and collaboration.
When serving an Indian child, facilitators work with the Child and Family Team (CFT) to identify and engage tribal representatives and culturally relevant supports, ensuring that the Tribe is invited to participate as an equal partner in planning and decision-making when appropriate.
The team encourages participation in tribal traditions, ceremonies, and culturally rooted services, recognizing the importance of these supports in promoting stability, identity, and long-term success.
Wraparound teams collaborate with tribal representatives and other culturally aligned supports to ensure that services reflect the values, preferences, and traditions of the youth and family.
When direct tribal partnerships are not immediately available, facilitators continue to explore and engage culturally relevant supports and resources to ensure that services remain respectful and responsive.
These practices are reinforced through supervision and coaching, ensuring that staff consistently apply culturally and tribally responsive approaches in their work.
Supporting Documentation
a. Wraparound Service Philosophy (310.15) – pgs. 1–2, commitment to cultural responsiveness, family voice and choice, individualized planning, and respect for family culture and identity; Family Preservation Personnel Policy (300.09) – pgs. 1–2, staff competencies related to culturally responsive practice, collaboration, family-centered engagement, and individualized service delivery; OC Wrap Training Plan – pgs. 1–2, ongoing staff training requirements related to engagement, collaboration, and culturally responsive Wraparound practice; Culture Discovery Tool – pg. 1, identification and discussion of family culture, traditions, language, values, and supports to guide culturally respectful planning and service delivery; Wraparound Family Team Development Procedures (310.11) – pgs. 1–2, engagement of tribal, natural, formal, and community supports identified by the family.
b. Wraparound Family Team Development Procedures (310.11) – pgs. 1–2, inclusion and engagement of tribal representatives, natural supports, and community supports within Child and Family Team development; Wraparound Service Philosophy (310.15) – pgs. 1–2, culturally responsive, individualized, and family-driven practice expectations; Culture Discovery Tool – pg. 1, exploration of family traditions, cultural practices, identity, and preferred supports/services; Facilitator: Role and Functions – pg. 1, facilitators engage formal and informal supports identified by the family and coordinate collaborative team planning based on family voice and choice ; Parent Partner: Role and Functions – pg. 1, supporting family advocacy, culturally responsive engagement, and strengthening supportive connections within the Wraparound process ; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, collaborative Child and Family Team process involving participation of identified supports and team members in planning and decision-making.
9.3 Flexible and Creative Work Environment
Olive Crest fosters a flexible and creative work environment that promotes staff engagement, shared responsibility, and continuous quality improvement aligned with High Fidelity Wraparound (HFW) principles.
Leadership, including Program Directors, Supervisors, and Coaches, actively engage staff in program quality and improvement efforts through supervision, team meetings, fidelity reviews, and use of data-informed practices. Staff receive ongoing feedback through tools such as Plan of Care (POC) reviews and team observation processes, supporting continuous learning and improvement.
A strong emphasis is placed on team cohesion and a positive work environment, where staff are encouraged to collaborate, support one another, and contribute to team-based problem solving. This is reinforced through group supervision, team meetings, and shared learning opportunities.
Olive Crest promotes open communication across all levels of the program, with structured opportunities for staff to provide input, ask questions, and share feedback. Leadership maintains accessibility and transparency, ensuring that staff feel supported and informed.
A clear sense of mission and alignment with Wraparound values is reinforced through onboarding, ongoing training, and supervision, ensuring that staff understand and apply the principles, phases, and activities of High Fidelity Wraparound in their daily practice.
The program environment encourages creativity and flexibility, allowing staff to develop individualized, family-centered strategies, adapt service delivery to meet family needs, and utilize flexible resources such as flex funds to support innovative solutions.
OLIVER supports this environment by providing real-time data and visibility into service delivery, allowing supervisors and staff to collaboratively identify needs, address challenges, and improve practice.
Through these structures, Olive Crest creates a culture of shared responsibility, innovation, and accountability that supports high-quality Wraparound implementation.
Supporting Documentation
a. Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, responsibilities related to CQI activities, coaching, supervision, documentation review, workforce development, and fidelity monitoring ; Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, support, review of work practices, coaching, and quality oversight; Olive Crest TOM Experience for Learning Community – pgs. 1–5, implementation of TOM observations, fidelity review, coaching feedback loops, supervision debriefing, and program improvement activities ; Wraparound Outcome Reporting Policy (310.03) – pgs. 1–2, use of WFI-EZ, IP-CANS/CANS, outcome measures, and family feedback to support CQI and program improvement; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, use of supervision review, reporting, engagement trends, coaching, and CQI monitoring at the individual, program, and system level .
b. Wraparound Service Philosophy (310.15) – pgs. 1–2, commitment to collaboration, teamwork, family voice and choice, and strengths-based practice; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, collaborative Child and Family Team process emphasizing teamwork, participation, and shared ownership; OC Wrap Training Plan – pgs. 1–2, workforce development and ongoing team-based Wraparound training; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, coaching and field-based support to strengthen team functioning, collaboration, and fidelity practice ; Olive Crest TOM Experience for Learning Community – pg. 5, improvement in teamwork, skilled facilitation, and collaborative planning through fidelity review and coaching processes .
c. Staff Supervision Policy (402.2) – pg. 1, consultation, support, problem-solving, coaching, and ongoing communication between leadership and staff; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, collaborative communication and information-sharing processes within Child and Family Team meetings; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, centralized documentation, team communication, meeting tracking, and information-sharing processes across assigned staff and team members ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, responsibilities related to staff support, communication, supervision, and collaborative problem-solving ; Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, multidisciplinary communication and collaborative planning processes involving providers and system partners .
d. Wraparound Service Philosophy (310.15) – pgs. 1–2, organizational commitment to High Fidelity Wraparound principles, values, family voice and choice, cultural responsiveness, strengths-based planning, and teamwork; Wraparound Phases and Activities Policy (310.05) – pgs. 1–3, implementation expectations related to Wraparound phases and activities; OC Wrap Training Plan – pgs. 1–2, workforce development and ongoing training related to HFW principles, facilitation, engagement, and implementation; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, coaching, fidelity review, documentation review, and staff development activities supporting compliance with HFW philosophy and implementation ; Olive Crest TOM Experience for Learning Community – pgs. 1–5, TOM observation and fidelity review processes used to reinforce adherence to HFW principles and improve implementation .
9.4 Hiring, Performance Evaluation, and Job Descriptions
Olive Crest ensures that all High Fidelity Wraparound (HFW) roles and functions are clearly defined, staffed, and supported through structured hiring practices, role-specific job descriptions, and ongoing performance evaluation and coaching.
The program includes all required Wraparound roles and functions, including Facilitators, Parent Partners, Behavior Specialists (Family Specialists), Clinicians, Supervisors, and leadership roles. Functions such as fidelity coaching and clinical supervision are incorporated through supervisory and leadership structures, ensuring that all required competencies are met within the program.
Each role has clearly defined job descriptions that outline the purpose, responsibilities, and required skills, including competencies related to engagement, facilitation, cultural responsiveness, needs-driven planning, and collaboration consistent with Wraparound principles.
Hiring practices are designed to identify candidates with the attitudes, skills, and values necessary for success in Wraparound. The hiring process includes structured interviews and opportunities for candidates to demonstrate key competencies such as communication, engagement, and problem-solving.
Employees are provided with clear performance expectations aligned with Wraparound standards and receive ongoing feedback through supervision, coaching, and performance evaluation processes. Supervisors utilize data, documentation review, and direct observation to provide timely, strengths-based feedback and support staff development.
Performance evaluation is continuous and integrated into regular supervision, rather than limited to annual reviews, ensuring that staff receive consistent guidance and opportunities for growth.
Training and workforce development structures further support staff success by reinforcing role expectations, building skills, and ensuring alignment with High Fidelity Wraparound practices.
OLIVER supports performance monitoring by providing visibility into service delivery, documentation, and productivity, allowing supervisors to coach staff using real-time data and ensure accountability.
Supporting Documentation
a. Facilitator: Role and Functions – pgs. 1–2, defined responsibilities and functions related to facilitation, engagement, planning, and coordination ; Parent Partner: Role and Functions – pgs. 1–2, peer support, advocacy, engagement, and family voice responsibilities ; Youth Partner: Role and Functions – pgs. 1–2, youth engagement, advocacy, and supportive relationship responsibilities ; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, fidelity observation, coaching, CQI, and staff development responsibilities ; Wraparound Clinician: Role and Functions – pgs. 1–2, clinical consultation, assessment support, safety planning, and coordination responsibilities ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, supervision, coaching, CQI, staffing oversight, and program implementation responsibilities ; Family Preservation Personnel Policy (300.09) – pgs. 1–2, staffing expectations, competencies, and workforce structure requirements.
b. Facilitator: Role and Functions – pgs. 1–2, facilitation skills, engagement expectations, coordination responsibilities, and required competencies ; Parent Partner: Role and Functions – pgs. 1–2, advocacy, engagement, mentoring, communication, and relationship-building competencies ; Youth Partner: Role and Functions – pgs. 1–2, youth engagement, relationship-building, advocacy, and communication skills ; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, coaching, fidelity review, modeling, facilitation, and CQI competencies ; Wraparound Clinician: Role and Functions – pgs. 1–2, clinical consultation, safety planning, collaboration, and assessment competencies ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, leadership, coaching, supervision, CQI, and communication competencies .
c. Family Preservation Personnel Policy (300.09) – pgs. 1–2, staffing qualifications, competencies, and expectations related to family-centered and culturally responsive practice; Facilitator: Role and Functions – pgs. 1–2, expectations related to engagement, facilitation, collaboration, and individualized planning ; Parent Partner: Role and Functions – pgs. 1–2, expectations related to lived experience, advocacy, engagement, and peer support ; Youth Partner: Role and Functions – pgs. 1–2, expectations related to youth engagement, advocacy, mentoring, and communication ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, expectations related to leadership, coaching, CQI, and Wraparound implementation ; Wraparound Service Philosophy (310.15) – pgs. 1–2, commitment to HFW principles, cultural responsiveness, family voice and choice, teamwork, and strengths-based practice.
d. Family Preservation Personnel Policy (300.09) – pgs. 1–2, staffing qualifications, competencies, and expectations related to engagement, collaboration, cultural responsiveness, and family-centered practice; Wraparound Manager/Supervisor: Role and Functions – pg. 1, supervisory responsibilities related to employee development, coaching, performance support, and evaluation ; OC Wrap Training Plan – pgs. 1–2, expectations related to workforce development, onboarding, and ongoing competency development; Wraparound Service Philosophy (310.15) – pgs. 1–2, expectations related to HFW values, collaboration, family voice and choice, and individualized service delivery.
e. Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, support, coaching, performance feedback, and review expectations; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, field observation, coaching, role play, documentation review, and CQI-informed staff development ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, employee supervision, coaching, performance support, CQI activities, and workforce development responsibilities ; Olive Crest TOM Experience for Learning Community – pgs. 1–5, TOM observation, coaching feedback loops, supervision debriefing, and fidelity improvement processes used to support staff performance and implementation ; OC Wrap Training Plan – pgs. 1–2, initial and ongoing training requirements supporting staff competency development and fidelity practice.
9.5 Workforce Stability
Description of Practice
Olive Crest implements multiple strategies to promote workforce stability, reduce turnover, and support staff retention, recognizing that a stable workforce is essential to delivering high-fidelity Wraparound services.
The program maintains manageable workloads through intentional staffing structures and caseload expectations that align with the intensity of Wraparound services. Supervisors monitor staff productivity and service delivery through OLIVER and provide ongoing support to ensure workloads remain balanced and sustainable.
Olive Crest offers competitive compensation aligned with community standards and contract expectations, ensuring that wages are appropriate for the level of work and cost of living within the service area.
The organization promotes internal growth and advancement opportunities, allowing staff to move into roles such as Lead Facilitator, Supervisor, or specialized program positions. These pathways are clearly communicated and accessible, including for staff with lived experience such as Parent Partners and Youth Partners.
In addition to formal promotions, Olive Crest provides opportunities for staff to take on leadership roles, mentorship responsibilities, and specialized assignments without requiring a formal position change, supporting professional growth and engagement.
Staff receive consistent supervision, coaching, and professional development, which supports skill development, job satisfaction, and retention.
The program fosters a supportive and collaborative work environment, emphasizing team cohesion, open communication, and shared responsibility, which contributes to staff engagement and long-term retention.
Through these combined strategies, Olive Crest maintains a stable workforce capable of delivering consistent, high-quality Wraparound services.
Supporting Documentation
a. Family Preservation Personnel Policy (300.09) – pgs. 1–2, staffing qualifications, workforce expectations, and organizational staffing structure supporting recruitment and retention; Riverside DPSS Wraparound Services Executed Contract – pgs. 23–24 and pgs. 76–79, staffing, training, and service delivery requirements tied to implementation of intensive Wraparound services; County of Orange Wraparound Contract – pgs. 76–79, staffing and training expectations supporting workforce sustainability and program implementation.
b. Staff Supervision Policy (402.2) – pg. 1, supervisory oversight, support, consultation, coaching, and review of service delivery practices; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, responsibilities related to staffing oversight, workload management, employee support, coaching, and supervision ; Riverside DPSS Wraparound Services Executed Contract – pgs. 23–24 and pg. 32, staffing expectations related to service intensity, crisis response, continuity of care, and support for families with complex needs; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, supervision review, service tracking, reporting, and CQI monitoring processes used to support staffing oversight and program operations .
c. Parent Partner: Role and Functions – pgs. 1–2, recognition and integration of lived experience within peer support and advocacy roles ; Youth Partner: Role and Functions – pgs. 1–2, youth voice, lived experience, mentoring, and advocacy responsibilities ; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, leadership and coaching opportunities supporting staff growth and professional development ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, leadership development, supervision, coaching, CQI, and workforce support responsibilities ; OC Wrap Training Plan – pgs. 1–2, workforce development and ongoing competency-building opportunities for staff across roles.
d. Wraparound Fidelity Coach Role and Functions – pgs. 1–2, opportunities for leadership, coaching, mentorship, and workforce development within existing program structures ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, leadership responsibilities related to employee development, coaching, supervision, and workforce support ; OC Wrap Training Plan – pgs. 1–2, ongoing professional development, training, and skill-building opportunities available to staff; Staff Supervision Policy (402.2) – pg. 1, supervisory support, coaching, and employee development processes supporting staff growth and retention.
9.6 High Fidelity Training Plan
Olive Crest maintains a comprehensive High Fidelity Wraparound (HFW) training plan that ensures all staff receive initial, ongoing, and booster training aligned with California Wraparound Standards and best practices.
All staff receive foundational Wraparound training through a combination of UC Davis RCFFP standardized training and internal training aligned with the Statewide standardized curriculum. This ensures that staff are grounded in Wraparound principles, phases, and core activities at the onset of employment.
The training plan includes both general Wraparound training and role-specific training tailored to positions such as Facilitators, Parent Partners, Behavior Specialists, Clinicians, and Supervisors. Training topics include engagement, needs-driven planning, facilitation, cultural responsiveness, crisis planning, and team-based service delivery.
Staff receive ongoing training and professional development through formal training sessions, group supervision, individual coaching, peer learning opportunities, and shadowing experiences, ensuring continuous skill development and fidelity to the model.
Booster trainings are provided at least annually, reinforcing core Wraparound principles and enhancing role-specific competencies based on program needs, CQI findings, and emerging best practices.
Clinical Supervisors and Wraparound Supervisors/Managers receive specialized training in leadership, supervision, fidelity coaching, and data-informed decision-making to support effective program oversight and staff development.
All staff receive training in ICWA and Tribal sovereignty, as well as cultural responsiveness and working with diverse populations. Additional training is provided to address the unique needs of specific populations served, including youth with complex behavioral health needs, system involvement, and trauma histories.
Training effectiveness is reinforced through supervision, coaching, and CQI processes, ensuring that learning is translated into practice and continuously improved over time.
OLIVER supports training and supervision by providing data and documentation that inform training needs, staff development, and program improvement.
Supporting Documentation
a. HFW staff are trained internally utilizing the Statewide Standardized Foundational HFW curriculum: OC Wrap Training Plan – pgs. 1–2, initial onboarding and foundational Wraparound training requirements for all staff; Inland Wrap Orientation – pgs. 1–4, overview of High Fidelity Wraparound principles, phases, team process, family voice and choice, and engagement expectations; Wraparound Service Philosophy (310.15) – pgs. 1–2, organizational commitment to High Fidelity Wraparound principles, values, and family-centered practice; Family Preservation Personnel Policy (300.09) – pgs. 1–2, workforce competency and training expectations supporting HFW implementation.
b. OC Wrap Training Plan – pgs. 1–2, ongoing role-specific and general Wraparound training expectations; Staff Supervision Policy (402.2) – pg. 1, supervision, consultation, coaching, and ongoing workforce development processes; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, field observation, role play, modeling, coaching, documentation review, and CQI-informed workforce development ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, supervision, employee development, coaching, CQI, and workforce support responsibilities ; Olive Crest TOM Experience for Learning Community – pgs. 1–5, fidelity observation, coaching feedback loops, supervision debriefing, and staff development activities .
c. OC Wrap Training Plan – pgs. 1–2, annual, booster, and ongoing training expectations for all Wraparound staff; Staff Supervision Policy (402.2) – pg. 1, supervisory support and ongoing reinforcement of Wraparound implementation practices; Olive Crest TOM Experience for Learning Community – pgs. 1–5, fidelity review and coaching processes used to reinforce and strengthen HFW practice implementation over time ; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, ongoing coaching and staff development activities supporting fidelity practice and continuous learning .
d. OC Wrap Training Plan – pgs. 1–2, leadership and role-specific training expectations for supervisors and managers; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, responsibilities related to supervision, CQI, fidelity monitoring, coaching, workforce development, and implementation oversight ; Wraparound Clinician: Role and Functions – pgs. 1–2, clinical consultation, coordination, assessment support, safety planning, and collaboration responsibilities ; Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, support, coaching, and review responsibilities; Olive Crest TOM Experience for Learning Community – pgs. 1–5, leadership involvement in fidelity review, supervision debriefing, coaching feedback loops, and CQI activities .
e. OC Wrap Training Plan – pgs. 1–2, ongoing workforce development and training expectations supporting culturally responsive practice and specialized population needs; Wraparound Service Philosophy (310.15) – pgs. 1–2, commitment to culturally responsive, individualized, and family-driven practice; Culture Discovery Tool – pg. 1, identification of family culture, traditions, language, identity, and supports to guide culturally respectful planning and service delivery; Family Preservation Personnel Policy (300.09) – pgs. 1–2, expectations related to culturally responsive engagement, collaboration, and individualized service delivery; Wraparound Family Team Development Procedures (310.11) – pgs. 1–2, inclusion and engagement of tribal, natural, formal, and community supports identified by the family.
9.7 Community-based Training Program
Olive Crest administers its High Fidelity Wraparound (HFW) training program in collaboration with youth, families, and community partners to ensure training reflects lived experience and supports system-wide understanding of Wraparound practices.
Youth, families, and peer partners—including Parent Partners and Youth Partners with lived Wraparound experience—are meaningfully incorporated into training and staff development activities. Their perspectives are used to enhance learning, strengthen engagement practices, and reinforce the importance of family voice and choice in service delivery.
Peer partners also contribute to onboarding, coaching, and group learning opportunities, helping staff understand the lived experience of families navigating systems and services.
Olive Crest extends training opportunities to community and system partners, including schools, behavioral health providers, and other stakeholders, to strengthen collaboration and ensure that team members across systems understand the Wraparound process and their role within it.
Training and outreach efforts include sharing information about Wraparound principles, phases, and team expectations to improve coordination and support effective participation on Child and Family Teams (CFTs).
The program actively engages in community collaboration and partnership-building to promote shared understanding of Wraparound and to support coordinated, family-centered care across the Children’s System of Care.
Training efforts are supported by the broader workforce development structure and are aligned with ongoing coaching, supervision, and CQI processes to ensure consistency and effectiveness.
Supporting Documentation
a. Parent Partner: Role and Functions – pgs. 1–2, peer support, advocacy, mentoring, family engagement, and collaboration responsibilities within the Wraparound process ; Youth Partner: Role and Functions – pgs. 1–2, youth engagement, mentoring, advocacy, and supportive relationship responsibilities ; OC Wrap Training Plan – pgs. 1–2, ongoing workforce development and training expectations supporting role-specific and experiential learning opportunities; Wraparound Service Philosophy (310.15) – pgs. 1–2, commitment to family voice and choice, collaboration, peer involvement, and individualized planning; Olive Crest TOM Experience for Learning Community – pgs. 1–5, collaborative coaching, fidelity review, and CQI processes involving multiple team perspectives and experiential learning .
b. Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, multidisciplinary collaboration, systems partnership discussions, and community coordination activities involving Child Welfare, Behavioral Health, schools, and community providers ; Riverside County Wraparound Collaborative Agenda – pg. 1, collaborative review of Wraparound implementation, systems coordination, and partnership activities ; OC Wrap Training Plan – pgs. 1–2, workforce development and ongoing Wraparound training expectations; Wraparound Family Team Development Procedures (310.11) – pgs. 1–2, inclusion and engagement of formal supports, natural supports, and community partners within the Child and Family Team process; Wraparound Family Team Meeting Procedures (310.12) – pgs. 1–2, collaborative team participation expectations involving system and community partners; Wraparound Service Philosophy (310.15) – pgs. 1–2, commitment to collaboration, community partnership, and coordinated team-based planning.
9.8 Coaching and Supervision
Olive Crest ensures that all staff receive an initial apprenticeship and ongoing coaching that reinforces High Fidelity Wraparound (HFW) principles, values, phases, and activities, as well as the effective use of flexible funds to meet family needs.
New staff participate in a structured onboarding and apprenticeship process that includes foundational Wraparound training, shadowing experienced staff, and guided practice. This process emphasizes core competencies such as engagement, facilitation, needs-driven planning, cultural responsiveness, and appropriate use of flex funds within the Plan of Care.
Following onboarding, staff receive ongoing coaching and supervision through individual supervision, group supervision, and fidelity-informed coaching practices. Supervisors and program leadership provide real-time feedback using documentation review, observation, and data from OLIVER to support skill development and continuous improvement.
Coaching emphasizes practical application of Wraparound principles, including team facilitation, crisis response, collaboration, and individualized planning, ensuring that staff are able to translate training into effective practice.
Olive Crest ensures that staff have access to supervision and coaching support 24/7, aligned with the flexible and crisis-responsive nature of Wraparound services. Staff are able to access supervisors or leadership for consultation, guidance, and decision-making support when urgent situations arise.
This structure supports staff in responding effectively to family needs in real time, while maintaining fidelity to the Wraparound model.
The program’s supervision and coaching model is reinforced through training, leadership engagement, and CQI processes, ensuring consistency, accountability, and high-quality service delivery.
Supporting Documentation
a. OC Wrap Training Plan – pgs. 1–2, onboarding, foundational Wraparound training, role-specific training, and ongoing workforce development expectations; Inland Wrap Orientation – pgs. 1–4, overview of High Fidelity Wraparound principles, phases, activities, team process, family voice and choice, and engagement expectations; Wraparound Service Philosophy (310.15) – pgs. 1–2, organizational commitment to HFW principles, strengths-based practice, family voice and choice, collaboration, and cultural responsiveness; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, field observation, modeling, role play, documentation review, coaching, and workforce development activities supporting implementation of HFW values and practices ; Wraparound Flex Funds Updates – pg. 1, flex fund approval, utilization, and individualized planning processes aligned with youth and family needs ; Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, coaching, support, and reinforcement of effective Wraparound implementation practices.
b. Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, support, coaching, and availability to address service delivery and crisis response needs; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, responsibilities related to staff support, supervision, coaching, crisis response coordination, and workforce oversight ; Wraparound Safety Plan Procedures (310.06) – pgs. 1–3, crisis response coordination and emergency support processes; Riverside DPSS Wraparound Services Executed Contract – pgs. 23–24 and pg. 32, staffing, crisis response accessibility, continuity of care, and support expectations for families with complex needs; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–3, centralized communication, documentation, service coordination, and supervisory review processes supporting staff responsiveness and crisis coordination ; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, ongoing coaching, field-based support, and staff consultation processes .
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
Olive Crest implements a robust Continuous Quality Improvement (CQI) process that supports ongoing monitoring, evaluation, and improvement of Wraparound services in alignment with High Fidelity Wraparound (HFW) standards.
The program utilizes a structured CQI approach that includes the collection, analysis, and application of data at both the individual case level and program level to inform practice, improve outcomes, and ensure accountability.
Data collection includes:
Demographic information of youth and families served
Fidelity data, including team observation and practice indicators
Outcome data, including family functioning, service effectiveness, and progress toward goals
OLIVER serves as the primary data system, allowing for real-time tracking of referrals, service delivery, documentation, demographics, and outcomes. This ensures that data is current, accurate, and accessible for analysis and decision-making.
Olive Crest utilizes multiple standardized tools to support CQI efforts, including:
Wraparound Fidelity Index (WFI-EZ)
Family Attachment and Changeability Index (FACI-8)
Team Observation Measure (TOM)
IP-CANS assessment data
These data sources are reviewed regularly through supervision, leadership review, and CQI processes to identify trends, inform training needs, and improve service delivery.
Data is collected at the point of service by staff and entered into OLIVER, ensuring accuracy and alignment with real-time service delivery. This data is then used for internal analysis and shared with county partners as required to support system-level CQI efforts.
Olive Crest collaborates with county partners and system stakeholders by contributing data, participating in reporting processes, and aligning with county-led CQI initiatives to support broader system improvement and statewide data efforts.
Through these processes, Olive Crest ensures that CQI is embedded in daily practice, supervision, and program operations, resulting in continuous improvement and high-quality Wraparound services.
Supporting Documentation
a. Wraparound Outcome Reporting Policy (310.03) – pgs. 1–2, collection, analysis, and review of demographic information, WFI-EZ results, IP-CANS/CANS data, outcome measures, and fidelity-related information to support CQI and program improvement; Olive Crest TOM Experience for Learning Community – pgs. 1–5, implementation of TOM observations, fidelity review, supervision debriefing, coaching feedback loops, and CQI-informed improvement processes ; Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, collaborative implementation discussions involving providers and system partners related to Wraparound practice, fidelity, outcomes, and CQI activities ; Interagency Family Plan of Care Review – pgs. 1–4, structured review indicators supporting fidelity monitoring, individualized planning review, and outcome-based practice evaluation ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–4, centralized system supporting collection, storage, reporting, and review of demographic information, service activity, assessments, fidelity indicators, outcomes, and CQI monitoring .
b. Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, multidisciplinary collaboration and information-sharing activities involving Child Welfare, Behavioral Health, schools, providers, and community partners ; Riverside County Wraparound Collaborative Agenda – pg. 1, systems collaboration, implementation review, and coordination activities involving system partners ; Riverside DPSS Wraparound Services Executed Contract – pgs. 4–6 and pg. 32, collaboration, documentation, reporting, and coordinated service expectations involving multiple systems partners; LA DMH MH122219 Contract – Quality Assurance/Quality Improvement and reporting requirements supporting Behavioral Health collaboration; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–4, centralized communication, reporting, documentation, and information-sharing processes across providers and systems partners .
c. Wraparound Outcome Reporting Policy (310.03) – pgs. 1–2, collection and review of outcome and fidelity data to support accountability and program improvement; Olive Crest TOM Experience for Learning Community – pgs. 1–5, TOM fidelity review, coaching feedback, supervision debriefing, and CQI-informed improvement planning ; Interagency Family Plan of Care Review – pgs. 1–4, structured review process supporting quality monitoring, individualized planning review, and fidelity assessment ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, reporting, supervision review, service monitoring, engagement trends, and CQI tracking processes used to support data accuracy and accountability ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, responsibilities related to CQI, documentation review, supervision, coaching, and implementation oversight .
d. OLIVER – DATA SYSTEM DESCRIPTION – pgs. 1–4, centralized documentation system supporting direct service documentation, assessment collection, meeting records, service tracking, reporting, supervision review, and CQI analysis processes ; Wraparound Outcome Reporting Policy (310.03) – pgs. 1–2, collection and reporting of fidelity, outcome, and demographic information; Olive Crest TOM Experience for Learning Community – pgs. 1–5, use of observation and fidelity data collection processes to inform supervision, coaching, and CQI activities ; Interagency Family Plan of Care Review – pgs. 1–4, review and scoring processes supporting analysis of fidelity and quality indicators .
10.2 Evaluation Metrics & Outcomes
Olive Crest utilizes collected data to evaluate program performance and drive continuous improvement at the individual, program, and system levels in alignment with High Fidelity Wraparound (HFW) standards.
At the practice level, supervisors and leadership use data from OLIVER, fidelity tools, and outcome measures to provide timely, individualized feedback to staff. This includes review of documentation, service delivery patterns, and fidelity indicators to support coaching, improve service quality, and ensure alignment with Wraparound principles.
Data is also used to identify staff training and development needs, informing targeted training, coaching, and supervision strategies to strengthen workforce capacity and improve practice.
At the program level, Olive Crest analyzes trends in outcomes, fidelity, service utilization, and engagement to identify areas for improvement and enhance overall program effectiveness. This includes reviewing data related to family functioning, service outcomes, and team processes to inform program adjustments and resource allocation.
At the system level, Olive Crest shares data, trends, and identified barriers with county partners and system stakeholders through reporting processes, contract monitoring, and collaborative meetings. This supports communication of system-level challenges and contributes to broader Continuous Quality Improvement (CQI) efforts and system alignment.
Standardized tools such as the WFI-EZ, FACI-8, TOM, and IP-CANS are used to inform decision-making and track progress, ensuring that data is meaningful and directly tied to practice and outcomes.
Through these processes, Olive Crest ensures that data is actively used to improve services, strengthen staff performance, enhance program effectiveness, and inform system-level decision-making.
Supporting Documentation
a. Wraparound Outcome Reporting Policy (310.03) – pgs. 1–2, use of outcome measures, WFI-EZ, IP-CANS/CANS, and family feedback to support service improvement, supervision, and workforce development; Olive Crest TOM Experience for Learning Community – pgs. 1–5, TOM observation process, fidelity scoring, supervision debriefing, coaching feedback loops, and action planning processes used to improve staff practice and identify training needs ; Wraparound Fidelity Coach Role and Functions – pgs. 1–2, documentation review, field observation, coaching, modeling, role play, and CQI-informed staff development activities ; Staff Supervision Policy (402.2) – pg. 1, supervisory consultation, coaching, support, and review of staff practice; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, reporting, supervision review, service monitoring, engagement trends, and CQI tracking processes supporting staff feedback and performance improvement .
b. Wraparound Outcome Reporting Policy (310.03) – pgs. 1–2, collection and review of fidelity, outcome, demographic, and satisfaction data to support program improvement and accountability; Olive Crest TOM Experience for Learning Community – pgs. 1–5, fidelity review, coaching feedback, CQI activities, and implementation improvement processes ; Interagency Family Plan of Care Review – pgs. 1–4, structured review indicators assessing individualized planning, fidelity practice, collaboration, and outcome-based interventions ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, responsibilities related to CQI activities, documentation review, workforce development, supervision, and program oversight ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, program-level reporting, service monitoring, supervision review, engagement trends, and CQI analysis supporting operational and program improvement decisions .
c. Riverside County Wraparound Collaborative Meeting Minutes – pgs. 1–4, multidisciplinary discussions regarding implementation barriers, systems coordination, fidelity improvement, resource needs, and community partnership activities ; Riverside County Wraparound Collaborative Agenda – pg. 1, collaborative review of implementation activities, systems coordination, and Wraparound program planning ; Olive Crest TOM Experience for Learning Community – pgs. 1–5, use of fidelity and practice data to identify implementation barriers and guide CQI activities ; OLIVER – DATA SYSTEM DESCRIPTION – pgs. 3–4, use of reporting, service trends, supervision review, and CQI monitoring to identify program and systems-level barriers impacting implementation ; Wraparound Manager/Supervisor: Role and Functions – pgs. 1–2, leadership responsibilities related to CQI, communication, systems collaboration, and implementation oversight .
Fidelity Indicators
1.1 Timely Engagement and Planning
(a) Bayfront contacts each new referral within 24 hours to initiate engagement, establish contact with the family, and begin the intake process.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Engagement and Team Preparation (Pages 3, 4)
(b) Within the first 30 days, the Facilitator leads the CFT in developing an individualized Plan of Care (POC).
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Initial Plan Development (Pages 4, 5)
(c) The CFT implements the POC and meets regularly (at least every 30–45 days) to monitor progress, review action items, and evaluate outcomes.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Plan Implementation and Ongoing Service Delivery (Pages 5, 6)
(d) Standardized tools are readministered at required intervals (typically every 90 days) and results are used to guide adaptations to strategies, services, and level of care. Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Plan Implementation and Ongoing Service Delivery (Pages 5, 6)
(e) Staff performance related to required timelines is routinely monitored and reviewed through supervisory oversight and CQI processes, and feedback is provided. Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Plan Implementation and Ongoing Service Delivery (Pages 5, 6)
(f) Staff maintain persistent engagement with families, utilizing flexible strategies to overcome barriers to participation and sustain involvement in services.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Access, Service Capacity, and Persistence (Page 14)
1.2 Led by Youth and Families
(a)Youth and families are recognized as the primary decisionmakers, and their perspectives, strengths, values, and cultural identities guide all aspects of engagement, planning, and service delivery. When a youth is identified as an Indian child, the Facilitator ensures that Tribal representatives are invited and engaged as equal participants. This process includes developing a vision for the future. And within the first 30 days developing a team mission aligned with the family’s vision.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Program Approach and Service Delivery Model, (Pages 1, 2)
Engagement and Team Preparation (Pages 3, 4)
(b) This process includes guided conversations with the youth and family to explore strengths, identify underlying needs, understand cultural identity and preferences. Information gathered during this process is documented and used to inform all subsequent planning and service delivery.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Engagement and Team Preparation (Pages 3, 4)
(c) Supervisors and fidelity coaches routinely observe CFT meetings and review documentation to provide structured, individualized feedback to staff to reinforce fidelity expectations, support skill development, and promote continuous improvement in practice.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Fidelity Monitoring, Coaching, and Continuous Quality Improvement (Pages 2, 3)
(d) Feedback from youth and families is routinely collected through satisfaction surveys, fidelity tools (WFIEZ, TOM), and other feedback mechanisms and used to inform individualized planning, staff coaching, and continuous quality improvement efforts.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Plan Implementation and Ongoing Service Delivery (Pages 5, 6)
1.3 Strength-Based
(a) The team develops and maintains a strengths inventory that includes strengths of the youth, family, team members, and community supports. This inventory is reviewed and updated regularly and is used to guide decision making, strategy development, and service implementation.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Initial Plan Development (Pages 4, 5)
(b) Standardized assessment tools are administered at intake, including the Integrated Practice Child and Adolescent Needs and Strengths (IPCANS) used to identify and document both strengths and underlying needs across multiple life domains.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Engagement and Team Preparation (Pages 3, 4)
(c) Facilitators receive ongoing coaching in core competencies, including engagement, identification of strengths and underlying needs and development of individualized strategies. Staff are provided with ongoing training, supervision, mentorship, and professional development to ensure adherence to High Fidelity Wraparound principles. Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Fidelity Monitoring, Coaching, and Continuous Quality Improvement (Pages 2,3)
Training, Coaching, and Supervision (Pages 9, 10)
(d) Feedback from youth and families is routinely collected through satisfaction surveys, fidelity tools (WFI-EZ, TOM) and used to inform individualized planning, staff coaching, and continuous quality improvement efforts.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Plan Implementation and Ongoing Service Delivery (Pages 5, 6)
1.4 Needs Driven
(a) Needs are defined as underlying conditions driving behaviors or challenges, ensuring that planning remains focused on root causes. The team collaboratively develops goals and brainstorms multiple individualized strategies. This process includes identifying and prioritizing underlying needs before developing a Plan of Care.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Initial Plan Development (Pages 4, 5)
(b) Facilitators receive ongoing coaching in core competencies, including identification of strengths and underlying needs and development of individualized strategies. Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Fidelity Monitoring, Coaching, and Continuous Quality Improvement (Pages 2, 3)
Training, Coaching, and Supervision (Pages 9-10)
(c) Standardized assessment tools are administered at intake, including the Integrated Practice Child and Adolescent Needs and Strengths (IPCANS) used to identify and document both strengths and underlying needs across multiple life domains.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Engagement and Team Preparation (Pages 3, 4)
(d) Transition from Wraparound services occurs when the team, with preference given to family voice and choice, determines that identified needs have been sufficiently met. Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Transition Planning and Discharge (Pages 7, 8)
1.5 Individualized
(a) Services are individualized and delivered in the least restrictive, community-based settings. Standardized tools ensure that planning remains individualized, strengths based, and continuously informed.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Program Approach and Service Delivery Model (Pages 1–2)
(b) Training includes individualized strategy development. Staff are provided with opportunities for ongoing training, supervision, mentorship, and career advancement. Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Workforce Development and Staff Retention (Pages 10, 11 )
(c) Facilitators receive ongoing coaching in core competencies, including development of individualized strategies. Information gathered is used to inform all subsequent planning and service delivery.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Fidelity Monitoring, Coaching, and Continuous Quality Improvement (Pages 2, 3)
Training, Coaching, and Supervision (Pages 9-10)
(d) The team develops and maintains a strengths inventory that includes community supports and is used to guide decision making. The team tracks measurable outcomes and updates the Plan of Care based on both data and evolving family needs.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Initial Plan Development, (Pages 4, 5 )
(e) Feedback from youth and families is routinely collected through satisfaction surveys, fidelity tools (WFIEZ, TOM) and used to inform staff coaching, and continuous quality improvement efforts.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Plan Implementation and Ongoing Service Delivery (Pages 5, 6)
1.6 Use of Natural and Community Based Supports
(a) The team develops and maintains a strengths inventory that includes strengths of the youth, family, team members, and community supports. This inventory is reviewed and updated regularly.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Initial Plan Development (Pages 4, 5)
(b) Facilitators receive ongoing coaching in core competencies, including engagement and development of individualized strategies. Bayfront prioritizes the identification and strengthening of natural supports as a key component of long-term sustainability.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Fidelity Monitoring, Coaching, and Continuous Quality Improvement, (Pages 2, 3)
Use of Natural Supports and Cultural Responsiveness (Page 13)
Training, Coaching, and Supervision (Pages 9-10)
(c) The team tracks measurable outcomes and updates the Plan of Care based on both data and evolving family needs. The strengths inventory includes community supports and is used to guide decision making, strategy development, and service implementation.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Plan Implementation and Ongoing Service Delivery (Pages 5, 6)
(d) Feedback from youth and families is routinely collected through satisfaction surveys, fidelity tools (WFIEZ, TOM) and used to inform individualized planning, staff coaching, and continuous quality improvement efforts.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Plan Implementation and Ongoing Service Delivery (Pages 5, 6)
1.7 Culturally Respectful and Relevant
(a) During intake, staff initiate a structured Strengths, Needs, Culture, and Vision discovery process. Information gathered during this process is documented and used to inform all subsequent planning and service delivery.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Engagement and Team Preparation (Pages 3, 4)
(b) Training includes foundational instruction in Wraparound principles, as well as skill-based training in engagement, strengths and needs identification and individualized strategy development. Services are culturally responsive and family perspectives, strengths, values, and cultural identities guide all aspects of engagement, planning, and service delivery.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Fidelity Monitoring, Coaching, and Continuous Quality Improvement (Pages 2, 3)
Training, Coaching, and Supervision (Pages 9, 10)
(c) Feedback from youth and families is routinely collected through satisfaction surveys, fidelity tools (WFIEZ, TOM) and used to inform staff coaching, and continuous quality improvement efforts.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Plan Implementation and Ongoing Service Delivery (Pages 5, 6)
1.8 High-Quality Team Planning and Problem Solving
(a) Within the first 30 days, the Facilitator leads the CFT in developing an individualized Plan of Care (POC). This process includes establishing team agreements.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Initial Plan Development (Pages 4, 5)
(b) Feedback from youth and families is routinely collected through satisfaction surveys, fidelity tools (WFIEZ, TOM), and other feedback mechanisms. The TOM is conducted through direct observation of Child and Family Team (CFT) meetings.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Fidelity Monitoring, Coaching, and Continuous Quality Improvement (Pages 2, 3)
Plan Implementation and Ongoing Service Delivery (Pages 5, 6)
(c) This feedback is reviewed and used to inform individualized planning, staff coaching, and continuous quality improvement efforts.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Plan Implementation and Ongoing Service Delivery (Pages 5, 6)
(d) The team tracks measurable outcomes, monitors completion of action items, and updates the Plan of Care based on both data and evolving family needs. Measurement results are used to inform discussions on plan adaptation, supporting collective ownership of the Plan of Care.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Plan Implementation and Ongoing Service Delivery (Page 5, 6)
Child and Family Team (CFT) (Page 9)
1.9 Outcomes Based Process
(a) Each strategy is translated into clear action steps, including assigned responsibilities, timelines, and expected outcomes.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Initial Plan Development (Pages 4, 5)
(b) The team tracks measurable outcomes, monitors completion of action items, and updates the Plan of Care, meeting regularly (at least every 30–45 days) to monitor progress, review action items, and evaluate outcomes.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Plan Implementation and Ongoing Service Delivery (Pages 5, 6)
(c) Results are used to guide adaptations to strategies, services, and level of care. The team updates the Plan of Care based on both data and evolving family needs.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Plan Implementation and Ongoing Service Delivery (Pages 5, 6)
(d) Standardized assessment tools are administered at intake, including the Integrated Practice Child and Adolescent Needs and Strengths (IPCANS). A Clinician is assigned to each case. Assessment findings are reviewed with the youth and family to support shared understanding.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Engagement and Team Preparation (Pages 3, 4)
(e) Data is reviewed in CFT meetings to assess progress toward goals and identify changes in functioning. Results are used to guide adaptations to strategies. Facilitators integrate both quantitative data and qualitative data to support decision making.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Plan Implementation and Ongoing Service Delivery (Pages 5, 6)
1.10 Persistence
(a) Setbacks are addressed through plan revision rather than service discontinuation, reinforcing persistence and problem-solving. Transition from Wraparound services occurs when the team, with preference given to family voice and choice, determines that identified needs have been sufficiently met.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Plan Implementation and Ongoing Service Delivery (Pages 5, 6)
(b) Supervisors and fidelity coaches routinely observe CFT meetings and review documentation to provide structured, individualized feedback to staff. Staff are provided with opportunities for ongoing training, supervision and mentorship. The Facilitator maintains responsibility for coordinating services, including facilitating referrals to additional providers when necessary.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Fidelity Monitoring, Coaching, and Continuous Quality Improvement (Pages 2, 3)
(c) Facilitators receive ongoing coaching in core competencies, including facilitation of team meetings, development of individualized strategies, and crisis and safety planning. Crisis and Safety Plans are continuously reviewed and updated.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Fidelity Monitoring, Coaching, and Continuous Quality Improvement (Pages 2, 3)
Plan Implementation and Ongoing Service Delivery (Pages 5, 6)
1.11 Transitions as a part of the Fourth Phase of HFW
(a) In the event of unexpected transitions, Bayfront follows all County-required disenrollment procedures. This includes timely notification, completion of required exit documentation, and coordination of service transitions. When youth remain within the service area, Wraparound services continue to follow the youth to ensure continuity of care.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Transition Planning and Discharge (Pages 7, 8)
(b) Transition from Wraparound services occurs when the team determines that identified needs have been sufficiently met. The process includes a culturally meaningful celebration that reinforces progress and long-term success.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Transition Planning and Discharge (Pages 7, 8)
Expected Outcomes
2.1 Youth and Family Satisfaction
Feedback from youth and families is routinely collected through satisfaction surveys, fidelity tools (WFIEZ, TOM) and used to inform continuous quality improvement efforts. Tribal representatives are invited and engaged as equal participants ensuring that Tribal voice is incorporated into all aspects of planning and decision making.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Engagement and Team Preparation (Pages 3-4)
Plan Implementation and Ongoing Service Delivery (Pages 5-6)
2.2 Improved School Functioning
Clinical interventions are integrated within the Plan of Care and are continuously adapted. This integrated approach supports stabilization and promotes improved functioning across life domains. Outcome measures evaluate overall wellbeing across life domains.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Integrated Behavioral Health Services (Page 2)
2.3 Improved Functioning in the Community
Clinical interventions are integrated within the Plan of Care. This integrated approach supports stabilization, reduces the need for higher levels of care, and promotes improved functioning across life domains. Outcome data, fidelity results, service timelines, and family feedback are reviewed to monitor performance indicators and identify opportunities for improvement.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Integrated Behavioral Health Services (Page 2)
Fidelity Monitoring, Coaching, and Continuous Quality Improvement (Pages 2-3)
2.4 Improved Interpersonal Functioning
Clinical interventions are integrated within the Plan of Care. This integrated approach supports stabilization and promotes improved functioning across life domains. Outcome measures include tools designed to evaluate caregiver stress and overall wellbeing across life domains.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Integrated Behavioral Health Services (Page 2)
2.5 Increased Caregiver Confidence
The Facilitator maintains responsibility for coordinating services and ensuring that identified needs are addressed throughout the duration of care, including facilitating referrals to additional providers when necessary. The Crisis and Safety Plan includes individualized proactive and reactive strategies with accessible crisis resources available 24/7. The Parent Training and Education Program helps caregivers develop skills in navigating systems, strengthening their ability to participate effectively and support their children’s needs.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Plan Implementation and Ongoing Service Delivery (Pages 5-6)
Crisis and Safety Planning (Page 12)
Parent Training, Education, and Family Support Services (Pages13-14)
Bayfront Youth & Family Services Policy and Procedures: Policy O-1.2 PARENT TRAINING, EDUCATION, AND PARENT RUN SUPPORT GROUPS AND SERVICES
2.6 Stable and Least Restrictive Living Environment
Services are individualized and delivered in the least restrictive, community-based settings to promote safety, permanency, and long-term stability. This integrated approach supports stabilization, reduces the need for higher levels of care.
Bayfront Youth & Family Services High Fidelity Wrap Program Description (Pages 1–2)
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Clinical interventions are integrated within the Plan of Care. This integrated approach supports stabilization, reduces the need for higher levels of care. Crisis and Safety Plans are continuously reviewed and updated to ensure effective stabilization and prevention of escalation.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Integrated Behavioral Health Services (Page 2)
Plan Implementation and Ongoing Service Delivery (Pages 5-6)
2.8 Reduction in Crisis Visits
The Crisis and Safety Plan includes individualized proactive and reactive strategies. The effectiveness of crisis strategies is continuously evaluated, ensuring that the plan remains responsive and effective. Bayfront prioritizes the identification and strengthening of natural supports as a key component of long-term sustainability.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Crisis and Safety Planning (Page 12)
Use of Natural Supports and Cultural Responsiveness (Page 13)
2.9 Positive Exit from HFW
Transition from Wraparound services occurs when the team, with preference given to family voice and choice, determines that identified needs have been sufficiently met and that the family can maintain stability. Setbacks are addressed through plan revision rather than service discontinuation.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Plan Implementation and Ongoing Service Delivery (Pages 5-6)
Transition Planning and Discharge (Pages 7-8)
Engagement
3.1 Orientation
(a) Bayfront’s Wraparound program is grounded in the principles of family voice and choice, team-based collaboration, cultural humility, persistence, and outcomes-based practice. Training includes foundational instruction in Wraparound principles and phases.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Program Approach and Service Delivery Model (Pages 1-2)
Training, Coaching, and Supervision (Pages 9-10)
(b) Bayfront coordinates with County partners ensures that all required enrollment documentation and communication with County representatives are completed in accordance with contractual requirements. Staff are trained in mandated reporting requirements.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Program Approach and Service Delivery Model (Pages 1-2)
Incident Reporting and Safety Oversight (Page 12)
(c) A multidisciplinary team, including Facilitators, Clinicians, Family Specialists, Youth Partners, and Parent Partners, collaborates with formal providers, natural supports, and system partners. When a youth is identified as an Indian child, the Facilitator ensures that Tribal representatives are invited and engaged as equal participants.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Program Approach and Service Delivery Model (Pages 1-2)
Engagement and Team Preparation (Pages 3-4)
3.2 Safety and Crisis stabilization
(a) Immediate safety concerns are addressed through the development of an initial crisis response plan as needed to stabilize the situation and ensure safety.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Engagement and Team Preparation (Pages 3-4)
(b) The POC integrates services across systems and includes a comprehensive Safety and Crisis Plan with individualized proactive and reactive strategies. Crisis and Safety Plans are continuously reviewed and updated based on assessment findings, observed risk, and family input to ensure effective stabilization and prevention of escalation. Bayfront Youth & Family Services High Fidelity Wrap Program Description
Initial Plan Development (Pages 4-5)
Plan Implementation and Ongoing Service Delivery (Pages 5–6)
(c) The POC integrates services across systems and includes a comprehensive Safety and Crisis Plan with individualized proactive and reactive strategies, clearly defined roles, and 24/7 support access.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Initial Plan Development (Pages 4-5)
3.3 Strengths, Needs, Culture and Vision Discovery
(a) During intake, staff initiate a structured Strengths, Needs, Culture, and Vision discovery process, including developing a vision for the future. Information gathered during this process is documented and used to inform all subsequent planning and service delivery.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Engagement and Team Preparation (Pages 3-4)
(b) This process includes guided conversations with the youth and family to explore strengths, identify underlying needs, understand cultural identity and preferences. Information gathered during this process is documented and used to inform all subsequent planning and service delivery. The team develops and maintains a strengths inventory. This inventory is reviewed and updated regularly.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Engagement and Team Preparation (Pages 3-4)
Initial Plan Development (Pages 4–5)
3.4 Engage All Team Members
(a) The team develops and maintains a strengths inventory that includes strengths of the youth, family, team members, and community supports.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Initial Plan Development (Pages 4-5)
(b) Bayfront coordinates with County partners, including probation, child welfare, and mental health liaisons.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Program Approach and Service Delivery Model (Pages 1-2)
(c) The Facilitator works collaboratively with the family to identify and engage CFT members, including formal providers, natural supports, and system partners. When a youth is identified as an Indian child, the Facilitator ensures that Tribal representatives are invited and engaged as equal participants.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Engagement and Team Preparation (Pages 3-4)
(d) Information gathered during this process is documented and used to inform all subsequent planning and service delivery. All elements of the Wraparound process are clearly documented in the youth’s record.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Engagement and Team Preparation (Pages 3-4)
3.5 Arrange Meeting Logistics
(a) Services are delivered in a flexible and responsive manner, recognizing that families may experience challenges, changes in circumstances, or setbacks that require ongoing engagement, persistence, and adaptation of strategies. Roles and responsibilities are clarified, and meeting logistics are coordinated to ensure accessibility and participation.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Program Approach and Service Delivery Model (Pages 1-2)
Engagement and Team Preparation (Pages 3-4)
(b) Youth and families are recognized as the primary decisionmakers, and their perspectives, strengths, values, and cultural identities guide all aspects of engagement, planning, and service delivery. The Facilitator works collaboratively with the family to identify and engage CFT members and ensure accessibility and participation.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Program Approach and Service Delivery Model (Pages 1-2)
Engagement and Team Preparation (Pages 3-4)
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
(a) Within the first 30 days, the Facilitator leads the CFT in developing an individualized Plan of Care (POC). This process includes establishing team agreements, developing a team mission aligned with the family’s vision. The team develops and maintains a strengths inventory.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Initial Plan Development (Page 4-5)
(b) The team develops and maintains a strengths inventory. This inventory is reviewed and updated regularly.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Initial Plan Development (Page 4-5)
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
(a) This process includes identifying and prioritizing underlying needs informed by both family input and standardized assessment data.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Initial Plan Development (Page 4-5)
(b) Measurement tools are used to support development of measurable, outcomes-based goals. Needs are defined as underlying conditions ensuring that planning remains focused on root causes.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Initial Plan Development (Page 4-5)
(c) The team collaboratively develops goals and brainstorms multiple individualized strategies.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Initial Plan Development (Page 4-5)
(d) The team collaboratively develops goals and brainstorms multiple individualized strategies. Each strategy is translated into clear action steps.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Initial Plan Development (Page 4-5)
(e) Facilitators receive ongoing coaching in core competencies, including identification of strengths and underlying needs, facilitation of team meetings, and development of individualized strategies.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Fidelity Monitoring, Coaching, and Continuous Quality Improvement (Page 2-3)
(f) Within the first 30 days, the Facilitator leads the CFT in developing an individualized Plan of Care (POC). The team collaboratively develops goals and individualized strategies.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Initial Plan Development (Page 4-5)
4.3 Develop an Individualized Child or Youth and Family Plan
(a) Facilitators receive ongoing coaching in core competencies, including engagement, facilitation of team meetings and development of individualized strategies. Training includes foundational instruction in Wraparound principles and phases.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Fidelity Monitoring, Coaching, and Continuous Quality Improvement (Pages 2-3)
Training, Coaching, and Supervision (Pages 9-10)
(b) The POC integrates services across systems. A multidisciplinary team collaborates with formal providers, natural supports, and system partners to ensure coordinated, integrated care.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Program Approach and Service Delivery Model (Pages 1-2)
(c) All elements of the Wraparound process are clearly documented in the youth’s record. The Facilitator ensures that communication with County representatives and team partners are completed.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Program Approach and Service Delivery Model (Pages 1-2)
(d) Fidelity data is aggregated, analyzed, and reviewed to inform training, supervision and program development. Outcome data and fidelity results are reviewed in CQI forums and used to inform targeted staff training and coaching plans.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Fidelity Monitoring, Coaching, and Continuous Quality Improvement (Pages 2-3)
Plan Implementation and Ongoing Service Delivery (Page 5-6)
4.4 Develop a Crisis and Safety Plan
(a) The POC integrates services across systems and includes a comprehensive Safety and Crisis Plan with individualized proactive and reactive strategies, clearly defined roles, and 24/7 support access.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Initial Plan Development (Pages 4-5)
(b) The team collaboratively develops goals and brainstorms multiple individualized strategies. Facilitators receive ongoing coaching in core competencies, including facilitation of team meetings and crisis and safety planning.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Initial Plan Development (Pages 4-5)
(c) Crisis and Safety Plans are continuously reviewed and updated based on assessment findings, observed risk, and family input to ensure effective stabilization and prevention of escalation. Fidelity data and outcome data are reviewed to inform training and coaching plans.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Plan Implementation and Ongoing Service Delivery (Pages 5-6)
Implementation
5.1 Implement The Plan of Care
a. The Facilitator leads the team in reviewing strategies and action items during meetings by using agendas and minutes to track progress, monitor assignments and timelines, and adjust plans as needed.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Implementation of the Wraparound Process
Engagement and Team Preparation (Pages 3-4)
Initial Plan Development, Pages 4, 5
Plan Implementation and Ongoing Service Delivery, Pages 5, 6
b. Staff receive continuous training and guidance to carry out the plan of care in accordance with High-Fidelity Wraparound principles, with an emphasis on acknowledging and celebrating progress and achievements as they happen.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Plan Implementation and Ongoing Service Delivery, Page 5-6
5.2 Review and Update The Plan of Care
a. Strategies, progress, and action items are reviewed in HFW team meetings, where updates to strengths, needs, and the Plan of Care are made collaboratively.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Initial Plan Development, Pages 4, 5, 6
Child and Family Team (CFT), Page 9
b. The facilitator leads the team to update and adjust the Plan of Care as progress is made, new needs emerge, or strategies evolve, ensuring changes are informed by ongoing strengths discovery and needs prioritization, and that all updates are clearly documented in the youth’s record.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Initial Plan Development, Pages 4, 5, 6
c. The facilitator tracks and shares updates on task completion, new assignments, team attendance, engagement of formal and natural supports, use of flex funds, and any revisions to the Plan of Care, with all updates communicated to team members at a minimum through documented meeting minutes.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Initial Plan Development, Page 4-5
d. Forms can be routinely updated and tailored to reflect the evolving needs of the youth, their family, and the team.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Initial Plan Development, Page 4-5
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
a. Team agreements are consistently used, regularly reviewed, and shared during HFW team meetings
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Initial Plan Development, Pages 4, 5
b. Facilitators are provided with continuous professional development and support to strengthen their team-building and engagement practices
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Training, Coaching, and Supervision, Page 9-10
c. Natural supports are tracked over time, and teams receive guidance and feedback through ongoing coaching and supervision
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Training, Coaching, and Supervision, Pages 9, 10
d. Clear onboarding processes are in place for new team members including formal and natural supports covering the HFW process, current plans and strategies, and opportunities for team-building
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
High Fidelity Wraparound (HFW) Integrated Training, Coaching, and Mentorship Curriculum, Page 15-17
Workforce Development and Staff Retention, Page 10-11
Transition
6.1 Develop a Transition Plan
a. The facilitator guides the team in determining readiness for transition by using established benchmarks and indicators that have been continuously reviewed and adjusted throughout the HFW process.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Transition Planning and Discharge, Page 7-8
b. After readiness is established, the facilitator works with the team to develop a personalized transition plan outlining needs, services, and supports, ensures it is shared with all team members, and documents it in the youth’s record.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Transition Planning and Discharge, Page 7-8
c. The individualized transition plan is developed through a collaborative, team-based process, with facilitators receiving training and coaching to effectively support this work.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Transition Planning and Discharge, Page 7-8
Training, Coaching, and Supervision, Page 9-10
d. The team confirms that the services and supports outlined in the transition plan will continue beyond formal HFW and that the family can effectively access them, including post-adoption services when applicable.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Transition Planning and Discharge, Page 7-8
6.2 Develop a Post-Transition Safety Plan
a. The youth’s file includes an updated crisis and safety plan that accounts for the transition, identifying possible post-transition crises and outlining family-selected prevention and response strategies that prioritize natural supports.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Transition Planning and Discharge, Pages 7, 8
b. The safety crisis transition plan is created through a collaborative, team-based process, with facilitators trained and coached to effectively support this approach.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Transition Planning and Discharge, Page 7 -8
Training, Coaching, and Supervision, Page 9-10
c. Established procedures support routine review of crisis and safety plans to confirm they include personalized, culturally appropriate strategies, a logical sequence of preventive and responsive actions, and strong integration of natural supports, while also guiding continuous improvement, training, and coaching efforts.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Transition Planning and Discharge, Page 7-8
6.3 Create a Commencement and Celebrate Success
a. Exits from the Wraparound process are acknowledged and marked in ways that align with each family’s cultural background, values, and personal preferences.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Transition Planning and Discharge, Page 7-8
b. Administrative systems enable celebrations through resources and staffing, while teams partner with families to honor their cultural preferences, and community partnerships and ensure full team participation.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Transition Planning and Discharge, Page 7-8
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
a) Youth and families are recognized as the primary decision makers of the treatment planning process.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Program Approach and Service Delivery Model, Pages 1-2
b) Satisfaction survey results are utilized to develop procedural, planning, and quality improvements in service delivery.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Fidelity Monitoring, Coaching, and Continuous Quality Improvement Pages 2-3
Expanded Use of Outcome and Assessment Measures, Page 3
Quality Assurance Tools and Documentation Review, Page 7
7.2 Community Leadership Team
a) Wraparound Program Manager and Wrap Supervisor/Community Developer are identified to represent Bayfront Youth and Family Services on the Community Leadership Team for LA County.
Bayfront Youth & Family Services High Fidelity Wrap Program Description,
Program Leadership and Staff Structure, Page 12
7.3 Eligibility and Equal Access
a) Clients are eligible to receive any services provided by Bayfront Youth and Family Services if medical necessity criteria are met.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Access, Service Capacity, and Persistence, Page 14
b) Staffing engagement of the HFW team is determined during the planning process to meet the level of care and youth/family needs.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
Program Leadership and Staff Structure, Page 12
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
a. Bayfront Youth and Family Services ensures funding is structured to support high-fidelity direct services and individualized supports that meet the immediate needs of youth and families.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Program Funding, Pages 17-18
b. Funding arrangements reflect the resources necessary to meet California Wraparound Standards, including workforce dvelopment and the staffing roles identified in Workforce Development standard 9.3.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Program Funding, Pages 17-18
c. Bayfront Youth and Family Services ensures program funding structures support the required data collection and management systems essential to Wraparound operations.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Program Funding, Pages 17-18
8.2 Equitable Funding Across System Partners
a. Bayfront Youth and Family Services maintains a system for identifying and leveraging federal, state, local, and private funding resources across the Children’s System of Care to support service delivery.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Program Funding, Pages 17-18
b. Bayfront Youth and Family Services analyzes and integrates funding streams into coordinated budgets and plans to maximize resources and ensure comprehensive, shared support for services.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Program Funding, Pages 17-18
c. Bayfront Youth and Family Services maintains or pursues formal cost-sharing agreements between Child Welfare, Probation, and Behavioral Health to ensure shared responsibility and coordinated care.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Program Funding, Pages 17-18
d. Bayfront Youth and Family Services explores and leverages multiple funding sources to expand access to High Fidelity Wraparound services.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Program Funding, Pages 17-18
8.3 Cost Savings are Reinvested
a. Bayfront Youth and Family Services uses structured data systems, including its EHR, to support fiscal accountability and enable transparent tracking and reinvestment of High Fidelity Wraparound savings, regularly communicating this information to stakeholders and the community through reports and collaborative forums.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Cost Savings Identification and Monitoring, Reinvestment of Cost Savings, Procedures to Ensure Compliance Page 18
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied., (c) N/A (AAP funded Wraparound)
a. Flexible funds are available to support High Fidelity Wraparound services and are incorporated into each youth and family’s individualized funding plan as needed. Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Availability, Access, and Approval of Flex Funds, Pages 17, 18
Bayfront Policy and Procedures, Policy: O-1.3 USE OF WRAPAROUND CASE RATE SUPPORT SERVICE (CRSS) FUNDS
b. Bayfront has clearly defined procedures for requesting and overseeing flexible funds, including prompt access for urgent family needs, a structured review and approval process, and an appeal pathway that explains denied requests.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description,
Availability, Access, and Approval of Flex Funds, Pages 17, 18
Bayfront Policy and Procedures, Policy: O-1.3 USE OF WRAPAROUND CASE RATE SUPPORT SERVICE (CRSS) FUNDS
8.5 Collaborative Oversight of Flex Funds
a. Bayfront Youth and Family Services documents and transparently communicates all flexible fund requests including amount, purpose, and HFW team recommendation to funders and providers.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description,
Availability, Access, and Approval of Flex Funds, Pages 17, 18
Policy and Procedures, Policy: O-1.3 USE OF WRAPAROUND CASE RATE SUPPORT SERVICE (CRSS) FUNDS
b. Bayfront Youth and Family Services pools and manages flexible funds to ensure equitable availability and responsiveness to the needs of all families served.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description,
Availability, Access, and Approval of Flex Funds, Pages 17, 18
Policy and Procedures, Policy: O-1.3 USE OF WRAPAROUND CASE RATE SUPPORT SERVICE (CRSS) FUNDS
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
a. Bayfront Youth and Family Services utilizes braided System of Care funding streams to ensure consistent availability of flexible funds and program resources.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description,
Flexible Funds Not Limited by Single Funding Sources, Page 18-19
b. Bayfront Youth and Family Services mitigates funding constraints by identifying and utilizing alternative funding streams while increasing reliance on other available resources to ensure uninterrupted support. Bayfront Youth & Family Services High Fidelity Wraparound Program Description,
Flexible Funds Not Limited by Single Funding Sources, Page 18-19
c. Bayfront Youth and Family Services ensures that restrictions tied to any single funding source do not hinder families’ access to flexible funds needed to address their individualized needs.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description,
Flexible Funds Not Limited by Single Funding Sources, Page 18-19
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
a. Bayfront Youth and Family Services monitors the demographics of the population served and prioritizes recruiting staff who reflect community diversity and needs. Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Workforce Development and Staff Retention, Pages 10, 11
Bayfront Policy and Procedures: H-5.5 DIVERSITY, EQUITY AND INCLUSION POLICY
b. When recruitment cannot fully meet cultural, racial, or linguistic needs, Bayfront Youth and Family Services addresses gaps by engaging natural and formal supports within the Child and Family Team to ensure appropriate cultural representation.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Use of Natural Supports and Cultural Responsiveness, Page 13
Workforce Development and Staff Retention, Pages 10, 11
Bayfront Policy and Procedures: Policy: H-5.5 DIVERSITY, EQUITY AND INCLUSION POLICY
c. Bayfront uses translators and external or natural resources when language needs cannot be met.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Workforce Development and Staff Retention, Pages 10, 11
9.2 Tribally Responsive Workforce
a. Bayfront Youth and Family Services trains staff in tribal sovereignty, traditions, and values to support respectful communication, collaboration, and culturally responsive practice.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Staff Training, Coaching, and Supervision, Pages 9, 10
High Fidelity Wraparound (HFW) Integrated Training, Coaching, and Mentorship Curriculum, Page 15-17
b. Bayfront Youth and Family Services collaborates with Tribal representatives, supports cultural engagement, and integrates Tribal resources into individualized care as needed.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Staff Training, Coaching, and Supervision, Pages 9, 10
High Fidelity Wraparound (HFW) Integrated Training, Coaching, and Mentorship Curriculum, Page 15-17
9.3 Flexible and Creative Work Environment
a. Bayfront Youth and Family Services supports program quality through staff development, recognition, and a positive, growth-focused work environment.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Workforce Development and Staff Retention, Pages, 10-11
b. Bayfront Youth and Family Services promotes cohesion by fostering a positive, collaborative team environment that encourages open communication, staff engagement, and shared success.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Workforce Development and Staff Retention, Pages, 10-11
c. Bayfront Youth and Family Services fosters open communication by encouraging transparent, two-way dialogue between staff and leadership through a supportive and accessible environment.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Workforce Development and Staff Retention, Pages, 10-11
d. Bayfront Youth and Family Services reinforces a clear sense of mission and alignment with High Fidelity Wraparound principles by promoting shared values, ongoing training, and consistent adherence to program practices across all levels of staff.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Workforce Development and Staff Retention, Pages, 10-11
High Fidelity Wraparound (HFW) Integrated Training, Coaching, and Mentorship Curriculum Page 15-17
9.4 Hiring, Performance Evaluation, and Job Descriptions
a. Each role and function is addressed within the HFW program either through dedicated positions or by integrating responsibilities across roles with clearly outlined duties and expectations.
Bayfront Youth & Family Services HFW Job Descriptions
b. Each role includes a clear description outlining its purpose, key responsibilities, and the skills, competencies, and attributes required to effectively carry out its functions. Bayfront Youth & Family Services HFW Job Descriptions
c. Job descriptions for all required positions are tailored to the HFW program and highlight the attitudes, skills, knowledge, and experience needed for success in each role. Bayfront Youth & Family Services HFW Job Descriptions
d. The hiring process is designed to give candidates opportunities to showcase the key skills and personal qualities needed to succeed in the role.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Workforce Development and Staff Retention, Page 10-11
e. Employees are given clear performance expectations and receive regular feedback and coaching to help guide their development and ensure success in their roles.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Program Approach and Service Delivery Model, Page 1-2
Fidelity Monitoring, Coaching, and Continuous Quality Improvement, Page 2-3
Plan Implementation and Ongoing Service Delivery, Pages 5, 6
Training, Coaching, and Supervision, Pages 9-10
High Fidelity Wraparound (HFW) Integrated Training, Coaching, and Mentorship Curriculum Pages 15-17
9.5 Workforce Stability
a. The organization aligns employee wages with local cost-of-living standards in the service area, ensuring compensation remains fair and responsive to regional economic conditions.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Workforce Development and Staff Retention, Page 10-11
b. The organization prioritizes sustainable workloads by monitoring caseload distribution and encouraging staff to communicate capacity concerns to ensure responsibilities remain manageable.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Workforce Development and Staff Retention, Page 10-11
c. Bayfront Youth & Family Services maintains transparent and accessible advancement pathways that recognize lived experience as a strength, ensuring opportunities for promotion are fair and not restrictive for staff with such backgrounds.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Workforce Development and Staff Retention, Page 10-11
d. The organization offers pathways for wage growth and leadership development that allow staff to advance professionally without requiring a formal change in position. Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Workforce Development and Staff Retention, Page 10-11
Bayfront Policy and Procedures: Policy H-1.0 JOB VACANCIES AND WORKFORCE STABILITY
9.6 High Fidelity Training Plan
a. (2) Staff are currently in the process of completing the required steps to be trained internally using the Statewide Standardized Foundational HFW curriculum, including participation in foundational and trainer-level Wraparound 101 trainings and accessing the curriculum materials.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
High Fidelity Wraparound (HFW) Integrated Training, Coaching, and Mentorship Curriculum, Pages 15-17
b. All staff are supported with continuous training in both overall Wraparound practices and their individual roles through a mix of formal instruction, team meetings, coaching, peer learning, and supervision, with annual refresher sessions to reinforce key concepts and maintain service quality.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
High Fidelity Wraparound (HFW) Integrated Training, Coaching, and Mentorship Curriculum, Pages 15-17
Plan Implementation and Ongoing Service Delivery, Page 5-6
Training, Coaching, and Supervision, Pages 9-10
c. All staff participate in at least annual refresher training (booster) in both general Wraparound practices and their specific roles.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
High Fidelity Wraparound (HFW) Integrated Training, Coaching, and Mentorship Curriculum, Pages 15-17
d. Clinical Supervisors and HFW Supervisors/Managers complete general Wraparound training and receive initial, ongoing, and refresher training tailored to their leadership and supervisory responsibilities.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
High Fidelity Wraparound (HFW) Integrated Training, Coaching, and Mentorship Curriculum, Page 15-17
e. All staff are provided with training on ICWA and Tribal sovereignty, and processes are established to identify and offer additional training to meet the diverse and specialized needs of different populations as they arise.
Bayfront Youth & Family Services High Fidelity Wrap Program Description
High Fidelity Wraparound (HFW) Integrated Training, Coaching, and Mentorship Curriculum, Pages 15-17
Engagement and Team Preparation, Pages 3-4
9.7 Community-based Training Program
a. Youth, families, and peer partners with current or prior Wraparound experience are actively engaged in delivering trainings as facilitators and mentors, and are provided with Wraparound-specific training to effectively fulfill these roles.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Parent Training, Education, and Family Support Services, Pages 13-14
Family Leadership and Advisory Participation, Page 14
Bayfront Policy and Procedures: Policy: O-1.2 PARENT TRAINING, EDUCATION, AND PARENT RUN SUPPORT GROUPS AND SERVICES
b. Bayfront Youth & Family Services collaborates with community partners by inviting them to attend or receive Wraparound trainings to strengthen their engagement on HFW teams and enhance their ability to support Wraparound within the System of Care.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Parent Training, Education, and Family Support Services, Pages 13-14
Family Leadership and Advisory Participation, Page 14
Bayfront Policy and Procedures: Policy: O-1.2 PARENT TRAINING, EDUCATION, AND PARENT RUN SUPPORT GROUPS AND SERVICES
9.8 Coaching and Supervision
a. All staff participate in a structured onboarding and apprenticeship process that builds foundational knowledge of High-Fidelity Wraparound principles and practices, develops applied skills through training and observation, and includes guidance on using flex funds to address family needs.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
High Fidelity Wraparound (HFW) Integrated Training, Coaching, and Mentorship Curriculum, Pages 15-17
b. Staff have continuous access to supervision and coaching support at all times, ensuring guidance is available whenever needed.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Training, Coaching, and Supervision, Pages 9-10
Bayfront Policy and Procedures: Policy: O-2.4 SUPERVISION
Bayfront Policy and Procedures: O-1.3 USE OF WRAPAROUND CASE RATE SUPPORT SERVICE (CRSS) FUNDS
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
a) Data derived from all reports and measurements are utilized in staff training and supervision to improve the fidelity and quality of care provided to youth and families.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Fidelity Monitoring, Coaching, and Continuous Quality Improvement (Pages 2-3)
Quality Assurance Tools and Documentation Review (Page 7)
b) Programmatic data results are analyzed and evaluated to improve program effectiveness based on organizational standards.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Fidelity Monitoring, Coaching, and Continuous Quality Improvement (Pages 2-3)
Expanded Use of Outcome and Assessment Measures (Page 3)
c) Data is collected when system barriers are identified and provided to organizational stakeholders as well as the Community Leadership Team to be addressed and navigate impacts to services.
Bayfront Youth & Family Services High Fidelity Wraparound Program Description
Fidelity Monitoring, Coaching, and Continuous Quality Improvement (Pages 2-3)
Plan Implementation and Ongoing Service Delivery (Pages 5-6)
Fidelity Indicators
1.1 Timely Engagement and Planning
a) The Monterey County High Fidelity Wraparound (HFW) Facilitator is required to initiate engagement activities with the youth and family as soon as possible but no later than 10 calendar days from the Interagency Placement Committee (IPC) approval. See Scope of Services/Payment Provisions, Section H.1.1.a, page 5. During the engagement phase, the assigned social worker shall assist the HFW Facilitator, when needed, in contacting and engaging the family timely to ensure the first contact with families is made as soon as possible but no later 10 calendar days from IPC approval. See FCS Wraparound Policy, section titled “Procedures – Engagement Phase.” The Contractor shall include the evaluation of the number of days from referral to first contact for each family in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.11., page 27.
b) The Contractor shall complete the initial Wraparound Plan of Care within 30 days from the start of services. See Scope of Services/Payment Provisions, Section H.6.4, page 15. The Contractor shall include the number of days it takes to complete the initial Plan of Care from the start of services for each family in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.12, page 27.
c) The HFW Facilitator shall schedule HFW Team meetings at least every 30-45 calendar days to review the Plan of Care. See Scope of Services/Payment Provisions, Section H.1.3.a, page 8. The Contractor shall include the frequency that the Plan of Care is reviewed for each family in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.13, page 27.
d) The Contractor shall ensure teams update the plan of care, distribute to all team members, and document the updated plan in the child or youth’s file at least every 90 days. See Scope of Services/Payment Provisions, Section H.6.10, page 15. The Contractor shall include the frequency that the Plan of Care is updated and distributed to each family in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.14, page 27.
e) The Contractor shall ensure staff and their supervisors are provided feedback on their ability to meet timelines for training and coaching purposes. See Scope of Services/Payment Provisions, Section L.3.1, page 26. The Contractor shall include the training and coaching topics that were provided to staff during the reporting period in the bi-annual report. The topics should address the areas of improvement identified by the evaluation of the fidelity indicators. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
f) The Contractor shall provide ongoing training and coaching to staff on timely engagement strategies that include encouraging alternate strategies when contact with family is difficult. See Scope of Services/Payment Provisions, Section J.2.1, page 20. The Contractor shall develop and provide a comprehensive bi-annual report that includes a list of training and coaching topics that were provided to staff during the reporting period. See Scope of Services/Payment Provisions, Section N.1.17 page 27.
1.2 Led by Youth and Families
a) The Contractor shall utilize a holistic approach that is youth-driven and family-focused. The HFW team prioritizes the youth and family’s perspectives and voices in developing and modifying a mix of strategies and supports to ensure the best fit with their preferences. See Scope of Services/Payment Provisions, Section H.3.2, page 12. The HFW Facilitator shall meet with the family to elicit and use the family’s perspective, including Tribes when applicable, to complete a Family Vision and document the Family Vision in the youth’s chart. See Scope of Services/Payment Provisions, Section H.1.1.c, page 6. During the first HFW Team meeting, the HFW Facilitator shall build upon the activities completed during the Engagement Phase and lead the team in creating a mission statement that defines the overall purpose of the HFW team in alignment with the family vision. See Scope of Services/Payment Provisions, Section H.1.2.a.iii, page 7. The Contractor shall routinely review the Family Vision Statement, Team Mission Statement, documentation, and family feedback to ensure HFW services are provided to fidelity. See Scope of Services/Payment Provisions, Section K.2.2, page 22. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
b) The Contractor shall ensure the youth and family’s values, culture, expertise, capabilities, interests, and skills are elicited, fully understood, celebrated, and clearly documented in the youth’s case file. They are viewed as critical to a successful process and are the basis for decision making and problem solving. See Scope of Services/Payment Provisions, Section H.3.2, page 12. The Contractor shall routinely review the youth’s case file for documentation of family values, culture, expertise, capabilities, interests, and skills to ensure HFW services are provided to fidelity. See Scope of Services/Payment Provisions, Section K.2.2.b, page 22. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
c) The Contractor shall ensure supervisors/coaches routinely observe HFW team meetings and review documentation to gather and provide feedback to staff to reinforce practice expectations, build skills, and increase confidence. See Scope of Services/Payment Provisions, Section I.1.1 and I.1.2, pages 16 and 17. The Contractor shall routinely review observations made by supervisors/coaches during HFW team meetings to ensure HFW services are provided to fidelity. See Scope of Services/Payment Provisions, Section K.2.2.d, page 22. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
d) Youth and families will report satisfaction with Wraparound as measured by the Wraparound Fidelity Index (WFI-EZ). See Scope of Services/Payment Provisions, Section F.6 page 2. The Contractor shall routinely elicit and review feedback from families (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) regarding their experience of the Wraparound process. See Scope of Services/Payment Provisions, Section K.2.2.e, page 22. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
1.3 Strength-Based
a) During the engagement phase, the HFW Facilitator shall facilitate conversations and activities with the youth and family to identify individual and family strengths, needs, culture, and their vision for a better future. See Scope of Services/Payment Provisions, Section H.1.1.c, page 6. The HFW Facilitator shall initiate a Strengths, Needs, Culture Discovery document with every youth and family before the first HFW Team meeting and include the Discovery in the youth’s chart. The HFW Facilitator shall update the Discovery every 90 days; have the team add new strengths, needs, and cultural preferences as they are discovered; include other resources in the family’s local community; provide the Discovery to new team members as they are identified; and include the Discovery in the Plan of Care. See Scope of Services/Payment Provisions, Section H.1.1.d, page 6. The Contractor shall routinely review the strengths inventory to ensure HFW services are strengths-based. See Scope of Services/Payment Provisions, Section K.2.3, page 22. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
b) The social worker, probation officer, or therapist shall attach the most current IP-CANS to the HFW referral. See HFW Referral, page 2. The Contractor shall include the strengths and needs that are identified in the IP-CANS in the Plan of Care document. See Scope of Services/Payment Provisions, Section H.1.2.c, page 7. The Contractor shall routinely review the IP-CANS to ensure HFW services are strength-based and provided to fidelity. See Scope of Services/Payment Provisions, Section K.2.3.b, page 22. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
c) The Contractor shall provide ongoing training and coaching on providing strengths-based, solution-focused services. See Scope of Services/Payment Provisions, Section J.2.3, page 20. The Contractor shall develop and provide a comprehensive bi-annual report that includes a list of training and coaching topics that were provided to staff during the reporting period. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
d) The Contractor agrees to implement policies, procedures, and data processes (e.g., CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), quality assurance phone calls, post Team Meeting verbal feedback or feedback forms, documentation review, etc.) to ensure routine evaluation of families receiving strength-based service. See Scope of Services/Payment Provisions, Section K.2.3, page 22. Contractor shall utilize their evaluation of the fidelity indicators to provide feedback to staff and their supervisors on their ability to provide strengths-based services. See Scope of Services/Payment Provisions, Section L.3.3, page 26. The Contractor shall include the training and coaching topics that were provided to staff during the reporting period in the bi-annual report. The topics should address the areas of improvement identified by the evaluation of the fidelity indicators. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
1.4 Needs Driven
a) During the first HFW Team meeting, the HFW Facilitator shall facilitate a discussion around the Strengths, Needs, Culture Discovery and lead the team in identifying and prioritizing underlying needs for each family. The HFW Facilitator shall also lead the team in developing an individualized HFW Plan of Care that includes collaboratively developing SMART goals for each of the underlying needs. See Scope of Services/Payment Provisions, Section H.1.2.b, page 7. The Contractor shall routinely review the Needs Statements and documentation in the youth’s file to ensure needs are identified and prioritized before goals and strategies are established. See Scope of Services/Payment Provisions, Section K.2.4.c, page 21. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
b) The Contractor shall provide ongoing training and coaching on identifying needs, developing needs statements that are reflective of the underlying reasons why problematic situations or behaviors are occurring, and utilizing needs-focused planning over problematic behavior-focused planning. See Scope of Services/Payment Provisions, Section J.2.4, page 20. The Contractor shall develop and provide a comprehensive bi-annual report that includes a list of training and coaching topics that were provided to staff during the reporting period. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
c) The social worker, probation officer, or therapist shall attach the most current IP-CANS to the HFW referral. See HFW Referral, page 2. The HFW Facilitator shall include the needs that are identified in the IP-CANS assessment in the Plan of Care. See Scope of Services/Payment Provisions, Section H.1.2.c.i, page 7. The Contractor shall routinely review the IP-CANS for each family to ensure services are driven by the family’s underlying needs. See Scope of Services/Payment Provisions, Section K.2.4.d, page 22. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
d) When the family has reached pre-determined benchmarks indicating sufficient progress towards completing the team mission and goals, and the youth, family, and team agree the family is ready for transition, the HFW team will begin developing a formal individualized transition plan. See Scope of Services/Payment Provisions, Section H.1.4.a, page 10. The Contractor shall routinely review the transition plan for each family to ensure the needs of the family have been met. See Scope of Services/Payment Provisions, Section K.2.4.f, page 22. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
1.5 Individualized
a) The Contractor shall ensure forms/documentation allow for sufficient flexibility in creating individualized plans for each child/youth and family. See Scope of Services/Payment Provisions, Section H.3.3, page 12. The HFW Facilitator shall lead teams in updating the Plan of Care during HFW Team meetings and forms shall be able to be updated and individualized to meet the youth, family, and team’s changing needs. See Scope of Services/Payment Provisions, Section H.1.3.a.vii, page 9. The Contractor shall routinely review the Plan of Care for each family to ensure the form/document allows for sufficient flexibility in creating an individualized plan. See Scope of Services/Payment Provisions, Section K.2.5.a, page 22. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
b) The Contractor shall provide ongoing training and coaching on providing flexible, creative, and highly individualized services and strategies. See Scope of Services/Payment Provisions, Section J.2.5, page 20. The Contractor shall develop and provide a comprehensive bi-annual report that includes a list of training and coaching topics that were provided to staff during the reporting period. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
c) The Contractor shall provide ongoing training and coaching to facilitators on leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences. See Scope of Services/Payment Provisions, Section J.2.6, page 20. The Contractor shall develop and provide a comprehensive bi-annual report that includes a list of training and coaching topics that were provided to staff during the reporting period. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
d) The Contractor shall routinely review and assess HFW Plans of Care for use of individualized strengths, needs, outcomes, and strategies and for the presence of strategies that capitalize on the assets of the family’s community and informal networks. See Scope of Services/Payment Provisions, Section K.2.5.b, page 22. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
e) The Contractor agrees to implement policies, procedures, and data processes (e.g., CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), quality assurance phone calls, post Team Meeting verbal feedback or feedback forms, documentation review, etc.) to routinely elicit and review feedback from families regarding their experience of receiving customized services. See Scope of Services/Payment Provisions, Section K.2.5.e, page 23. The Contractor shall utilize their evaluation of the fidelity indicators to provide feedback to staff and their supervisors on their ability to provide individualized services. See Scope of Services/Payment Provisions, Section L.3.5, page 26. The Contractor shall include the training and coaching topics that were provided to staff during the reporting period in the bi-annual report. The topics should address the areas of improvement identified by the evaluation of the fidelity indicators. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
1.6 Use of Natural and Community Based Supports
a) During the engagement phase, the Permanency Specialist shall initiate a natural supports inventory with all youth and families and document the inventory in the child or youth’s case file. See Scope of Services/Payment Provisions, Section H.1.1.f page 6. The Contractor shall review the natural and community supports inventory to ensure one was created and updated for every family. See Scope of Services/Payment Provisions, Section K.2.6.a page 23. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
b) The Contractor shall provide ongoing training and coaching to staff on the identification, engagement, and integration of natural supports in the HFW process and in decreasing reliance on formal supports. See Scope of Services/Payment Provisions, Section J.2.14, page 21. The Contractor shall develop and provide a comprehensive bi-annual report that includes a list of training and coaching topics that were provided to staff during the reporting period. See Scope of Services/Payment Provisions, Section N.1.17 page 27.
c) Once the Plan of Care has been developed, the HFW Facilitator shall review the plan with team to get consensus that the Plan of Care includes natural supports and sustainable community resources, or the Plan includes strategies to identify and develop community and natural supports before the child or youth and family transition out of the HFW Program. See Scope of Services/Payment Provisions, Section H.1.2.c.v, page 7. The Contractor shall routinely review and assess for the inclusion of natural supports in the plan and for use of community and natural supports in the assigning of strategies and action items. See Scope of Services/Payment Provisions, Section K.2.6.b, page 23. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
d) The Contractor agrees to implement policies, procedures, and data processes (e.g., CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), quality assurance phone calls, post Team Meeting verbal feedback or feedback forms, documentation review, etc.) to routinely elicit and review feedback from families regarding their experience of having natural supports engaged on their team. See Scope of Services/Payment Provisions, Section K.2.6.d, page 23. The Contractor shall utilize their evaluation of the fidelity indicators to provide feedback to staff and their supervisors on their ability to engage natural supports. See Scope of Services/Payment Provisions, Section L.3.6, page 26. The Contractor shall include the training and coaching topics that were provided to staff during the reporting period in the bi-annual report. The topics should address the areas of improvement identified by the evaluation of the fidelity indicators. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
1.7 Culturally Respectful and Relevant
a) During the engagement phase, the HFW Facilitator shall initiate a Strengths, Needs, Culture Discovery document with every youth and family and include the Discovery in the youth’s chart. See Scope of Services/Payment Provisions, Section H.1.1.d, page 6. The youth and family’s values, culture, expertise, capabilities, interests, and skills are elicited, fully understood, celebrated and clearly documented in the youth’s case file. They are viewed as critical to a successful process and are the basis for decision making and problem-solving. See Scope of Services/Payment Provisions, Section H.3.2, page 12. The Contractor shall review the Discovery to ensure it was completed prior to the development of the Plan of Care. See Scope of Services/Payment Provisions, Section K.2.7.a, page 23. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
b) The Contractor shall provide ongoing training and coaching to staff on the elicitation and use of family and culture in planning and service delivery and in providing culturally respectful and relevant strategies. See Scope of Services/Payment Provisions, Section J.2.15, page 21. The Contractor shall develop and provide a comprehensive bi-annual report that includes a list of training and coaching topics that were provided to staff during the reporting period. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
c) The Contractor agrees to implement policies, procedures, and data processes (e.g., CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), quality assurance phone calls, post Team Meeting verbal feedback or feedback forms, documentation review, etc.) to routinely elicit and review feedback from families regarding their experience receiving services and strategies that are culturally relevant and respectful. See Scope of Services/Payment Provisions, Section K.2.7.d, page 23. The Contractor shall utilize data and family responses to provide feedback to staff and their supervisors on their ability to provide culturally relevant and respectful services and strategies. See Scope of Services/Payment Provisions, Section L.3.7, page 26. The Contractor shall include the training and coaching topics that were provided to staff during the reporting period in the bi-annual report. The topics should address the areas of improvement identified by the evaluation of the fidelity indicators. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
1.8 High-Quality Team Planning and Problem Solving
a) During the first HFW Team meeting, the HFW Facilitator shall lead the team in developing formal agreements on how the team will engage during meetings and make agreement. Within 72 business hours of the HFW Team meeting, the HFW Facilitator shall document the team agreements in the youth’s file. See Scope of Services/Payment Provisions, Sections H.1.2.a and H.1.2.f, pages 7 and 8. The Contractor shall review the youth’s file to ensure team agreements were created and documented. See Scope of Services/Payment Provisions, Section K.2.8.a, page 23. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
b) The Contractor agrees to implement policies, procedures, and data processes (e.g., CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), quality assurance phone calls, post Team Meeting verbal feedback or feedback forms, documentation review, etc.) to routinely elicit and review feedback from families and HFW teams regarding their experience of team engagement and collaboration. See Scope of Services/Payment Provisions, Section K.2.8.b, page 23. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
c) The Contractor shall utilize their evaluation of the fidelity indicators to provide feedback to staff and their supervisors on their ability to engage and collaborate with the family and HFW team. See Scope of Services/Payment Provisions, Section L.3.8, page 26. The Contractor shall include the training and coaching topics that were provided to staff during the reporting period in the bi-annual report. The topics should address the areas of improvement identified by the evaluation of the fidelity indicators. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
d) During every HFW Team meeting, the HFW Facilitator shall lead the team in reviewing and updating the Plan of Care. This includes reviewing the meeting minutes, strategies, progress, and action items; utilizing data from the current IP-CANS to support assessment of current strategies and team decision making; adjusting the Plan of Care accordingly based on successes or new needs that are identified. The Facilitator shall document any adjustments on the Plan of Care including completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the Plan of Care. See Scope of Services/Payment Provisions, Section H.1.3.a, page 8. The Contractor shall routinely review and assess HFW Plans of Care and meeting minutes for the shared ownership and follow through on strategies and action items. See Scope of Services/Payment Provisions, Section K.2.8.c, page 23. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
1.9 Outcomes Based Process
a) During the development of the Plan of Care, the HFW Facilitator shall lead the team in developing an individualized HFW Plan of Care that includes collaboratively developing goals (using the SMART framework) and outcomes from the identified needs with the team; brainstorming and documenting multiple strategies; and prioritizing and selecting strategies and developing action items with timeframes. See Scope of Services/Payment Provisions, Section H.1.2.b, page 7. The Contractor shall review Plans of Care for the inclusion of specific, measurable strategies and action items with timeframes. See Scope of Services/Payment Provisions, Section K.2.9.a, page23. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
b) During every HFW Team meeting, the HFW Facilitator shall lead the team in reviewing and updating the Plan of Care. This includes reviewing meeting minutes, strategies, progress, and action items. See Scope of Services/Payment Provisions, Section H.1.3.a.iii, page 8. The Contractor shall review meeting minutes or other forms of communication to ensure action items are tracked by facilitators and updated at HFW team meetings. See Scope of Services/Payment Provisions, Section K.2.9.b, page 23. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
c) During HFW Team meetings, the HFW Facilitator shall document any adjustments on the Plan of Care including completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the Plan of Care. See Scope of Services/Payment Provisions, Section H.1.3.a.iiic, page 8. The Contractor shall review documentation for changes to strategies and action items and how these changes were communicated to all team members. See Scope of Services/Payment Provisions, Section K.2.9.c, page24. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15 page 27.
d) The social worker, probation officer, or therapist shall attach the most current IP-CANS to the HFW referral. See Wraparound Referral, page 2. The Contractor shall update the IP-CANS for children/youth ages six through 20 years, and the Pediatric Symptom Checklist (PSC-35) for children/youth ages three through 18 years during HFW Team meetings whenever indicated by the team, every six-month reassessment, and at time of discharge. See Scope of Services/Payment Provisions, Section H.6.8, page 15. During HFW Team meetings, the HFW Facilitator shall include the strengths and needs that are identified in the IP-CANS in the Plan of Care. See Scope of Services/Payment Provisions, Section H.1.2.c, page 7. The Contractor shall review for documentation that the IP-CANS was shared amongst all team members. See Scope of Services/Payment Provisions, Section K.2.9.d, page 24. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
e) During every HFW Team meeting, the HFW Facilitator shall utilize data from the current IP-CANS to support assessment of current strategies and team decision making. See Scope of Services/Payment Provisions, Section H.1.3.a.iiib, page 9. The Contractor shall review that the IP-CANS is used to support tracking and team decision-making, but does not replace using tracking of needs, goal completion, and action item completion to plan for transition. See Scope of Services/Payment Provisions, Section K.2.9.e, page 24. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
1.10 Persistence
a) During every HFW Team meeting, the HFW Facilitator shall support and lead the team to keep working with a youth and family even when faced with setbacks or limited progress until the HFW team (with preference given to family voice and choice) agrees that services should end. See Scope of Services/Payment Provisions, Section H.1.3.a.vi, page 9. The Contractor shall review documentation of case closures for family voice and choice and support offered to teams when faced with setbacks or limited progress. See Scope of Services/Payment Provisions, Section K.2.10.a, page 24. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
b) The Contractor shall develop and implement clear processes for teams to access help when facing challenges how to request additional coaching or supervision, how to access/request flexible funding, and how to access additional support. See Scope of Services/Payment Provisions, Section H.5.6, page 14. The Contractor shall routinely review cases for requests for additional coaching and supervision, use of flexible funding, and additional supports provided. See Scope of Services/Payment Provisions, Section K.2.10.b, page 24. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15 page 27.
c) The Contractor shall provide ongoing training and coaching to staff on post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision. See Scope of Services/Payment Provisions, Section J.2.16, page 21. The Contractor shall develop and provide a comprehensive bi-annual report that includes a list of training and coaching topics that were provided to staff during the reporting period. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
1.11 Transitions as a part of the Fourth Phase of HFW
a) The HFW Facilitator shall lead the team in developing a formal individualized transition plan that includes who the family should contact after HFW if they are not able to access the supports and services identified in the transition plan. See Scope of Services/Payment Provisions, Section H.1.4.c, page 9. The Contractor shall review transition plans to ensure they are adequate. See Scope of Services/Payment Provisions, Section K.2.11.b, page 24. The Contractor shall routinely elicit and review feedback from families (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) regarding their experience transitioning to case closure. See Scope of Services/Payment Provisions, Section K.2.11.e, page 24. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15 page 27.
b) At the end of the HFW Transition Team meeting, the HFW Facilitator shall lead the team in deciding how the conclusion of HFW will be celebrated in a manner that reflects a positive transition, is culturally relevant, and is meaningful to the youth and family. The team shall discuss options for community resourcing and partnerships in addition to how flex funds can be accessed to support celebrations. See Scope of Services/Payment Provisions, Section H.1.4.g, page 10. The Contractor shall review documentation of the transition phase to ensure celebrations are documented and align with the family’s culture, values, and preferences. See Scope of Services/Payment Provisions, Section K.2.11.c, page 24. The Contractor shall include their evaluation of fidelity indicators in the bi-annual report. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
Expected Outcomes
2.1 Youth and Family Satisfaction
The Contractor agrees to implement policies, procedures, and/or data processes (e.g., CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), quality assurance phone calls, post Team Meeting verbal feedback or feedback forms, documentation review, etc.) to ensure routine evaluation of the effectiveness of the Wraparound program in the following areas: Child or youth and family satisfaction – children, youth, and families are satisfied with their Wraparound experience and their progress. See Scope of Services/Payment Provisions, Section K.3.1, page 24. The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The report shall include the evaluation of HFW outcomes. See Scope of Services/Payment Provisions, Section N.1.16, page 27.
2.2 Improved School Functioning
The Contractor agrees to implement policies, procedures, and/or data processes (e.g., CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), quality assurance phone calls, post Team Meeting verbal feedback or feedback forms, documentation review, etc.) to ensure routine evaluation of the effectiveness of the Wraparound program in the following areas: Improved School Functioning – children and youth experience improved educational and vocational functioning as a result of their involvement in Wraparound. They have more consistent attendance, are participating at or above grade level or according to their educational plan, and/or are developing needed vocational experience. See Scope of Services/Payment Provisions, Section K.3.2, page 24. The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The report shall include the evaluation of HFW outcomes. See Scope of Services/Payment Provisions, Section N.1.16 page 27.
2.3 Improved Functioning in the Community
The Contractor agrees to implement policies, procedures, and/or data processes (e.g., CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), quality assurance phone calls, post Team Meeting verbal feedback or feedback forms, documentation review, etc.) to ensure routine evaluation of the effectiveness of the Wraparound program in the following areas: Improved Functioning in the Community- children and youth experience improved functioning in the community as a result of their involvement in Wraparound. The youth has experienced less frequent contacts with emergency service providers, including medical and law enforcement providers, and they are participating in community activities. See Scope of Services/Payment Provisions, Section K.3.3, page 25. The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The report shall include the evaluation of the HFW outcomes. See Scope of Services/Payment Provisions, Section N.1.16, page 27.
2.4 Improved Interpersonal Functioning
The Contractor agrees to implement policies, procedures, and/or data processes (e.g., CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), quality assurance phone calls, post Team Meeting verbal feedback or feedback forms, documentation review, etc.) to ensure routine evaluation of the effectiveness of the Wraparound program in the following areas: Improved Interpersonal Functioning – children, youth, and their families experience improved interpersonal functioning as a result of their involvement in Wraparound. There is less stress and strain at home attributed to behaviors and they are able to develop or maintain positive family relationships and friendships. See Scope of Services/Payment Provisions, Section K.3.4, page 25. The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The report shall include the evaluation of the HFW outcomes. See Scope of Services/Payment Provisions, Section N.1.16, page 27.
2.5 Increased Caregiver Confidence
The Contractor agrees to implement policies, procedures, and/or data processes (e.g., CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), quality assurance phone calls, post Team Meeting verbal feedback or feedback forms, documentation review, etc.) to ensure routine evaluation of the effectiveness of the Wraparound program in the following areas: Increased Caregiver Confidence – families have access to effective, needed services and supports. Caregivers feel increased confidence in their ability to manage future problems, and they know how to find and access services and effectively address crises. See Scope of Services/Payment Provisions, Section K.3.5, page 25. The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The report shall include the evaluation of the HFW outcomes. See Scope of Services/Payment Provisions, Section N.1.16, page 27.
2.6 Stable and Least Restrictive Living Environment
The Contractor agrees to implement policies, procedures, and/or data processes (e.g., CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), quality assurance phone calls, post Team Meeting verbal feedback or feedback forms, documentation review, etc.) to ensure routine evaluation of the effectiveness of the Wraparound program in the following areas: Stable and Least Restrictive Living Environment – children and youth experience permanency and stability in their community-based living situation. Children and youth do not experience a new placement in an institution (such as detention, psychiatric hospital, treatment center, or Short-Term Residential Treatment Program (STRTP) and/or have not moved between residential settings. See Scope of Services/Payment Provisions, Section K.3.6, page 25. The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The report shall include the evaluation of HFW outcomes. See Scope of Services/Payment Provisions, Section N.1.16, page 27.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
The Contractor agrees to implement policies, procedures, and/or data processes (e.g., CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), quality assurance phone calls, post Team Meeting verbal feedback or feedback forms, documentation review, etc.) to ensure routine evaluation of the effectiveness of the Wraparound program in the following areas: Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits- youth experience stability with regard to their behavioral health, necessitating fewer or no visits to the hospital. See Scope of Services/Payment Provisions, Section K.3.7, page 26. The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The report shall include the evaluation of HFW outcomes. See Scope of Services/Payment Provisions, Section N.1.16, page 27.
2.8 Reduction in Crisis Visits
The Contractor agrees to implement policies, procedures, and/or data processes (e.g., CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), quality assurance phone calls, post Team Meeting verbal feedback or feedback forms, documentation review, etc.) to ensure routine evaluation of the effectiveness of the Wraparound program in the following areas: Reduction in Crisis Visits- Youth and natural supports are able to avert most crisis and manage most impending crises without professional support. See Scope of Services/Payment Provisions, Section K.3.8, page 26. The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The report shall include the evaluation of HFW outcomes. See Scope of Services/Payment Provisions, Section N.1.16, page 27.
2.9 Positive Exit from HFW
The Contractor agrees to implement policies, procedures, and/or data processes (e.g., CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), quality assurance phone calls, post Team Meeting verbal feedback or feedback forms, documentation review, etc.) to ensure routine evaluation of the effectiveness of the Wraparound program in the following areas: Positive Exit from HFW – children, youth, and their families exit Wraparound based on stabilization and adequate progress in meeting needs; children, youth, and families are not discharged from Wraparound due to an adverse event. See Scope of Services/Payment Provisions, Section K.3.9, page 26. The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The report shall include the evaluation of HFW outcomes. See Scope of Services/Payment Provisions, Section N.1.16, page 27.
Engagement
3.1 Orientation
a) Prior to submitting a Wraparound referral, the social worker should explain HFW services to families and support families in understanding the reason for recommending a referral to HFW. Social workers can share the HFW overview video with families to clearly explain what HFW is, how it works, and the role each member plays. See FCS Wraparound Policy, Section titled “Procedures – Preparing the Family,” page 11. In addition, the deputy probation office shall also explain HFW services to the family, discuss the referral with the CFT, and provide program materials to families, including brochures and HFW overview videos. See Probation Department Wraparound Protocol, section titled, “Family Engagement,” page 3. Once HFW is approved for a family, the HFW Facilitator shall fully explain the HFW process to orient the youth and family to the HFW process during first contact with families as soon as possible. At a minimum, the explanation shall include: (a) an overview of the principles and phases; (b) legal and ethical considerations including upholding family voice/choice, confidentiality, preventing conflicts of interest, consent to services, and mandated reporting requirements; and (c) the role of each team member, including the family and natural supports and Tribes in the case of an Indian child. See Scope of Services/Payment Provisions, Section H.1.1.a, page 5. If the family notifies the contractor that they might have Indian ancestry at any point of service provision, the Contractor shall immediately notify the assigned social worker or probation officer immediately to address Indian Child Welfare Act eligibility. See Scope of Services/Payment Provisions, Section I.3.3 page 18. The Contractor agrees to routinely elicit and review feedback from families (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) regarding how the HFW team oriented them to the HFW process. See Scope of Services/Payment Provisions, Section K.2.1.e page 22.
3.2 Safety and Crisis stabilization
a) The HFW Facilitator shall assess for any initial crisis and safety concerns throughout the engagement phase. If pressing concerns are brought forward, the Facilitator shall schedule an emergency HFW team meeting to team shall develop an immediate crisis response plan. The Facilitator shall provide the plan to the family and document the plan in the chart. The Facilitator shall also provide a copy of the crisis response plan to the social worker, probation officer, and/or therapist assigned to the case. See Scope of Services/Payment Provisions, Section H.1.1.b page 5. During the engagement phase, the assigned social worker shall bring forward any initial crisis and safety concern and/or need for an immediate crisis response plan to the HFW provider and team. See FCS Wraparound Policy, section titled “Engagement Phase,” number 5, page 12. The Contractor shall review all Immediate Crisis Response Plans in their evaluation of the effectiveness of the HFW program to ensure services are needs driven. See Scope of Services/Payment Provisions, Section K.2.4.b page 5.
b) The HFW team shall use the crisis plan to inform, but not replace, the HFW Safety plan developed during the Plan Development phase. See Scope of Services/Payment Provisions, Section H.1.1.b.ii, page 5. If there was a Crisis Response Plan developed during the Engagement Phase, the assigned social worker shall ensure the Crisis Response Plan is used to inform, but not replace, the HFW Safety Plan. See FCS Wraparound Policy, section titled “Plan Development Phase,” number 11.c, page 13. The Contractor shall also review all Immediate Crisis Response Plans in their evaluation of the effectiveness of the HFW program to ensure the Crisis Response Plan does not replace the HFW Safety Plan. See Scope of Services/Payment Provisions, Section K.2.4.b page 22.
c) During the first contact, the HFW Facilitator shall provide information to youth and families that includes information on how to access 24/7 crisis response when needed. See Scope of Services/Payment Provisions, Section H..1.1.a.iv, page 5. The Contractor shall include information regarding how to access 24/7 crisis response on the Crisis Response Plan and Safety Plan. See Scope of Services/Payment Provisions, Sections H.1.1.b.iii, page 6. Social workers should review Crisis Response Plans and Safety Plans to ensure information has been included regarding how to access 24/7 crisis response. See FCS Wraparound Policy, section titled “Engagement Phase,” number 5.b, page 12 and section titled “Plan Development Phase,” number 11, page 13. Probation officers support development of crisis and safety plans that includes 24/7 support, coordinate services, incorporate natural supports. See Probation Wraparound Protocol, section titled “Plan of Care,” page 5.
3.3 Strengths, Needs, Culture and Vision Discovery
a) The HFW Facilitator shall elicit and use the family’s perspective, including Tribes when applicable, to complete a Family Vision with every family and document the Family Vision in the youth’s chart. The Facilitator shall clearly communicate the Family Vision to the HFW team. See Scope of Services/Payment Provisions, Section H.1.1.c page 6. County staff can document the Family Vision on the Desk Guide. See HFW Desk Guide, section titled Engagement Phase. The Contractor shall review the Family Vision documented in the youth’s chart their evaluation of the effectiveness of the HFW program to monitor that services are being led by youth and families. See Scope of Services/Payment Provisions, Section K.2.2.a page 22.
b) Before the first HFW Team meeting, the HFW Facilitator shall initiate a Strengths, Needs, Culture Discovery document with every youth and family before the first HFW Team meeting. The Facilitator shall include the Discovery in the youth’s chart, update the Discovery every 90 days, and have the team add new strengths, needs, and cultural preferences as they are discovered. The Facilitator shall provide the Discovery to new team members as they are identified. See Scope of Services/Payment Provisions, Section H.1.1.d, page 6. County staff can track the date the Discovery was completed and the dates the Discovery was updated. See HFW Desk Guide, section title Plan Development Phase. The Contractor shall review the Strengths, Needs, Culture Discovery document in their evaluation of the effectiveness of the HFW program to assess that services are strengths-based, needs driven, and culturally relevant. See Scope of Services/Payment Provisions, Section K.2 page 21.
3.4 Engage All Team Members
a) As part of the referral process, the social worker, probation officer, or therapist shall list on the Wraparound Referral all key family members and natural supports of the child/youth being referred. See Wraparound Referral, page 1. Before the first HFW Team meeting, the Permanency Specialist shall initiate a natural supports inventory with all youth and families and document the inventory in the child or youth’s case file. See Scope of Services/Payment Provisions, Section H.1.1.f, page 6. The Contractor shall review the Natural Supports Inventory document in their evaluation of the HFW program to assess the use of natural supports in the HFW process. See Scope of Services/Payment Provisions, Section K.2.6.a, page 23.
b) During Interagency Placement Committee meetings, the Contractor will be able to identify the System of Care partners who should be included on the HFW team since there will be a representative from each Children’s System of Care in attendance. See Scope of Services/Payment Provisions, Section G.3.3, page 4. During Wraparound Leadership, the Contractor shall report when the assigned System of Care partners are not fully engaged in the HFW process. See Scope of Services/Payment Provisions, Section G.3.6.b, page 4.
c) The Permanency Specialist shall work with the youth and family to identify potential team members (including formal, natural supports, and Tribes, in the case of an Indian child) and discuss their role on the team. See Scope of Services/Payment Provisions, Section H.1.1.g, page 6. During the engagement phase, the assigned social worker shall work with the family to identify potential HFW team members, including natural supports. The Contractor shall review the Natural Supports Inventory document in their evaluation of the HFW program to assess the use of natural supports in the HFW process. See Scope of Services/Payment Provisions, Section K.2.6.a, page 23.
d) The HFW Facilitator shall document engagement and team building activities in the youth’s file. See Scope of Services/Payment Provisions, Section H.1.1.i, page 6. The Contractor shall review documentation of engagement and team building activities in their evaluation of the HFW program. See Scope of Services/Payment Provisions, Section K.2.1.f, page 22. The assigned social worker shall document all efforts to engage the family in the child welfare case management system. See FCS Wraparound Policy, section titled “Engagement,” number 9, page 12.
3.5 Arrange Meeting Logistics
a) The HFW Facilitator shall ensure that meetings take place at a time and location that is convenient and accessible to all team members with priority given to family needs and family voice and choice. The Facilitator shall take into consideration family schedules, culture, and history of trauma, and ensuring equitable access for all youth and families. The Facilitator shall plan for and arrange meeting logistics such as transportation, interpretation, telehealth capability, etc. See Scope of Services/Payment Provisions, Section H.1.1.h, page 6. The Wraparound program will operate seven days per week. Program sites will be open from 8:30 AM to 6:00 PM. Service hours are flexible and adjusted based on client need, meaning staff may work early in mornings or late in evenings. Staff also remain available to clients for emergency needs on a 24/7 on-call basis. Services will be provided primarily in the community, such as family homes or client schools, but may also be provided at Contractor sites depending on the family’s preference. The Contractor shall provide transportation as needed. See Scope of Services/Payment Provisions, Section H.5.3, page 14 and Behavioral Health Contract Exhibit A, section III.3, page 2.. The Contractor shall elicit feedback from youth and families in their evaluation of the HFW program to assess if services accommodate families. See Scope of Services/Payment Provisions, Section K.2.2.e, page 22. In addition, assigned social workers shall elicit feedback from youth and families while they are receiving HFW services. County staff should document feedback from families in the County survey. The survey responses will be reviewed during Wraparound Leadership meetings. See FCS Wraparound Policy, section titled “Youth and Families as Key Decision Makers,” number 2, page 15.
b) The Contractor shall provide ongoing training and coaching to staff on working collaboratively with families and other members of the HFW team to schedule meetings that are in alignment with family needs and preferences as well as maximize participation. See Scope of Services/Payment Provisions, Section J.2.2, page 20. The Contractor shall provide a copy of the annual training plan to the COUNTY at the beginning of each fiscal year but no later than July 30th. See Scope of Services/Payment Provisions, Section J.1.4, page 19. The Contractor shall develop and provide a comprehensive bi-annual report that includes training and coaching topics provided to staff during the reporting period. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
a) The HFW Facilitator shall hold a HFW Team meeting within 30 days of IPC approval. Building upon the activities completed during engagement, the Facilitator shall lead the team in developing formal agreements on how the team will engage during meetings and make agreements; identifying and documenting additional strengths of the youth and family, other team members, and the community in a team strengths inventory; and creating a team mission statement that defines the overall purpose of the HFW team in alignment with the family vision. See Scope of Services/Payment Provisions, Section H.1.2.a, page 6. The Contractor shall document all Plan of Care preparation activities in the youth’s case file. See Scope of Services/Payment Provisions, Section H.1.2.f, page 8. The assigned social worker shall assist the team in developing team agreements, a team strengths inventory, and a mission statement. See FCS Wraparound Policy, section titled “Plan Development Phase,” number 3. County staff can document the Team Mission Statement on the HFW Desk Guide. See HFW Desk Guide, section title “Plan Development Phase.” The probation officer collaborates with the team to develop a Family Plan of Care within 30 days that reflects family vision, culture, and needs (prioritized). Ensure goals are measurable, strengths-based, and informed by IP-CANS data. Support development of crisis and safety plans that includes 24/7 support, coordinate services, incorporate natural supports. See Probation Wraparound Protocol, section titled “Plan of Care,” page 5.
b) The HFW Facilitator shall lead the team in identifying and documenting additional strengths of the youth and family, other team members, and the community in a team strengths inventory. See Scope of Services/Payment Provisions, Section H.1.2.a.ii, page 7. Within 72 hours business hours of the HFW Team meeting, the HFW Facilitator shall document all preparation activities during the meeting. See Scope of Services/Payment Provisions, Section H.1.2.f, page 8. The Contractor agrees to implement policies, procedures, and/or data processes (e.g., CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), Team Observation Measure (TOM 2.0), Document Assessment Review Tool (DART), quality assurance phone calls, post Team Meeting verbal feedback or feedback forms, documentation review, etc.) to ensure routine evaluation of services being strength-based by reviewing the Strengths Inventory, reviewing the IP-CANS, and eliciting feedback from families. See Scope of Services/Payment Provisions, Section K.2.6, page 22. The Contractor shall develop and provide a comprehensive bi-annual report that includes an evaluation of strength-based services. See Scope of Services/Payment Provisions, Section N.1.15, page 27. During the Plan Development Phase, the assigned social worker shall ensure the Plan of Care is based on the family’s strengths. See FCS HFW Policy, section titled “Plan Development Phase,” number 4, page 13.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
a) The HFW Facilitator shall lead the team in identifying, prioritizing, and documenting underlying needs. See Scope of Services/Payment Provisions, Section H.1.2.b, page 7. As part of the referral process, the assigned social worker shall provide a copy of the most up-to-date IP-CANS for the family and present the underlying needs of the family at IPC. See FCS HFW Policy, section titled “Referral Process,” number 2.d, page 11. During the Engagement Phase, the assigned social worker shall ensure underlying needs identified in the IP-CANS are being prioritized before goals and strategies are developed for the youth and family. See FCS Wraparound Policy, section titled “Plan Development Phase,” number 5. County staff may indicate on the HFW Desk Guide if needs identified in the IP-CANS were prioritized. See HFW Desk Guide, section titled “Plan Development Phase.”
b) During the HFW Team meeting, the HFW Facilitator shall lead the team in developing an individualized HFW Plan of Care that includes collaboratively developing goals (using the SMART framework) and outcomes from the identified needs with the youth, family, and rest of the team (including System of Care providers). See Scope of Services/Payment Provisions, Section H.1.2.b.ii, page 7.
c) During the HFW Team meeting, the HFW Facilitator shall lead the team in developing an individualized HFW Plan of Care that includes collaboratively developing goals (using the SMART framework) and outcomes from the identified needs with the youth, family, and rest of the team (including System of Care providers). See Scope of Services/Payment Provisions, Section H.1.2.b.ii, page 7. The assigned social worker shall help the team develop measurable goals and outcomes from the identified needs. See FCS HFW Policy, section titled “Plan Development Phase,” number 6, page 13.
d) The HFW Facilitator shall lead the team in brainstorming and documenting multiple strategies. See Scope of Services/Payment Provisions, Section H.1.2.b.iii, page 7. The Contractor agrees to implement policies, procedures, and/or data processes (e.g., CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), Team Observation Measure (TOM 2.0), Document Assessment Review Tool (DART), quality assurance phone calls, post Team Meeting verbal feedback or feedback forms, documentation review, etc.) to ensure routine evaluation of services being individualized by reviewing the documented individualized brainstormed strategies. See Scope of Services/Payment Provisions, Section K.2.5, page 22. The Contractor shall develop and provide a comprehensive bi-annual report that includes an evaluation of individualized services. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
e) The Contractor shall provide ongoing training and coaching to facilitators on leading teams in identifying, prioritizing, and selecting strategies and developing action items. See Scope of Services/Payment Provisions, Section J.2.7, page 21. The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The report shall include training and coaching topics provided to staff during the reporting period. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
f) Once the preparation steps have been completed, the HFW Facilitator shall lead the team in developing the HFW Plan of Care during the meeting. See Scope of Services/Payment Provisions, Section H.1.2.b page 7. The assigned social worker shall attend all HFW team meetings to ensure the individualized HFW Plan of Care is developed in a team-based, collaborative environment. See FCS HFW Policy, section titled “Plan Development Phase,” number 2, page 13.
4.3 Develop an Individualized Child or Youth and Family Plan
a) The Contractor shall provide ongoing training and coaching to staff on facilitators engaging the team in a planning process that elicits multiple perspectives, builds trust and shared vision, and demonstrates the HFW principles. See Scope of Services/Payment Provisions, Section J.2.8, page 21. The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The report shall include training and coaching topics provided to staff during the reporting period. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
b) Once the Plan Care has been developed, the HFW Facilitator shall review the Plan of Care with the team to get consensus that the Plan of Care addresses needs across multiple life domains and Children’s System of Care partners as prioritized by the HFW team. See Scope of Services/Payment Provisions, Section H.1.2.c.ii, page 7. As part of the referral process, the social worker, probation officer and/or therapist shall provide current court reports, psychosocial history, probation reports, coordinated service plans, current mental health assessments, and/or CSE-IT assessments. See HFW Referral, page 2.
c) Within 72 business hours of the HFW Team meeting, the HFW Facilitator shall document the Plan of Care in the child’s case file. See Scope of Services/Payment Provisions, Section H.1.2.f, page 8. The assigned social worker must include copy of the plan in child’s case file. See FCS HFW Policy, section titled “Plan Development Phase,” number 14, page 13. All activities shall be recorded in the Probation Care Management System under the Activities node. See Probation Wraparound Policy, section titled “Recording Requirements,” page 8.
d) The Contractor shall review Plans of Care in the routine evaluation of timely planning, alignment with family vision and team mission statement, alignment with family strengths and needs, flexibility and individualized strategies, inclusion of natural supports, cultural relevance, shared ownership and follow through on action items, inclusion of measurable strategies and action items with timeframes, ongoing revisions, and the gradual transition from formal services. See Scope of Services/Payment Provisions, Section K.,2 page 21. The Contractor shall utilize this evaluation to provide feedback to staff and their supervisors, for training and coaching purposes. See Scope of Services/Payment Provisions, Section L.3, page 15. The Contractor shall develop and provide a comprehensive bi-annual report that includes the training and coaching topics provided to staff during the reporting period. The topics should address the areas of improvement identified by the evaluation process. See Scope of Services/Payment Provisions, Section N.1.17, page 27. In addition, the Wraparound Leadership Team will review a random Plan of Care once per quarter to review for fidelity. See Wraparound Leadership Team Meeting Agenda, page 2.
4.4 Develop a Crisis and Safety Plan
a) If the team identifies potential safety, high-risk or crisis situations during the meeting, the HFW Facilitator shall lead the team in developing a Crisis and Safety Plan that identifies and prioritizes safety needs, potential risk and crisis situations, as well as highly individualized proactive and reactive strategies for the youth, family, and team members to respond effectively. The Facilitator shall document the identified safety, high-risk, or crisis situation on a Crisis and Safety Plan; lead the team in brainstorming potential proactive and reactive crisis management strategies for the youth family, and team members to respond effectively; and document the strategies chosen by the family in the plan, include who should be called for support 24/7, provide a copy of the crisis and safety plan to all HFW team members. See Scope of Services/Payment Provisions, Section H.1.2.e, page 7. Within 72 business hours of the HFW Team meeting, the HFW Facilitator shall document the Crisis and Safety Plan in the child’s case file. See Scope of Services/Payment Provisions, Section H.1.2.f, page 7. The assigned social worker shall assist the team in developing a crisis and safety plan that identifies and prioritizes safety needs, potential risk and crisis situations, as well as highly individualized proactive and reactive strategies chosen by the family members and includes who should be called for support 24/7. See FCS HFW Policy, section titled “Plan Development Phase,” number 11, page 13. The probation officer supports development of crisis and safety plans that includes 24/7 support, coordinate services, incorporate natural supports. See Probation Wraparound Protocol, section titled “Plan of Care,” page 5.
b) The Contractor shall provide training and coaching to facilitators on developing Crisis and Safety Plans in a team-based, collaborative environment. See Scope of Services/Payment Provisions, Section J.2.12, page 21. The Contractor shall develop and provide a comprehensive bi-annual report that includes a list of training and coaching topics that were provided to staff during the reporting period. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
c) The Contractor shall review Crisis and Safety in the routine evaluation of the fidelity indicators including individualized strategies, cultural relevancy, use of natural supports, and persistence. See Scope of Services/Payment Provisions, Section K.2 page 21. The Contractor shall utilize this evaluation to provide feedback to staff and their supervisors, for training and coaching purposes. See Scope of Services/Payment Provisions, Section L.3, page 15. The Contractor shall develop and provide a comprehensive bi-annual report that includes the training and coaching topics provided to staff during the reporting period. The topics should address the areas of improvement identified by the evaluation process. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
Implementation
5.1 Implement The Plan of Care
a) The HFW Facilitator shall schedule HFW Team meetings at least every 30-45 days to engage the team. During every HFW Team meeting, the HFW Facilitator shall lead the team in reviewing and updating the Plan of Care. This includes reviewing meeting minutes, strategies, progress, and action times; utilizing data from current IP-CANS to support assessment of current strategies and team decision making; and adjusting the Plan of Care accordingly based on success or new needs that are identified. See Scope of Services/Payment Provisions, Section H.1.3.a, page 8. County staff may indicate on the HFW Desk Guide if the facilitator continually review strategies and action items at HFW Team meetings. See HFW Desk Guide, section titled “Implementation Phase.” The assigned social worker shall follow up on individual assignments from the action plan and provide updates to the team. See FSC HFW Policy, section titled “Implementation Phase,” number 4, page 14. The probation officer shall ensure the Plan of Care is actively carried out and adjusted as needed. See Probation Wraparound Protocol, section titled “Implementation,” page 6.
b) The Contractor shall provide ongoing training and coaching to staff on implementing the Plan of Care in alignment with the HFW principles. Training and processes shall address celebrating successes as they occur. See Scope of Services/Payment Provisions, Section J.2.9, page 21. The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The report shall include training and coaching topics provided to staff during the reporting period. See Scope of Services/Payment Provisions, Section N.17, page 27. County staff can indicate on the HFW Desk Guide if the HFW team celebrated successes as they occur. See HFW Desk Guide, section titled “Implementation Phase.”
5.2 Review and Update The Plan of Care
a) The HFW Facilitator shall schedule HFW Team meetings at least every 30-45 days to engage the team. During every HFW Team meeting, the HFW Facilitator shall review the Plan of Care. The Facilitator reviews meeting minutes, strategies, progress, and action items. See Scope of Services/Payment Provisions, Section H.1.3.a.iiia, page 9. The Contractor shall review meeting minutes or other forms of communication to ensure strategies are reviewed, progress is monitored, and action items are tracked by facilitators and updated at HFW team meetings. See Scope of Services/Payment Provisions, Section K.2.9.b page 23. The Contractor shall utilize this evaluation to provide feedback to staff and their supervisors, for training and coaching purposes. See Scope of Services/Payment Provisions, Section L.3 page 15. The Contractor shall develop and provide a comprehensive bi-annual report that includes the training and coaching topics provided to staff during the reporting period. The topics should address the areas of improvement identified by the evaluation process. See Scope of Services/Payment Provisions, Section N.1.17 page 27.
b) The HFW Facilitator shall lead the team to adjust the Plan of Care accordingly based on success or needs that are identified. See Scope of Services/Payment Provisions, Section H.1.3.a.iiic, page 9. Within 72 business hours of the meeting, the HFW Facilitator shall complete meeting minutes and document completion of tasks and new assignments in the child’s file. See Scope of Services/Payment Provisions, Section H.1.3.b. page 9.
c) The Facilitator documents any adjustments on the Plan of Care including completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the Plan of Care. See Scope of Services/Payment Provisions, Section H.1.3.a.iid, page 9.
d) Forms shall be able to be updated and individualized to meet the youth, family, and team’s changing needs. See Scope of Services/Payment Provisions, Section H.1.3.a.vii. page 9.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
a) At the beginning of every HFW Team meeting, the HFW Facilitator shall lead the team in reviewing team agreements. During the meeting, the Facilitator shall continually assess and address team cohesion, trust, and commitment to ensure effective collaboration. See Scope of Services/Payment Provisions, Section H.1.3.a, page 8.
b) The Contractor shall provide ongoing training and coaching to staff on building, engaging, and maintaining effective teams. See Scope of Services/Payment Provisions, Section J.2.10, page 21. The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The report shall include training and coaching topics provided to staff during the reporting period. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
c) During every HFW Team meeting, the HFW Facilitator shall lead the team and document use of natural supports. See Scope of Services/Payment Provisions, Section H.1.3.a.iiid. page 9. The Contractor shall ensure routine evaluation of the team’s use of natural supports by reviewing the natural supports inventory, assessing the Plan of Care for use of natural supports, and receiving feedback from families. See Scope of Services/Payment Provisions, Section K.2.,6 page 23. The Contractor shall use this evaluation to provide feedback to staff and their supervisors for training and coaching purposes. See Scope of Services/Payment Provisions, Section L.3.6, page 26.
d) During every HFW Team meeting, the HFW Facilitator shall lead the team in orienting and engaging new team members as they are added. This includes providing an overview of the HFW process, providing legal/ethical considerations and signing releases, having team members explain their roles, and engaging in team building exercises. See Scope of Services/Payment Provisions, Section H.1.3.a.i page 8.
Transition
6.1 Develop a Transition Plan
a) During the HFW Team meeting, the HFW Facilitator shall obtain consensus from the team, youth, and family that the family’s needs have sufficiently been met based on the benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process. See Scope of Services/Payment Provisions, Section H.1.4.b., page 9. The assigned social worker shall assist the HFW team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting through the HFW process. See FCS HFW Policy, section titled “Transition Phase,” number 1, page 14. The probation officer supports a family-driven transition by assessing readiness based on progress, ensuring team agreement, and assisting in the development of a structured transition plan. See Probation Wraparound Protocol, section titled “Transition Planning,” page 6.
b) The HFW Facilitator shall lead the team in developing a formal, individualized transition plan. The transition plan shall include the needs, services, and supports that will persist past formal HFW. See Scope of Services/Payment Provisions, Section H.1.4c., page 10. Once the transition plan has been developed, the HFW Facilitator shall lead provide a copy of the plan to all team members once it has been reviewed by the HFW supervisor. See Scope of Services/Payment Provisions, Section H.1.4.d, page 10. Within 72 business hours of the meeting, the HFW Facilitator shall complete meeting minutes and documentation in the child’s file. See Scope of Services/Payment Provisions, Section H.1.4.h, page 10.
c) When the family has reached pre-determined benchmarks indicating sufficient progress towards completing the team mission and goals, and the youth, family, and team agree the family is ready for transition, the HFW team will begin developing a formal individualized transition plan. See Scope of Services/Payment Provisions, Section H.1.4.a, page 9. The Contractor shall provide ongoing training and coaching to staff on how to develop an individualized transition plan in a team based, collaborative environment. See Scope of Services/Payment Provisions, Section J.2.11, page 21. The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The report shall include training and coaching topics provided to staff during the reporting period. See Scope of Services/Payment Provisions, Section N.1.17, page 27.
d) During the HFW Team meeting, the Facilitator shall lead the team in developing a formal, individualized transition plan the includes agreement from the team that the family will be able to access the identified services and supports past HFW. The team shall also identify who the family should contact after HFW if they are not able to access the supports and services identified in the transition plan. See Scope of Services/Payment Provisions, Section H.1.4.c, page 9.
6.2 Develop a Post-Transition Safety Plan
a) During the HFW Team meeting, the HFW facilitator shall lead the team in developing a crisis and safety plan (or adjusting current crisis and safety plan) that identifies potential crisis situations that may occur after transitioning from formal HFW. The plan shall include the potential crisis situations that may occur after transition, the proactive and reactive crisis management strategies that are chosen by the family, the identified natural supports who can support the plan, and strategies identified by the youth and family that are culturally relevant. See Scope of Services/Payment Provisions, Section H.1.4.e page 10. Within 72 business hours of the meeting, the HFW Facilitator shall document the Crisis and Safety Transition Plan in the child’s file. See Scope of Services/Payment Provisions, Section H.1.4.h, page 10.
b) During the HFW Transition Team meeting, the HFW Facilitator shall lead the team in developing a Crisis and Safety Transition Plan. See Scope of Services/Payment Provisions, Section H.1.4.e, page 10. Contractor shall provide ongoing training and coaching to staff on how to develop Crisis and Safety Plans in a in a team-based, collaborative environment. See Scope of Services/Payment Provisions, Section J.2.17 page 22. The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The report shall include training and coaching topics provided to staff during the reporting period. See Scope of Services/Payment Provisions, Section N.1 page 25. The assigned social worker shall assist the team in developing a crisis and safety plan that identifies potential crisis situations that may occur after transitioning from formal HFW. See FCS HFW Policy, section titled “Transition Phase,” number 5, page 14. The probation officer helps support the development of a culturally responsive post-transition crisis/safety plan. See Probation Wraparound Protocol, section titled “Transition Planning,” page 6.
c) The Contractor agrees to implement policies, procedures, and/or data processes (e.g., CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), Team Observation Measure (TOM 2.0), Document Assessment Review Tool (DART), quality assurance phone calls, post Team Meeting verbal feedback or feedback forms, documentation review, etc.) to ensure routine evaluation of the effectiveness of the Wraparound program. The Contractor shall routinely review and assess crisis and safety plans for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports. See Scope of Services/Payment Provisions, Section K.2.11.d, page 24. The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The report shall include at minimum, the evaluation of the fidelity indicators. See Scope of Services/Payment Provisions, Section N.1.15, page 27.
6.3 Create a Commencement and Celebrate Success
a) At the end of the HFW Transition Team meeting, the HFW Facilitator shall lead the team in deciding how the conclusion of HFW will be celebrated in a manner that reflects a positive transition, is culturally relevant, and is meaningful to the youth and family. See Scope of Services/Payment Provisions, Section H.1.4.g, page 10. The assigned social worker shall celebrate with the team the family’s transition out of HFW according to the family’s culture, values, and preferences. See FCS HFW Policy, section titled “Transition Phase,” number 6, page 14. The probation officer celebrates family success. See Probation Wraparound Protocol, section titled “Transition Planning,” page 6.
b) The HFW Facilitator shall discuss options for resourcing and partnership and access flex funds to support celebrations. See Scope of Services/Payment Provisions, Section H.1.4.g, page 10.
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
a) The System of Care Partners agree to create a Community Advisory Committee that includes youth and families with lived experience. The Community Advisory Committee will participate in decisions regarding local policy and program implementation. See Children’s System of Care MOU, Part 1, section titled “Policy Development, Coordination, and Monitoring as a full System of Care, number 2, page 5. Social workers, supervisors, and program managers shall identify HFW youth and families who want to participate in the Community Advisory Committee meeting and inform them that they can receive a $75 stipend for participating. See FCS HFW Policy, section titled “Youth and Families as Key Decision-Makers,” number 4 and 5, page 15. Probation officers shall inform families of eligibility for a $75 stipend for participation in advisory meetings. See Probation Wraparound Protocol, section titled “Quality Assurance and Family Feedback,” page 7.
b) The Contractor agrees to implement policies, procedures, and/or data processes (e.g., CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), Team Observation Measure (TOM 2.0), Document Assessment Review Tool (DART), quality assurance phone calls, post Team Meeting verbal feedback or feedback forms, documentation review, etc.) to ensure routine evaluation of fidelity indicators and outcomes. See Scope of Services/Payment Provisions, Section K, page 21. The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements that includes family feedback collected during the evaluation of the fidelity measures and outcomes. The Contractor shall present the Bi-Annual report to the Monterey County Interagency Leadership Team (ILT). See Scope of Services/Payment Provisions, Section N.1, page 26. During ILT meetings, the system of care partners will review youth and family feedback to inform all levels of the HFW program, including service planning and implementation, policy and procedure development, workforce development, and quality improvement. See Children’s System of Care MOU, Part Seven, section A, page 9. Social workers, probation officers, and/or therapists who receive feedback from families regarding HFW services can utilize the Monterey County HFW Survey to provide this feedback to the Wraparound Leadership Team. The Wraparound Leadership Team will review all survey entries during semi-monthly meetings. See Wraparound Leadership Team Meeting Agenda.
7.2 Community Leadership Team
a) The purpose of the County of Monterey Wraparound Leadership Team is to work collaboratively and engage in shared decision-making to ensure the California Wraparound Standards are met at the organizational and systems level. See County of Monterey Wraparound Leadership Team Meeting Agenda, page 1. System of care partners agree to participate in the semi-monthly Wraparound Leadership Team meetings. See Children’s System of Care MOU, Part Six, section B, page 9. Tribal partners, family members, youth, and other child-serving agencies may also participate in Wraparound Leadership Team meetings to inform decision-making. See County of Monterey Wraparound Leadership Team Meeting Agenda, page 1.
b) The Contractor agrees to actively participate in the Monterey County Wraparound Leadership Team. See Scope of Services/Payment Provisions, Section G.3.4, page 4 and Behavioral Health Contract, Exhibit A, section X.2, page 6. Social workers shall invite tribal partners to Wraparound Leadership Team meetings when an Indian child is receiving Wraparound services. The tribal partners may participate in decision-making around HFW implementation in the County of Monterey, barriers to services for their Indian child, or to provide feedback; however, the tribal partners should be informed that they will not be able to participate in case-specific discussions regarding other HFW families and youth. See FCS HFW Policy, section titled “Wraparound Leadership Team Meeting,” page 15.
c) The Wraparound Leadership Team shall discuss Interagency Leadership Team (ILT) communication including updates from the ILT liaisons, key decisions from ILT impacting HFW, and items needing Wraparound Leadership input or action. See County of Monterey Wraparound Leadership Team Meeting Agenda, page 1. During ILT meetings, the Wrap Leadership members will report on the agenda items discussed during Wraparound Leadership Team meetings. See Children’s System of Care MOU, Part Six, page 9.
d) System of care partners agree to participate in the semi-monthly Wrap Leadership Team meetings. The Wraparound Leadership Team works to ensure all other child serving entities are provided opportunities to participate in the Wrap Leadership Team; actively identify and remove interagency and system barriers that interfere with interagency collaboration and effective service delivery to families; identify and support cross-agency training and community collaboration to promote family-centered and culturally relevant practices and support high fidelity to the CA HFW model; ensure there is a process in place to review family plans on the community and systems level based on the values, principles, and activities of the HFW process; ensure there is a process in place to regularly review the use of, access to, and procedures around flex funds to ensure individualized family needs are being met, and ensure there is a process in place to regularly review HFW data at the organizational, community, and systems levels, and to use data to inform Continuous Quality Improvement (CQI) efforts that reflect HFW values and HFW implementation Standards. See Children’s System of Care MOU, Part Six, section B, page 9.
7.3 Eligibility and Equal Access
a) Eligibility Criteria: The youth and/or family is experiencing a disturbance in one or more of the following areas: school, community relations, emotional functioning or family relations; AND/OR: Intensive service coordination, delivery, and/or support is required to assist the family or caretaker in meeting the youth’s needs; AND The youth has a family, relative, legal guardian, or other significant person in their life that is open to participating in a strengths-based, family-centered process and resides within close geographic proximity; Otherwise, family finding efforts can be used already provided in other Seneca Monterey County contracts to identify such persons; AND The youth is eligible under California Welfare and Institutions Code (WIC) 300 or 602 (i.e. is a dependent or ward of the Juvenile Court); OR The youth has an open child welfare case or juvenile probation petition pending at the time of referral; or the youth has a severe mental illness. The County expects that the majority of youth and families will be full-scope Medi-Cal eligible and qualify for EPSDT SMHS. In efforts to engage families at the earliest point possible, there may be a limited number of youth and families served who are not Medi-Cal eligible or do not meet the medical necessity criteria for SMHS. For youth not already involved with DSS or JPD, CONTRACTOR shall conduct the assessment for medical necessity. See Scope of Services/Payment Provisions, Section G.2, page 3. See FCS HFW Policy, section titled “Eligibility Criteria.” See Behavioral Health Contract Exhibit A, section VI.3, page 5. For the Probation Department, the youth is a court ward at imminent risk of removal or is returning from STRTP placement; the youth demonstrates complex needs; CFT meetings have been conducted as part of supervision; a valid pre-placement case plan or placement case plan is in place; the youth has an open case with Children’s Behavioral Health or is actively receiving mental health services (e.g., AB 3015, ICT, Door to Hope, School-Based); and the youth meets Medi-Cal medical necessity (when applicable). See Probation Wraparound Protocol, section titled “Eligibility Criteria.”
b) The youth who meet the eligibility criteria shall be able to receive services and shall not be excluded based on the severity or nature of their need. See Scope of Services/Payment Provisions, Section G.2, page 3. See Family and Children’s Services Policies and Procedures, Section “Eligibility Criteria.”
c) The Wraparound Leadership Team, consisting of staff from Department of Social Services, Department of Health, Juvenile Probation Department, the Contractors, and other child-serving entities who want to participate, shall maintain Wraparound slots, manage the waitlist, and authorize modification to slot numbers listed above as individual family and youth needs arise from each agency. See Scope of Services/Payment Provisions, Section G.3.6, page 4.
d) The Contractor shall remain available to clients for emergency needs on a 24/7 on-call basis. See Scope of Services/Payment Provisions, Section H.5.3.c, page 14. The Contractor shall provide staff with access to supervision or coaching 24/7 as needed. See Scope of Services/Payment Provisions, Section J.1.3.a, page 20. The County shall pay Contractor for an administrator on call (.36 FTE) and provide on-call stipends and overtime for crisis response. See FCS Exhibit C-1, Budget.
e) The Contractor agrees to develop and maintain up-to-date solid internal social marketing tools. Marketing materials will include, but are not limited to, 8×11 or tri-fold materials, ongoing e-mail communication via newsletter or e-blasts, etc. that specifically includes agreed upon specific Wraparound Monterey County branding and information on how to refer youth and families who are interested and may qualify. See Scope of Services/Payment Provisions, Section H.5.5, page 14.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
a) The Contractor shall demonstrate adherence to California High-Fidelity Wraparound Standards and high-fidelity service model with four phases described in the standards (engagement, plan development, implementation, and transition). See Scope of Services/Payment Provisions, Section H.1, page 5. The Department of Social Services has earmarked $20,00 in the Contractor’s HFW budget to meet the individualized needs of youth and families. See FCS Exhibit C-1, Budget. The Wraparound Leadership Team will regularly review the use of, access to, and procedures around flex funds to ensure individualized family needs are being met. See Wraparound Leadership Team Meeting Agenda, page 2.
b) Both the Department of Social Services and the Health Department executed HFW contracts to fund workforce development and staffing including required roles or functions from the Workforce Development standard. The combined contracts fund the following HFW roles: Wraparound Fidelity Coach, Program Supervisor, HFW Facilitator, Family Specialist, Parent Partner, Youth Partner, Permanency Specialist, Administrator On-Call, Clinician, and Community Developer. See Scope of Services/Payment Provisions, Section I, page 16, and Exhibit C-1, Budget. Within the HFW staffing model, each role does not need to be assigned to a separate individual. One individual may serve in the capacity of two separate roles (i.e., fidelity coach and supervisor). While all roles are required to be made available to all youth, not all youth and their families will benefit from having all roles represented on their team. A HFW facilitator is required for all youth receiving HFW, as the intervention cannot function without a designated facilitator. See the Behavioral Health Contract Exhibit A, section IV, page 3.
c) The Contractor shall actively evaluate the effectiveness of their HFW program in achieving the types of outcomes routinely associated with the HFW model implementation to ensure youth and families receive HFW services according to the Ten Principles of Wraparound. The Contractor shall, minimally, track and evaluate the following: demographic information, fidelity indicators, and HFW outcomes. See Scope of Services/Payment Provisions, Section I, page 16. System of Care Partners agree that for the Monterey County HFW program, budgets and contracts at all levels allocate funding for essential Wraparound operations which include required staffing, workforce development, data collection, data management systems, and the costs of services. See Children’s System of Care MOU, Part Six, section D.2, page 10.
8.2 Equitable Funding Across System Partners
a) The ILT agrees to include HFW on the standing ILT agenda to ensure implementation and maintenance of HFW funding. System of Care Partners agree that for the Monterey County HFW program, federal, state, local, or private resources available across the Children’s System of Care will be leveraged to the maximum extent to meet the needs of youth and families served by HFW so that service is funded adequately. See Children’s System of Care MOU, Part Six, section D.3 page 10.
b) System of care partners shall collaborate on analyzing available funding streams and developing a plan/budget to leverage funding to the maximum extent. See Children’s System of Care MOU, Part Six, section D.3.b page 10.
c) The Department of Social Services contract for HFW services includes services for youth involved in child welfare, probation, and behavioral health. See Scope of Services/Payment Provisions, Section H.1, page 5. The Health Department contract for HFW services includes services for youth involved in child welfare, probation, and behavioral health. See the Behavioral Health Contract Exhibit A. The Department of Social Services has an executed Inter-Departmental Memorandum with the Probation Department for probation to pass through HFW Aftercare Funding to the Department of Social Services. See Wraparound Aftercare IDM.
d) System of Care Partners agree that for the Monterey County HFW program, multiple funding sources shall be explored by System of Care partners and leveraged as much as possible to expand access to HFW services. See Children’s System of Care MOU, Part Six, section D.3.a, page 10.
8.3 Cost Savings are Reinvested
a) System of Care Partners agree that for the Monterey County HFW program, the Monterey County Department of Social Services will report at Interagency Leadership Team meetings how savings achieved by HFW are reinvested to expand or enhance services and resources for youth and families. See Children’s System of Care MOU, Part Six, section D.6, page 11.
8.4 Availability, Access, and Approval of Flex Funds
1) Timely access for families that meet urgent needs
2) A defined approval process that includes the evaluation criteria defined above
3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.
a) The Contractor shall obtain approval from the HFW Team prior to utilizing Wraparound Flexible funding. Any requests over $500 shall be approved by DSS prior to purchase. Any denial of flex funds may be appealed to the Interagency Leadership Team. The Contractor shall provide an itemized list of flexible funding used monthly with the invoice. See Scope of Services/Payment Provisions, Section O.6, page 26 and Exhibit C-1, Budget.
b) (1) The Contractor shall have a process to ensure families have timely access to flexible funds to meet their urgent and individualized needs when these needs are not readily met by other resources; (2) There is a defined approval process that ensures requests for flexible funds are evaluated based on approval/recommendation of the Wraparound team and whether the use of funds (a) adds value to the team mission and supports the individualized care plan, (b) builds on family strengths, (c) meets identified child, youth, and family needs, (d) is culturally relevant and realistic for the family, (e) builds on natural supports and/or community capacity, (f) represents a good deal for the investment, and (c) includes a plan for sustainability; and (3) The process shall include procedures for families to appeal denied requests, which includes communication with teams, youth and families regarding why the funds were denied. See Scope of Services/Payment Provisions, Section H.6.18, page 15.
8.5 Collaborative Oversight of Flex Funds
a) The Contractor shall provide an itemized list of flexible funding used monthly with the invoice. The itemized list shall include the amount, the purpose, and the HFW team recommendation of the flex fund request. See Scope of Services/Payment Provisions, Section O.6, page 28. The use of flex funds will be reviewed at the Wraparound Leadership Team meetings. The review shall include a usage summary, discussion of barriers, and recommendations. See Wrapround Leadership Team Meeting Agenda.
b) System of care partners agree that for the Monterey County HFW program, flex funds are pooled and held to meet the needs of all families served. See Children’s System of Care MOU, Part Six, section D.8, page 11.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
a) System of care partners agree that for the Monterey County HFW program, flex funds and program resources are funded by braiding of available System of Care funding to ensure their availability. See Children’s System of Care MOU, Part Six, section D.7, page 11.
b) System of care partners agree that for the Monterey County HFW program, when funding limitations exist in a single funding source, alternate funding options are explored or reliance on other funding sources is increased to fill the gap. See Children’s System of Care MOU, Part Six, section D.9, page 11.
c) System of care partners agree that for the Monterey County HFW program, requirements of any single funding source do not prohibit families from accessing flexible funds to meet their needs. See Children’s System of Care MOU, Part Six, section D.10, page 11.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
a) The Contractor shall track demographic information regarding the children, youth, and family population(s) served. See Scope of Services/Payment Provisions, Section K.1, page 21. The Contractor shall utilize this data to monitor the demographic composition of the population served and implement processes to recruit/hire staff according to population needs. See Scope of Services/Payment Provisions, Section I.2.3, page 18.
b) When unable to recruit/hire according to cultural, racial, and linguistic needs, the Contractor shall make efforts to meet families’ needs for cultural representation through alternative means such as engaging natural or formal supports on the HFW team. See Scope of Services/Payment Provisions, Section I.2.4, page 18.
c) Services shall be provided in the family’s preferred language. The Contractor will provide translation and interpretation services in the instance that no bilingual staff are available. See Scope of Services/Payment Provisions, Section I.2.5, page 18.
9.2 Tribally Responsive Workforce
a) The Contractor shall provide ongoing training and coaching to staff on tribal sovereignty, traditions, and values, as well as how to ensure respectful communication, collaboration, and advocacy. See Scope of Services/Payment Provisions, Section J.2.13, page 21. The Contractor shall develop and provide a comprehensive bi-annual report that includes a list of training and coaching topics that were provided to staff during the reporting period. See Scope of Services/Payment Provisions, Section N.1.17 page 27.
b) As part of the referral process, the assigned social worker shall ensure that the HFW provider knows when an Indian child is referred to HFW and assist in connecting the HFW provider with the child’s Tribe. See FCS HFW Policy, section titled “Referral Process, number 3, page 12. The probation officer shall ensure Tribal coordination when applicable. See Probation Wraparound Protocol, section titled “Family Engagement,” page 3. When serving an Indian child, HFW teams shall build partnerships with tribal representatives, encouraging participation in tribal traditions and ceremonies and understanding the value of services and supports that the Tribe can offer. See Scope of Services/Payment Provisions, Section I.3.2, page 18.
9.3 Flexible and Creative Work Environment
a) The Contractor shall ensure leadership (including managers and supervisors) is committed to and has specific processes or initiatives to engage staff in program quality and improvement. See Scope of Services/Payment Provisions, Section I.4.2.a, page 18.
b) During HFW Team meetings, the HFW Facilitator shall continually assess and address team cohesion, trust, and commitment to ensure effective collaboration. The Contractor shall ensure leadership (including managers and supervisors) is committed to and has specific processes or initiatives to engage staff in cohesion (minimally including creating a positive team environment). See Scope of Services/Payment Provisions, Section I.4.2.b, page 18.
c) The Contractor shall ensure leadership (including managers and supervisors) is committed to and has specific processes or initiatives to engage staff in open communication. See Scope of Services/Payment Provisions, Section I.4.2.c, page 18.
d) The Contractor shall ensure leadership (including managers and supervisors) is committed to and has specific processes or initiatives to engage staff in creating a clear sense of mission and compliance with HFW philosophy (principles, values, phases and activities). See Scope of Services/Payment Provisions, Section I.4.2.d, page 19.
9.4 Hiring, Performance Evaluation, and Job Descriptions
a) The Department of Social Services and Health Department contract with the same provider to deliver HFW services. The combined contracts fund the following HFW roles: Wraparound Fidelity Coach, Program Supervisor, HFW Facilitator, Family Specialist, Parent Partner, Youth Partner, Permanency Specialist, Administrator On-Call, Clinician, and Community Developer. See Scope of Services/Payment Provisions, Section I, page 16. Within the HFW staffing model, each role does not need to be assigned to a separate individual. One individual may serve in the capacity of two separate roles (i.e., fidelity coach and supervisor). While all roles are required to be made available to all youth, not all youth and their families will benefit from having all roles represented on their team. A HFW facilitator is required for all youth receiving HFW, as the intervention cannot function without a designated facilitator. See the Behavioral Health Contract Exhibit A, section IV, page 3.
b) Each contracted role has a distinct purpose in achieving HFW in Monterey County. A description and responsibility of each role is outlined in the HFW contracts. See Scope of Services/Payment Provisions, Section I.1, page 16 and the Behavioral Health Contract Exhibit A, section IV, page 3.
c) The Contractor shall develop job descriptions for all required positions that are specific to HFW and reflect the attitude, skills, knowledge, and experience most likely to identify individuals who will be successful in the position. The Contractor shall provide the job descriptions to the County. See Scope of Services/Payment Provisions, Section I.5.1, page 19.
d) The Contractor shall implement hiring processes that include opportunities that allow candidates to demonstrate specific attitudes and skills essential to the position. See Scope of Services/Payment Provisions, Section I.5.2, page 19.
e) The Contractor shall provide employees with clear expectations for their performance and receive frequent feedback and coaching to support their success. See Scope of Services/Payment Provisions, Section I.5.2, page 19.
9.5 Workforce Stability
a) The Contractor’s human resources management in the organization shall implement strategies and processes that result in the maintenance of a stable workforce which minimally include matching wage to cost of living in Monterey County. See Scope of Services/Payment Provisions, Section I.6.1.a, page 19.
b) The Contractor’s human resources management in the organization shall implement strategies and processes that result in the maintenance of a stable workforce which minimally include maintaining manageable workloads for staff. See Scope of Services/Payment Provisions, Section I.6.1.b, page 19.
c) The Contractor’s human resources management in the organization shall implement strategies and processes that result in the maintenance of a stable workforce which minimally include have clearly communicated and accessible promotion/advancement structures that are not prohibitive for those with lived experience. See Scope of Services/Payment Provisions, Section I.6.1.c, page 19.
d) The Contractor’s human resources management in the organization shall implement strategies and processes that result in the maintenance of a stable workforce which minimally include providing wage increase or leadership opportunities that do not require a position change to achieve. See Scope of Services/Payment Provisions, Section I.6.1.d, page 19.
9.6 High Fidelity Training Plan
a) The Contractor’s training plan shall include staff receiving an initial HFW training by attending the Statewide Standardized Foundational HFW training through the UC Davis RCFFP. Once CONTRACTOR develops an approved HFW curriculum and becomes a certified HFW trainer, initial HFW training can shift internally. See Scope of Services/Payment Provisions, Section J.1.1.a, page 19. Contractor shall provide a copy of the annual training plan to the County at the beginning of each fiscal year but no later than July 30th. See Scope of Services/Payment Provisions, Section J.1.4, page 20.
b) The Contractor’s training plan shall include ongoing training both in general Wraparound and specific roles through formal trainings, meetings, coaching, peer shadowing, and/or supervision for all staff. See Scope of Services/Payment Provisions, Section J.1.1.b, page 20. Contractor shall provide a copy of the annual training plan to the COUNTY at the beginning of each fiscal year but no later than July 30th. See Scope of Services/Payment Provisions, Section J.1.4, page 21.
c) The Contractor’s training plan shall include booster trainings at least annually in general Wraparound and specific roles for all staff. See Scope of Services/Payment Provisions, Section J.1.1.c, page 20. Contractor shall provide a copy of the annual training plan to the County at the beginning of each fiscal year but no later than July 30th. See Scope of Services/Payment Provisions, Section J.1.4, page 20.
d) The Contractor’s training plan shall include specific trainings for all clinical supervisors and HFW supervisors/managers attend general Wraparound training as well as receive initial, ongoing, and booster trainings specific to their leadership/supervisory role. See Scope of Services/Payment Provisions, Section J.1.1.d, page 19. The Contractor shall provide a copy of the annual training plan to the County at the beginning of each fiscal year but no later than July 30th. See Scope of Services/Payment Provisions, Section J.1.4, page 210
e) The Contractor’s training plan shall include ICWA and Tribal sovereignty training for all staff and mechanisms that are in place to identify and provide training that supports populations with specific and unique needs as needed. See Scope of Services/Payment Provisions, Section J.1.1.e, page 20. Contractor shall provide a copy of the annual training plan to the County at the beginning of each fiscal year but no later than July 30th. See Scope of Services/Payment Provisions, Section J.1.4, page 20.
9.7 Community-based Training Program
a) The Contractor shall administer the training plan in collaboration with community members and families with HFW experience as part of the training team. Youth, families, and peer partners with current or prior Wraparound experience shall be meaningfully incorporated into the delivery of required Wraparound trainings. See Scope of Services/Payment Provisions, Section J.1.2, page 20. Contractor shall include in the training plan the names of the community members and families who were involved in the development of the annual training plan. See Scope of Services/Payment Provisions, Section J.1.4.a, page 21.
b) The Contractor shall invite community partners to attend Wraparound trainings or offer trainings on Wraparound to strengthen their participation on HFW teams or to strengthen their role in supporting HFW within the System of Care. See Scope of Services/Payment Provisions, Section J.1.2,b page 20.
9.8 Coaching and Supervision
a) The Contractor shall provide team members with initial apprenticeship and ongoing coaching that emphasizes Wraparound values, principles, phases, and activities, as well as effective use of flex funds to meet the family’s need. See Scope of Services/Payment Provisions, Section J.1.3, page 20. The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The report shall include training and coaching topics provided to staff during the reporting period. See Scope of Services/Payment Provisions, Section N.1.12, page 27.
b) The Contractor shall provide staff with access to supervision or coaching 24/7 as needed. See Scope of Services/Payment Provisions, Section J.1.3.a, page 20.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
a) The Contractor shall collaborate with the County to implement a local CQI evaluation plan to routinely and reliably monitor the overall quality of HFW in Monterey County. The following data points shall be included in the local evaluation plan: demographic information regarding the children, youth, and family population(s) served; Wraparound Fidelity Indicators; and HFW Outcomes. See Scope of Services/Payment Provisions, Section L.1, page 25. The Contractor shall achieve and maintain Full Fidelity Designation for High Fidelity Wraparound as required by DHCS. Fidelity Designation for HFW in Medi-Cal and under BHSA builds on the family-based aftercare certification process through the California High Fidelity Wraparound County Plan Approval and Provider Certification Portal. See Behavioral Health Contract, Exhibit A, section VIII.1, page 5.
b) System of care partners agree to share information necessary to implement a local CQI evaluation plan. See Children’s System of Care MOU, Part Six, section E.2, page 11.
c) The Contractor shall ensure collected data is current, accurate, and used to inform and improve practice locally. See Scope of Services/Payment Provisions, Section L.1.2, page 26. The Contractor shall follow all HFW Policy Manual which establishes training, technical assistance, fidelity monitoring and data collection standards for BHPs and behavioral health practitioners to implement HFW under Medi-Cal and the BHSA. See Behavioral Health Contract, Exhibit A, section VIII.2, page 5.
d) The Contractor shall ensure data is collected at the level closest to the individual and subsequently uploaded in an appropriate format for analysis at the next appropriate level. See Scope of Services/Payment Provisions, Section L.1.3, page 26. Contractor must collect data on member outcomes to ensure HFW is effective. The HFW COE, as stated in the HFW Provider Manual, will require every HFW provider site to use WrapStat. The WrapStat is used to collect member outcomes data, including data from the DART, WFI-EZ, and additional questions within WrapStat. HFW provider sites must use the WrapStat at the following intervals: at intake; at the end of HFW service provision, or annually, whichever is sooner; any member of the HFW team who has access to WrapStat can collect member outcomes data; to complement data collected by HFW provider sites, the COE will also engage with caregivers of youth receiving HFW to complete the WFI-EZ annually from a representative sample of youth enrolled for a certain timeframe (e.g., between 3 and 15 months). See Behavioral Health Contract, Exhibit A, section IX.1, page 6.
10.2 Evaluation Metrics & Outcomes
a) The Contractor shall utilize the evaluation of each Wraparound Fidelity Indicator to provide feedback to staff and their supervisors, for training and coaching purposes, minimally, on their ability to meet timelines; prioritize the youth and family’s perspective; provide strengths-based services; provide services that are needs driven; provide individualized services; engage natural supports; provide culturally relevant and respectful services and strategies; engage and collaborate with the family and HFW team.; monitor the success of the HFW Plan of Care; view setbacks and challenges as an indicator of a need to revise the plan; provide adequate transitions; and develop crisis and safety plans in a team based, collaborative environment that have individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports. The Contractor shall also utilize evaluation data to monitor HFW Outcomes to improve practice locally and provide accountability for achievement of desired outcomes. See Scope of Services/Payment Provisions, Section L, page 25. The Contractor shall develop a provide a bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The report shall include evaluation of Wraparound Fidelity Indicators, evaluation of HFW Outcomes, and the training/coaching topics provided to staff during the reporting period (the topics should address areas of improvement identified by the evaluation process), and areas of improvement during the review period as identified by the CQI process. See Scope of Services/Payment Provisions, Section N.1, page 27. The Contractor will submit to County aggregate data and member outcomes data for review on a regular basis to ensure HFW is being delivered effectively and meeting the needs of youth. See Behavioral Health Contract, Exhibit A, section IX.2, page 6.
b) The Contractor shall develop and provide a comprehensive bi-annual report of program outcomes, services delivered, challenges, and achievements, and may be requested to present the report at a County organized, public meeting. The Contractor shall present the Bi-Annual report to the Monterey County Interagency Leadership Team meeting. See Scope of Services/Payment Provisions, Section N, page 27. The Contractor shall collaborate with the County to implement a local CQI evaluation plan to routinely and reliably monitor the overall quality of HFW in Monterey County. The following data points shall be included in the local evaluation plan: demographic information regarding the children, youth, and family population(s); Wraparound Fidelity Indicators, and HFW Outcomes. See Scope of Services/Payment Provisions, Section L.1, page 25.
c) HFW data shall be reviewed at semi-monthly Wraparound Leadership Team Meetings to identify key trends and develop CQI actions. The Wraparound Leadership Team shall identify and remove system barriers that impact HFW implementation including access issues, eligibility restrictions, and service gaps. See County of Monterey Wraparound Leadership Team Meeting Agenda, pages 1 -2.
Fidelity Indicators
1.1 Timely Engagement and Planning
a.) The HFW Facilitator will make initial outreach contact to the child, youth and family within 24 to 48 hours after case assignment, but no later than 10 calendar days. Engagement attempts will include multiple methods such as phone calls, text messages, emails, home visits and coordination with referral party to schedule the initial Family Team Meeting as noted in Timely Engagement and Planning in the HFW Fidelity Indicators pg. 1
b.) The HFW Facilitator will begin to develop an initial Plan of Care within 30 days of opening services. The Plan of care will be developed more fully through the planning phase with active participation from the youth, family, and identified team members to develop individualized goals, interventions, and supports. HFW Plan of Care Policy pg. 1
c.) The HFW Team updates the Plan of Care at least every 30-45 days and more frequently when appropriate, during Family Team Meetings. HFW Plan of Care Pg. 1
d) The HFW Teams will update the plan of care, and distribute to all team members, and document the updated plan in the child or youth’s file at least every 90 days and more often as needed. HFW Plan of Care Policy Pg. 1-2
(e) The HFW coach will provide feedback to the HFW teams and their supervisors. Supervisors will review case timelines with staff during weekly supervision meetings to ensure Wraparound Plans of Care are completed within 30 calendar days of starting services. A monthly report will be used to track due dates and identify any plans that are approaching or past the deadline. Staff will receive feedback on their timeliness during supervision, and any barriers to meeting timelines are discussed and addressed. Timeliness data is also reviewed quarterly as part of the CQI process to identify trends, improve performance, and ensure ongoing compliance. HFW Facilitator, Coaching and Supervision, Pg. 1-2
(f) The HFW staff receive training during onboarding and annual refresher training on strategies for engaging families in a timely manner. Training includes the use of alternative engagement methods when families are difficult to reach, such as contacting families at different times of day, using phone calls, text messages, emails, mailed letters, and coordinating with identified supports or referral sources when appropriate. HFW Training Plan Pg. 1-2
1.2 Led by Youth and Families
A) HFW Facilitator will explain to the family the definition of the family vision and team mission statement. The Parent Partner will build rapport with the caregiver to support the caregiver with developing the family vision. The Family Specialist will build rapport with the youth to support the youth with developing the family vision. The HFW will collaborate with the family to identify their goals, preferences, strengths, and desired outcomes. The Family Vision and Team Mission statements are developed collaboratively during the initial planning process, documented on the plan of care, and reviewed during team meetings to guide decision making. For Indian children, the Tribe is invited to participate as an equal member of the HFW team, and Tribal perspectives are incorporated into all aspects of planning and service delivery. Pre-CFT Preparation, Child and Family Team Meeting Facilitation Guidelines, pg. 1
B) HFW teams will utilize eco maps, case exploration activities to learn the family’s value, culture, interest, expertise, skills and natural supports. This information is incorporated into the HFW Plan of Care and used to guide service planning and develop strategies and support. Pre-CFT Preparation, Child and Family Team Meeting Facilitation Guidelines, pg. 1
C) HFW Coach/Supervisor will observe the HFW team meetings monthly and review documentation to assess adherence to Wraparound principles, including family voice and choice. Feedback is provided during supervision sessions to reinforce program expectations, build skills, increase confidence, and support continuous professional development. HFW Facilitator, Coaching and Supervision, Pg. 1-2
D) QA staff will invite the family to participate in an initial satisfaction survey and or quality assure phone call no later than 45 days after the enrollment, after 6 months of HFW and at the exit to share their experience in HFW. Feedback is reviewed bi-annually by supervisors to assess family experience, identify opportunities for improvement, and support continuous quality improvement efforts. 2.1 HFW Youth and Family Satisfaction Policy pg. 1
1.3 Strength-Based
A) The Parent and Family Specialist will assist the youth and caregiver with identifying their strengths and family community during the weekly sessions. In the CFT the HFW Facilitator will guide the family to complete the strengths inventory which will also include the family’s community. The strengths inventory will be reviewed and updated in the weekly CFT meetings. Pre-CFT Preparation, Child and Family Team Meeting Facilitation Guidelines, pg. 1
B) The HFW Facilitator will complete the CANS and utilize the CANS ratings to support the youth’s individualized strengths. These strengths are added to the family’s strengths list and used to help guide planning and support strategies throughout services. CANS Policy, pg. 1
C) HFW staff will receive initial and annual training on providing strengths-based services and monthly coaching. High Fidelity Training Plan pg. 1
D) QA staff will invite the family to participate in an initial satisfaction survey no later than 45 days after the enrollment, after 6 months of HFW and at the exit to share their experience of strengths-based services. QA staff will collect the data and present the data to the HFW staff and their supervisors during staff meetings. Supervisors will also utilize the data during training and coaching. Feedback will be used for continuous quality improvement and to inform staff of training, coaching, and supervision activities. 2.1 HFW Youth and Family Satisfaction Policy pg. 1; Youth and Family Satisfaction Survey Form
1.4 Needs Driven
a) The Parent Partner and Family Specialist will assist the youth and caregiver with identifying and developing their underlying needs during the weekly sessions. In the CFT the HFW Facilitator will guide the family with developing their underlying needs before the goals and strategies are established. Identification and Prioritization of Needs, Child and Family Team Meeting Facilitation Guidelines, pg. 2
b) After the initial HFW training the staff will receive annual training and monthly coaching on how to identify needs and develop needs statements that are reflective of the underlying reasons why problematic situations/behaviors are occurring and utilizing needs-focused planning. High Fidelity Training Plan pg. 1
c) The HFW Facilitator will complete the CANS and utilize the CANS ratings to support the youth with identifying their individualized needs. CANS Policy, pg. 1
d) During monthly CFT meetings, the HFW team will review progress toward meeting identified needs using information from the CANS, team observations, family feedback, and progress toward goals. Transition planning will occur when the team, youth, and family determine that prioritized needs have been sufficiently met and the family has the resources, supports, and skills necessary to sustain progress after HFW services end.
HFW Transition and Case Closure pg. 1-2
1.5 Individualized
a) HFW team members will utilize the Strength Needs Assessment Summary, Natural and Community Support Inventory and Family Safety Crisis Plan to create individualized plans for the client and family. Engage all Team Members, Child and Family Team Meeting Facilitation Guidelines, pg. 1
b) HFW staff will receive annual training and monthly coaching to support the consistent delivery of flexible, creative, culturally responsive, and highly individualized services and strategies that are customized to the unique strengths, needs, values, and preferences of each youth and family.
Coaching and Supervision Guidelines, pg. 1
c) HFW Facilitators will receive annual training and monthly coaching on how to lead the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences. HFW Training Plan pg 1-2
d) Supervisor/HFW Coach will review and assess the initial plan of care and revised plan of care to ensure that the plans incorporate individualized strengths, needs, outcomes, and strategies and for the presence of strategies that capitalize on the assets of the family’s community and informal networks. HFW – Plan of Care Policy Pg. 2
E) QA staff will invite families to participate in an initial satisfaction survey no later than 45 days after enrollment, at six months of service, and upon discharge to provide feedback regarding their experience receiving customized and individualized services. QA staff will collect and analyze the data and present findings to HFW staff and supervisors during staff meetings. Feedback will be used for continuous quality improvement and to form staff trainings, coaching, and supervision practices. HFW- 2.1 Youth and Family Satisfaction Policy pg. 1
1.6 Use of Natural and Community Based Supports
a) The Parent Partner and Family Specialist will assist the youth and caregiver with identifying natural and community support during the weekly sessions. In the CFT the HFW Facilitator will guide the family with completing a natural and community support inventory within the first 30 days of opening services with the family and update the form every 90 days or as needed. Engage All Team Members, Child and Family Team Meeting Facilitation Guidelines, pg. 1
b) HFW staff will receive annual training and monthly coaching on how to remain consistent with the identification, engagement, and integration of natural supports in the HFW process and in decreasing reliance on formal supports. Coaching and Supervision Guidelines, pg. 1
c) Supervisor/HFW Coach will review and assess the client’s care plan to ensure that natural and community support are included in the strategies and action items. HFW – Plan of Care Policy Pg. 2
d) QA staff will invite the family to participate in an initial satisfaction survey no later than 45 days after the enrollment, after 6 months of HFW and at the exit to share their experience of having natural supports engage on their teams. QA staff will collect the data and present the data to the HFW staff and their supervisors during staff meetings bi-annually. Supervisors will also utilize the data during training and coaching purposes.
Feedback will be used for continuous quality improvement and to inform staff training, coaching, and supervision practices. HFW- 2.1 Youth and Family Satisfaction Policy pg. 1
1.7 Culturally Respectful and Relevant
A) The HFW team will complete a Strengths, Needs, and Culture Discovery process within the first 30 days of enrollment and prior to the development of the initial Plan of Care. Information regarding the family’s traditions, values, beliefs, cultural identity, heritage, language preferences, and community connections will be documented in the case record and incorporated into service planning. The Strengths Inventory and cultural information will be reviewed and updated during Child and Family Team meetings to ensure services remain culturally relevant and responsive to the family’s needs and preferences. Strengths Discovery, Child and Family Team Meeting Facilitation Guidelines, pg. 2
B) HFW staff will receive annual training and monthly coaching to maintain consistent with providing culturally respectful and relevant strategies.
HFW Training Plan pg 1-2
C) QA staff will invite the family to participate in an initial satisfaction survey no later than 45 days after the enrollment, after 6 months of HFW and at the exit to share their experience of the team’s mindfulness of engaging in cultural relevant and respectful services and strategies. QA staff will collect the data and present the data to the HFW staff and their supervisors during staff meetings bi-annually. Supervisors will utilize the data to inform staff training, coaching, supervision, and continuous quality improvement activities. HFW- 2.1 Youth and Family Satisfaction Policy pg. 1
1.8 High-Quality Team Planning and Problem Solving
A) HFW Facilitator will explain the purpose of the team agreements and then collaborate with the HFW team to develop the team agreements for the CFT which will be filed in the youth’s chart. HFW Plan of Care Policy, pg. 1-2
B) QA) staff will invite families to complete satisfaction surveys within 45 days of enrollment, after six months of HFW services, and at discharge. The surveys will gather feedback about the family’s experience with team engagement and collaboration throughout the Wraparound process. HFW- 2.1 Youth and Family Satisfaction Policy pg. 1
C) QA staff will collect the data and present feedback on team engagement and collaboration to the HFW staff and their supervisors during staff meetings bi-annually. Supervisors will also utilize the data for training and coaching purposes. HFW Training Plan pg. 1-2
D) HFW Supervisor will review plans of care and CFT meeting minutes monthly to ensure that all team members are collaborating and following up on the strategies and action items. Coaching and Supervision Guidelines pg. 1-2
1.9 Outcomes Based Process
A) The HFW Facilitator will develop the Plan of Care within 30 calendar days of enrollment. The Plan of Care will include specific and measurable strategies, action items, responsible team members, and target completion dates. HFW Plan of Care Policy, pg. 1-2
B) HFW Facilitator will monitor, track and update the action items at least once a month or more often as needed during the HFW CFT meetings. HFW Plan of Care Policy, pg. 1-2
C) The HFW Facilitator will work with the team to review and update strategies and action items as the youth’s and family’s needs change. Any changes to the Plan of Care will be communicated to all team members and updated copies will be provided. HFW Plan of Care Policy, pg. 1-2
D) HFW Facilitator will complete the IP-CANS and share the outcomes to the HFW team during the initial HFW CFT meeting to help identify strengths, needs, and priorities for planning and service delivery. CANS Policy, pg. 1
E) HFW Facilitator and the team will use data from the IP-CANS along with tracking the youth’s needs, goal completion and action items from the plan of care to support team decision making to plan for transition. CANS Policy, pg. 1 / Transition and Case Closure Procedures, Pg. 1