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
At Casa Esperanza, we prioritize effective engagement by adhering to California’s High-Fidelity Wraparound (HFW) fidelity indicators, which guide our interactions with families and enhance the internal coherence of our organization. This commitment is reflected in a series of structured processes and documentation:
a. The HFW Manager Supervisor meticulously monitors the initial contact made following a referral, as outlined in the Treatment Tracker on page 1. This ensures that families receive timely support from the outset.
b. The completion of the Plan of Care is another critical milestone tracked by the HFW Manager Supervisor; this documentation, referenced in the Treatment Tracker, page 1, confirms that families have a clear, actionable plan.
c. Regular reviews of the Plan of Care during team meetings are recorded by the HFW Manager Supervisor, ensuring that all team members remain aligned and engaged in the youth’s care process (see Treatment Tracker, page 1).
d. Updates to the Plan of Care are systematically monitored by the HFW Manager Supervisor, reinforcing our commitment to adapting to the evolving needs of each family (see Treatment Tracker, page 1).
e. To foster transparency and collaboration, the HFW Manager Supervisor discusses the Treatment Tracker with staff and supervisors every week during staff meetings; these discussions occur in reference to Treatment Tracker, page 1.
f. Our dedicated staff members receive specialized training from the Fidelity Coach, focusing on impactful engagement and team-building exercises designed to enrich interpersonal connections; details can be found in Engagement and Team Building Activities, pages 1-2.
1.2 Led by Youth and Families
We believe that effective implementation of the HFW model hinges on integrating family perspectives that honor their values, cultural backgrounds, and unique expertise. This input is actively sought during meetings and visits, with comprehensive documentation maintained in the youth’s case file, as evidenced by the following processes:
a. The HFW Facilitator actively elicits valuable insights from youth and families, gathering their perspectives through the Strengths-Needs-Culture-Discovery Form, pages 1-2, to ensure their voices are at the forefront of care.
b. The HFW Facilitator diligently works to ascertain the family’s core values and perspectives, creating a holistic understanding of their needs as seen in the Strengths-Needs-Culture-Discovery Form, pages 2-3.
c. Observations made by the HFW Fidelity Coach during meetings are documented to provide constructive feedback to staff, ensuring continual growth and adherence to best practices (see Coaching Observation Form, page 1).
d. Feedback from youth and families is collected through satisfaction surveys, overseen by the HFW Manager Supervisor, allowing us to assess the effectiveness of our approaches and make necessary adjustments (see Youth and Family Satisfaction Surveys, page 1).
1.3 Strength-Based
Our approach is grounded in the belief that each individual has strengths. The Manager takes the lead in developing a strengths inventory form that reflects the unique strengths identified through the IP-CANS assessment.
a. The HFW Facilitator conducts an insightful strengths inventory for each team member, as documented in the Team Strengths Inventory, page 1, fostering a culture of recognition and empowerment.
b. The HFW Family Specialist applies insights gained from the IP-CANS assessment to underline the family’s strengths, as detailed on page 1 of the IP-CANS.
c. Staff members partake in specialized training that emphasizes solution-focused, strength-based methodologies; this can be found in our Training Curriculum, page 1.
d. The HFW Manager Supervisor continually collects feedback from the youth and family through satisfaction surveys, ensuring that our services resonate well with those we support (see Youth and Family Satisfaction Surveys, page 1).
1.4 Needs Driven
Using insights from both the Strengths Inventory and the IP-CANS, we work collaboratively with families to identify and document their perceived needs.
a. The HFW Facilitator utilizes identified needs to set and prioritize goals, as outlined in the Strengths-Needs-Culture-Discovery Form, page 3, ensuring a focused approach to support.
b. The HFW Fidelity Coach conducts training centered on needs-focused planning, enriching the skillset of our staff (see Training Curriculum, page 1).
c. The HFW Facilitator carefully reviews the documented needs from the IP-CANS, as noted on page 1, to ensure they are at the forefront of our planning efforts.
d. Transition planning is meticulously developed based on feedback collected during Team meetings, emphasizing collaborative engagement (see Wraparound Team Meeting Template, page 1).
1.5 Individualized
At Casa Esperanza, we are unwavering in our commitment to crafting individualized plans that reflect the unique circumstances and aspirations of each youth and their family.
a. The HFW Facilitator leverages the Plan of Care to pinpoint personalized strategies tailored to meet the specific needs of the youth and family (see Plan of Care, page 2).
b. Ongoing training provided by the HFW Fidelity Coach focuses on implementing flexible and individualized strategies, ensuring responsiveness to family preferences (see Training Curriculum, page 1).
c. The HFW Fidelity Coach offers continuous coaching to staff, emphasizing the importance of customizing the HFW process and Plan of Care to create a supportive environment (see Coaching Observation Form, page 1).
d. Monthly chart audits conducted by the HFW Clinical Supervisor serve to rigorously review the elements of the Plan of Care, maintaining our standards of care and quality assurance (see HFW Chart Audit, page 1).
e. Feedback from youth and families is consistently gathered through satisfaction surveys, overseen by the HFW Manager Supervisor, reinforcing our dedication to improvement and responsiveness (see Youth and Family Satisfaction Surveys, page 1).
1.6 Use of Natural and Community Based Supports
The HFW Manager Supervisor plays a pivotal role in cultivating a comprehensive inventory of natural and community support resources available to families in need. This comprehensive catalog outlines the various types of support that families currently use or may require over time, covering essential domains such as health, housing, recreation, financial assistance, nutrition, legal affairs, communication, spiritual needs, education, and other critical areas of life.
a. The HFW Facilitator is responsible for compiling the support inventory for each family, ensuring it is updated monthly. This is documented through the Natural Supports Inventory Form, which provides a clear snapshot of available resources.
b. To empower staff, the HFW Fidelity Coach delivers specialized training focused on the engagement and integration of natural supports, as outlined in the Training Curriculum, page 2.
c. Maintaining high standards of care, the HFW Clinical Supervisor conducts monthly chart audits to thoroughly review the various elements of the plan of care, ensuring alignment with best practices; refer to the HFW Chart Audit on page 1 for further details.
d. Central to fostering improvement, the HFW Manager Supervisor actively seeks feedback from youth and families through satisfaction surveys designed to capture their experiences and perspectives; see Youth and Family Satisfaction Surveys, page 1.
1.7 Culturally Respectful and Relevant
In creating a personalized Plan of Care, the HFW Facilitator collaborates closely with the youth and their family members to explore their unique cultural perspectives. This rich discussion encompasses various dimensions, including language, spirituality, religion, rituals, customs, food preferences, leisure activities, traditions, beliefs, and values, ensuring that every facet of their identity is honored.
a. The HFW Facilitator diligently elicits information that encapsulates the cultural perspectives of the youth and family, utilizing the Strengths-Needs-Culture-Discovery Form, page 3 to guide these conversations.
b. To enhance the skills of the staff, the HFW Fidelity Coach offers comprehensive training on effectively eliciting and incorporating family and cultural insights into both planning and service delivery, as detailed in the Training Curriculum, page 2.
c. Continuous improvement is achieved through feedback mechanisms, where the HFW Manager Supervisor collects valuable insights from youth and families via satisfaction surveys; refer to Youth and Family Satisfaction Surveys, page 1.
1.8 High-Quality Team Planning and Problem Solving
The team planning process is marked by collaboration, as team agreements are developed in partnership with each youth and their family. The HFW Facilitator works shoulder to shoulder with them, weaving in input from the youth, their family, and their support network to create a meaningful agreement.
a. As a part of the engagement process, the HFW Facilitator formulates team agreements for each client’s HFW team, as documented in the Team Agreement form on page 1.
b. Feedback is essential for growth, and the HFW Manager Supervisor gathers insights from youth and families through satisfaction surveys; see Youth and Family Satisfaction Surveys, page 1 for more information.
c. The HFW Manager Supervisor also plays a crucial role in providing monthly updates on family feedback to the staff, utilizing the CQI Indicators Form on page 1.
d. To maintain accountability and quality, the HFW Clinical Supervisor conducts meticulous monthly chart audits, reviewing both the elements of the plan of care and the minutes from team meetings; see the HFW Chart Audit, page 1.
1.9 Outcomes Based Process
In a commitment to measurable progress, the Facilitator meticulously crafts a Plan of Care (POC) featuring clear, measurable, achievable, relevant, and time-bound strategies. To ensure accountability, action items are assigned to team members, along with specific deadlines, which are consistently tracked in HFW meetings until they are fully completed.
a. The HFW Facilitator integrates quantifiable strategies, benchmarks, time-oriented results, and individual strengths into the plan of care, as illustrated on pages 2-3 of the Plan of Care.
b. Weekly tracking of action items is the standard for the HFW Facilitator, ensuring progress is monitored, and adjustments are made promptly; refer to the Plan of Care, pages 2-3.
c. The HFW Facilitator is also empowered to adjust and tailor the Plan of Care form, adapting to any necessary changes in circumstances, as noted on pages 2-3 of the Plan of Care.
d. The HFW Family Specialist diligently completes the IP-CANS assessment and shares its findings at the team meeting; see IP-CANS, page 1 for details.
e. Information from the IP-CANS is thoughtfully incorporated into the Plan of Care, enhancing its relevance; see Plan of Care, pages 2-3.
1.10 Persistence
The HFW team remains steadfast in collaboration with youth and families, especially when encountering setbacks or limited progress. The HFW Manager Supervisor leads weekly staff meetings dedicated to reviewing the status and progress of each family, fostering a culture of accountability and support. For those facing challenges, the HFW staff conducts a thorough analysis of the underlying causes and develops actionable plans to overcome these barriers.
a. The HFW Fidelity Coach observes team dynamics and provides constructive feedback when challenges arise, utilizing the insights gathered in the Coaching Observation Form on page 2.
b. To facilitate access to resources, the HFW Manager Supervisor supplies protocols for reaching services that can assist families, detailed in the Fidelity Indicators policy on page 4.
c. Staff training is crucial, and the HFW Fidelity Coach equips team members with skills in safety planning, conflict resolution, and brainstorming techniques, as outlined in the Training Curriculum, pages 2-3.
1.11 Transitions as a part of the Fourth Phase of HFW
Understanding the significance of seamless transitions, HFW staff are proactive in preventing service gaps. Should a youth or family miss a meeting or activity, the HFW Family Specialist or HFW Parent Partner promptly reaches out to reconnect and reschedule, ensuring continuous support.
a. The HFW team is dedicated to facilitating smooth transitions, which are characterized by warm hand-offs to ongoing service providers, as described in the Transition Plan on page 1.
b. In partnership with the active participation of the youth and family, the HFW team celebrates successes through thoughtfully developed plans for recognition, as documented in the Commencement and Celebration of Success Plan on page 1.
Expected Outcomes
2.1 Youth and Family Satisfaction
The HFW Family Specialist will play a pivotal role in gathering insights and feedback regarding the satisfaction levels of youth and their families. This information can be meticulously documented and reviewed in the Treatment Tracker (tab 2) and detailed in the Expected Outcomes policy on page 1.
2.2 Improved School Functioning
The HFW Family Specialist is tasked with the critical responsibility of tracking and assessing information on the functioning of youth in academic environments. Relevant data can be meticulously accessed in the Treatment Tracker, tab 2, along with the guidelines provided in the Expected Outcomes policy on page 1.
2.3 Improved Functioning in the Community
Under the supervision of the HFW Manager Supervisor, the HFW Facilitator and Family Specialist will diligently assess and evaluate the youth’s engagement and functioning within community settings. Comprehensive information can be found in the Treatment Tracker, tab 2, complemented by the Expected Outcomes policy articulated on page 2.
2.4 Improved Interpersonal Functioning
The HFW Family Specialist will be responsible for collecting detailed information about interpersonal functioning using the IP-CANS assessment. Essential data and documentation should be referenced in the Treatment Tracker, tab 2, alongside directives specified in the Expected Outcomes policy on page 2.
2.5 Increased Caregiver Confidence
The HFW Family Specialist will actively gather insights that reflect increased caregiver confidence, a vital component for supporting youth. This information should be carefully cataloged in the Treatment Tracker, tab 2, in conjunction with the guidelines presented in the Expected Outcomes policy on page 2.
2.6 Stable and Least Restrictive Living Environment
The HFW Manager Supervisor will thoroughly monitor and evaluate the youth’s placement status monthly, ensuring it aligns to maintain a stable, least restrictive living environment. Updates or changes regarding a new placement will be promptly documented in the Treatment Tracker, tab 2, and reinforced in the Expected Outcomes policy on page 3.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
To enhance the quality of care, the HFW Manager Supervisor will meticulously track the youth’s admissions to inpatient facilities monthly. This ongoing monitoring will be documented in the Treatment Tracker, tab 2, and is supported by the criteria outlined in the Expected Outcomes policy on page 3.
2.8 Reduction in Crisis Visits
The HFW Manager Supervisor will consistently oversee and evaluate the frequency of crisis visits experienced by the youth, ensuring a proactive approach to crisis management. Important insights regarding these visits can be found in the Treatment Tracker, tab 2, as well as in the Expected Outcomes policy on page 3.
2.9 Positive Exit from HFW
The HFW Manager Supervisor will closely monitor the youth’s progress and transition dates, ensuring a smooth and positive exit from the HFW program. This critical information regarding the exit process can be effectively tracked in the Treatment Tracker, tab 2, and detailed in the Expected Outcomes policy on page 3.
Engagement
3.1 Orientation
Upon the youth’s admission into the Home and Family Wellness (HFW) program, both the young individual and their family are welcomed through a comprehensive orientation. This session serves as a vital introduction, outlining the program’s core principles and the crucial legal and ethical considerations relevant to the family’s well-being. The orientation also clarifies the distinct roles of each team member, emphasizes the importance of natural supports—including connections to relevant tribal resources, when applicable—and addresses other critical aspects necessary for a successful journey within the HFW program.
a. At the commencement of the engagement phase, the HFW Manager Supervisor personally guides the orientation, elucidating the foundational principles and developmental phases integral to HFW. Refer to the Orientation Format on pages 1-3 for detailed insights.
b. During the initial engagement phase, the HFW Manager Supervisor explicates the legal and ethical considerations pertinent to the HFW program. More information can be found in the Orientation Format on pages 1-3.
c. In cases involving Indian children, the HFW Manager Supervisor offers additional orientation on the specific roles of team members. Refer to Orientation Format, pages 1-3, for comprehensive details.
3.2 Safety and Crisis stabilization
Recognizing that youths entering the HFW program may face various safety concerns—including, but not limited to, tendencies toward runaway behavior, suicidal or homicidal thoughts, or other significant risk factors—a proactive initial crisis plan is developed before more formalized crisis and safety plans.
a. During the engagement phase, the HFW Facilitator or designated representative engages in open dialogue regarding potential crisis and safety concerns. Detailed procedures are available in the Crisis Plan on page 1.
b. The HFW Facilitator or designee is tasked with crafting a thoughtful crisis plan that equips both the youth and their family with essential resources and strategies to navigate challenges effectively during the engagement phase. Reference the Crisis Plan on page 1 for specifics.
c. The HFW Facilitator or designee provides crucial information concerning the crisis plan, including how to access a 24/7 response service, ensuring support is readily available when needed. See the Crisis Plan on page 1 for further details.
3.3 Strengths, Needs, Culture and Vision Discovery
Throughout the engagement process, the HFW Facilitator takes the time to meet with the family, creating a safe space to discuss their inherent strengths, pressing needs, cultural values, and overarching family vision.
a. The HFW Facilitator collaborates with each family to co-create a compelling Family Vision, capturing their aspirations and dreams. For more details, refer to the Strengths-Needs-Culture-Discovery form on page 3.
b. Within 90 days of the family’s entry into the program, the HFW Facilitator diligently develops a comprehensive plan that encompasses the family’s strengths, needs, cultural context, and broader vision. More information can be found in the Strengths-Needs-Culture-Discovery form on page 5.
3.4 Engage All Team Members
During the engagement phase, the HFW Facilitator undertakes the important task of completing the Natural Supports Inventory. This process involves a collaborative effort among the youth, their family, and HFW team members to evaluate and identify natural supports within their networks and determine which can actively contribute to the team process.
a. Each youth and family is given a tailored Natural Supports Inventory by the HFW Facilitator, designed to include all relevant supports. Refer to the Natural Supports Inventory on page 1 for specifics.
b. In this collaborative setting, the HFW Facilitator identifies key partners from the Children’s System of Care to be included on the HFW team. More details can be found in the Natural Supports Inventory on page 1.
c. The HFW Facilitator carefully identifies potential team members and delineates their respective roles, ensuring clarity and purpose. See the Natural Supports Inventory on page 1 for additional information.
d. The HFW Facilitator meticulously documents all team-building activities, promoting transparency and cohesion within the group. Detailed records are available in the Wraparound Team Minutes on page 1.
3.5 Arrange Meeting Logistics
Meetings are scheduled with careful consideration of the availability and circumstances of both the youth and their families. Casa Esperanza prioritizes flexibility, encouraging its HFW staff to adapt their working hours, including evenings or weekends, to facilitate participation from both youth and families during these crucial meetings.
a. The HFW staff acknowledge their responsibility for maintaining flexibility in their working hours and practices. Comprehensive insights are available in the Facilitator Job Description on page 1.
b. All HFW staff undergo training that equips them with effective strategies to interact flexibly with the youth and families, ensuring inclusivity and accessibility. Refer to the Training Curriculum on page 1 for detailed information.
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
Before formulating the HFW Plan of Care, it is essential to complete a series of collaborative tasks, including team agreements, a comprehensive inventory of team strengths, and a clear mission statement, in partnership with each family. These documents are meticulously recorded in the youth’s file, ensuring that every family member’s unique strengths identified during the engagement process are accurately reflected and updated as further strengths emerge.
a. The HFW Facilitator takes the lead in creating the team agreements, strengths inventory, and mission statement in collaboration with each youth and their family. For detailed guidance, refer to the Team Strengths Inventory, Team Agreement Form, and Team Mission Statement, all found on page
b. Throughout the HFW process, the HFW Facilitator remains vigilant in updating the strengths of the youth and family, as recorded in the Team Strengths Inventory on page 1.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
In the lead-up to crafting the HFW Plan of Care, it is crucial to identify, articulate, and prioritize the underlying needs specific to each family. These identified needs are documented in the youth’s file. From these needs, measurable goals and outcomes are derived, emphasizing a strength-based rather than a deficit-focused approach to goal setting.
a. The HFW Facilitator is responsible for elucidating the underlying needs of the youth and family, using the Strengths-Needs-Culture-Discovery Form found on page 3 as a resource.
b. Measurable goals and outcomes are anchored in the recognized needs of the youth and family, as outlined on page 1 of the Measurable Goals and Outcomes Form.
c. Engaging the entire HFW team in the goal-setting process is a pivotal aspect of the approach, as documented in the Measurable Goals and Outcomes Form on page 1.
d. The HFW Facilitator conducts brainstorming sessions designed to foster creativity and collaboration in identifying impactful goals and outcomes, as noted in the Wraparound Team Minutes on page 1.
e. To enhance the team’s skills in Needs Focused Planning, the HFW Fidelity Coach provides targeted training, detailed in the Training Curriculum on page 1.
f. The development of the Plan of Care is inherently a team-based effort, fostering input and collaboration as documented in the Wraparound Team Minutes on page 1.
4.3 Develop an Individualized Child or Youth and Family Plan
The Plan of Care is a comprehensive document that intricately weaves together the goals and objectives outlined by team members, ensuring it is tailored to the specific needs of the youth and family. This plan is meticulously documented in the youth’s file, circulated to all team members, and adheres to established effectiveness criteria.
a. The HFW Fidelity Coach provides training and coaching on effective team engagement to strengthen the collaborative process, as referenced in the Coach Observation notes on page 2 and the Training Curriculum on page 1.
b. The HFW Facilitator ensures that the goals and objectives align with the standards set forth by the Children’s System of Care, which is documented in the Plan of Care on page 1.
c. A complete version of the Plan of Care, encompassing all requisite elements, is shared with team members, referenced through the Plan of Care on page 1 and the Strengths-Needs-Culture-Discovery Form on page 5.
d. To maintain a high standard of care, the HFW Manager Supervisor conducts monthly audits of the chart for updates to the Plan of Care, as outlined in the HFW Chart Audit on page 1.
4.4 Develop a Crisis and Safety Plan
To prepare for potential challenges, individualized Crisis and Safety Plans are crafted and documented in the youth’s file. These plans are designed to specifically address safety concerns, identify high-risk situations, and outline crises, alongside proactive and reactive strategies selected collaboratively with family members. Importantly, the plans include clear guidance on who to contact for 24/7 support.
a. The development of the Crisis and Safety Plan is undertaken by the HFW Facilitator or their designee, based on insights gleaned from the initial Crisis Plan, as indicated in the Crisis and Safety Plan on page 1.
b. Input and feedback from the HFW team play a crucial role in crafting this plan, ensuring it reflects the collective knowledge and perspectives of all members, as documented in the Crisis and Safety Plan on page 1.
c. To ensure ongoing relevance and effectiveness, the HFW Facilitator reviews the Crisis and Safety Plan monthly or as necessary, affirming its adaptability to the family’s evolving needs, as noted in the Crisis and Safety Plan on page 1.
Implementation
5.1 Implement The Plan of Care
The HFW Facilitator plays a pivotal role in guiding the team’s execution of the Plan of Care, ensuring that every component is realized effectively. Once the Plan of Care receives thorough review and approval, and each team member has been provided with their individual copies, the HFW Facilitator diligently monitors the various assignments and action items that emerge from this comprehensive plan.
a. The HFW Facilitator creates a collaborative environment where team members can engage in thoughtful discussions about the strategies outlined in the Plan of Care. This includes facilitating modifications to action items when necessary, as detailed in the Wraparound Team Minutes, page 1.
b. Training sessions led by the HFW Fidelity Coach equip the team with the knowledge and skills required to implement and adapt the Plan of Care effectively, ensuring that everyone is aligned and prepared for their roles, as illustrated in the Training Curriculum, page 1.
5.2 Review and Update The Plan of Care
In a structured team meeting, the HFW team dedicates time to a thorough review of the Plan of Care, which encompasses evaluating strategies, assessing progress, and addressing action items. The HFW Facilitator plays a critical role in identifying emerging needs during this collaborative session, making necessary adjustments to the Plan of Care, and developing new strategies and action items to address them.
a. During these meetings, the HFW Facilitator meticulously reviews strategies, progress, and action plans, ensuring that all team members are informed and engaged, as recorded in the Wraparound Team Minutes, page 1.
b. The HFW Facilitator takes the lead in adapting the plan to meet newly identified needs and acknowledges when established goals have been successfully achieved, as documented in the Wraparound Team Minutes, page 1.
c. A record of task completions and newly assigned responsibilities is meticulously maintained by the HFW Facilitator, ensuring accountability and clarity, as seen in the Wraparound Team Minutes, page 1.
d. To accommodate changing circumstances, the HFW Facilitator updates necessary forms, ensuring they align with the current needs of the team, as noted in the Wraparound Team Minutes, page 1.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
The HFW Facilitator actively fosters a sense of unity and trust within the team by consistently utilizing team agreements throughout all phases of the HFW process. These agreements are regularly revisited with team members to incorporate necessary updates and are prominently presented during team meetings.
a. The team agreements serve as a foundational tool at HFW Team Meetings, reinforcing shared values and expectations, as referred to in the Team Agreement Form, page 1.
b. The HFW Fidelity Coach provides effective training on building high-functioning teams, equipping team members with the skills to enhance collaboration and cohesion, as described in the Training Curriculum, pages 3 and 4.
c. The HFW Facilitator closely monitors the engagement and involvement of natural supports, ensuring that they are effectively integrated into the team process and documented in the Natural Supports Inventory, page 1.
d. To support the onboarding of new members, the HFW Facilitator utilizes the Orientation Format, ensuring that all newcomers are fully informed and integrated into the HFW process, as detailed in the Orientation Format, page 1.
Transition
6.1 Develop a Transition Plan
The High-Fidelity Wraparound (HFW) team, consisting of the youth, family members, and a blend of formal and informal support systems, collaborates to assess whether the youth and family have successfully met the goals outlined in the HFW Plan of Care. This assessment is grounded in specific benchmarks and indicators that the youth and family previously identified and agreed upon within the Plan of Care.
a. The HFW Facilitator meticulously utilizes these established benchmarks from the Plan of Care to evaluate the readiness of the youth and family for transition; consult the Plan of Care on page 2 for detailed reference.
b. Drawing on insights from the family and the youth’s ongoing needs post-program, the HFW Facilitator crafts a comprehensive Transition Plan; see Transition Plan on page 1 for specifics.
c. During a collaborative team meeting, the HFW Facilitator takes the lead in establishing the Transition Plan, ensuring that input from all team members is actively integrated; please refer to the Wraparound Team Minutes on page 1 for additional context.
d. The HFW Facilitator is responsible for identifying specific services and supports that have been verified as available to the youth and family following their transition out of the program; detailed information can be found in the Transition Plan on page 1.
6.2 Develop a Post-Transition Safety Plan
The existing Crisis and Safety Plan, originally constructed during the HFW process, will serve as a robust foundation for the HFW Facilitator to modify and adapt according to the evolving needs of the youth and family both during and after the transition. If necessary, a new Crisis and Safety Plan may be developed to address these needs better.
a. The HFW Facilitator or a designated team member will update the existing Crisis and Safety Plan to accurately reflect any new requirements or contacts; for a detailed outline, refer to the Crisis and Safety Plan on page 1.
b. The HFW Facilitator or designee will engage in a collaborative effort to develop or modify the Crisis and Safety Plan during team meetings, gathering valuable insights and contributions from all team members involved; see Wraparound Team Minutes on page 1 for further details.
c. Utilizing the Team Meeting as an important platform, the HFW Facilitator or designee will conduct a thorough review of the Crisis and Safety Plan with the youth, family, and team members to ensure collective understanding and collaboration; consult the Wraparound Team Minutes on page 1 for a recap of discussions.
6.3 Create a Commencement and Celebrate Success
The transitions experienced by youth and families mark significant milestones in their journey, signifying profound progress. Throughout their involvement in the HFW process, these individuals have reached noteworthy goals that deserve thoughtful acknowledgment and celebration.
a. The HFW Facilitator will utilize the Commencement and Celebration of Success framework to engage with the family, openly discussing their envisioned approach to celebrating these accomplishments; see the Commencement and Celebration of Success Plan on page 1 for guidance.
b. To ensure a fitting tribute to their journey, the HFW Facilitator actively involves staff and team members to align with the family’s needs while planning the celebration; refer to the Commencement and Celebration of Success Plan on page 1 for further instructions.
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
In our dedicated quest to enhance the well-being of our community, Casa Esperanza is excited to announce the establishment of a vibrant and engaging advisory board for the Healing Families and Youth (HFW) program. This board will comprise enthusiastic volunteers, including youth and their families who have either completed the HFW process or are currently navigating it.
a. The HFW Manager Supervisor will orchestrate regular advisory group meetings, fostering a collaborative environment to gather invaluable insights and perspectives from families; please refer to the Advisory Group Agenda on page 1.
b. These advisory group meetings will serve as pivotal opportunities for the HFW Manager Supervisor to solicit constructive feedback from families regarding the decision-making process, aiming to refine and enhance our services, workforce implementation, and policy frameworks; additional details can be found in the Advisory Group Agenda, page 1.
7.2 Community Leadership Team
In a crucial role within our organization, the HFW Manager, Supervisor, or an appointed representative will serve as a vital liaison on the HFW Community Leadership Team.
a. The HFW Manager-Supervisor, or designated representative will actively participate in Community Leadership Meetings; for a more detailed overview, refer to the Manager-Supervisor Job Description on page 2.
7.3 Eligibility and Equal Access
At Casa Esperanza, we recognize the significance of having a well-equipped and resourceful HFW team that is more than capable of delivering exceptional services to all youth and their families transitioning from the Short-Term Residential Therapeutic Program (STRTP).
a. The HFW Manager Supervisor conducts thorough evaluations of each youth and family to assess their eligibility, ensuring that we accept individuals regardless of the severity or nature of their needs; specifics can be referenced in the Eligibility Criteria on page 2.
b. Furthermore, the HFW Manager Supervisor is committed to staffing the organization with an adequate and skilled team, ensuring that we provide the appropriate intensity and frequency of services needed to support our families effectively; see the Organizational Chart on page 1 for additional information.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
Our contracts are strategically designed to incorporate high-fidelity direct services and supports tailored to address the immediate, unique needs of both youth and their families. For further details, please refer to the Fiscal Supports Policy on page 1. These contracts also mandate comprehensive workforce development and staffing, delineating specific roles and functions critical to our mission (as outlined in the Fiscal Supports Policy on page 1). Furthermore, they emphasize the necessity of robust data collection and management systems to enhance service delivery.
a. The HFW Manager Supervisor diligently reviews all contracts to ensure that adequate funding is earmarked to support the diverse needs of youth and families, as highlighted in the Fiscal Supports Policy on page 1.
b. In an effort to foster a stable and effective environment for HFW activities, the HFW Manager Supervisor assesses contracts to guarantee sufficient hiring and retention of qualified staff, in accordance with the guidelines outlined in the Fiscal Supports Policy on page 1.
c. Additionally, the HFW Manager Supervisor evaluates contracts to confirm that they allocate necessary resources for data collection and management systems, as referenced in the Fiscal Supports Policy on 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, specifically designated for the vulnerable youth and families served by Casa Esperanza, represent a vital and flexible component of the program’s financial framework.
a. The HFW Manager Supervisor is tasked with the careful allocation of flex funds, ensuring that resources are distributed in a manner that meets the needs of those we serve; refer to the Fiscal Supports Policy on pages 1-2 for more information.
b. To facilitate the effective utilization of these funds, the HFW Manager Supervisor undertakes the responsibility of training staff on the processes involved in disbursing flex funds and maintaining accurate documentation, as detailed in the Fiscal Supports Policy on pages 1-2.
8.5 Collaborative Oversight of Flex Funds
The overall approval process for all flex fund requests falls under the meticulous oversight of the HFW Manager Supervisor.
a. The HFW Manager Supervisor guarantees that each flex fund request is thoroughly documented, maintaining transparency and accountability, as outlined in the Fiscal Supports Policy on page 2.
b. In a bid to ensure equitable access, the HFW Manager Supervisor manages the flex funds as a collective pool, making them available to all families in need, as emphasized in the Fiscal Supports Policy on page 2.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
In a concerted effort to uphold the accessibility of flex funds for every family, the Executive Director collaborates closely with the HFW Manager and Supervisor.
a. Together, they conduct a thorough review of the program’s funding and, when necessary, actively seek to secure additional flex funds to address any shortfall, as outlined in the Fiscal Supports Policy on pages 2-3.
b. Should they encounter any funding constraints, the Executive Director and HFW Manager Supervisor proactively reach out to the Community Leadership Team and their county liaison to explore solutions, as detailed in the Fiscal Supports Policy on pages 2-3.
c. Through their joint efforts, the Executive Director and HFW Manager Supervisor ensure that sufficient flex funds remain accessible to all families, fostering a supportive environment for those we serve, as specified in the Fiscal Supports Policy on pages 2-3.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
At Casa Esperanza, the Executive Director diligently compiles extensive statistical data, providing insightful profiles of the youth residing at the facility. This framework serves as the foundation for cultivating a workforce that reflects the diverse demographics of the clients it serves.
a. The HFW Manager Supervisor plays a vital role in ensuring that our staff composition reflects the rich tapestry of the community’s demographics; refer to the Workforce Development and Human Resource Management Policy and Procedures, page 1, for more details.
b. When necessary, the HFW Manager Supervisor actively identifies and utilizes natural community supports to enhance cultural representation, reinforcing the values outlined in the Workforce Development and Human Resource Management Policy and Procedures, page 1.
c. Recognizing the importance of clear communication, the HFW Manager Supervisor also provides essential translation services to bridge any language barriers, as detailed in the Workforce Development and Human Resource Management Policy and Procedures, page 1.
9.2 Tribally Responsive Workforce
At Casa Esperanza, the HFW staff participates in specialized training focused on the Indian Child Welfare Act (ICWA). This training not only enhances their understanding of legal frameworks but also deepens their appreciation for Native American culture and heritage.
a. The HFW Manager Supervisor organizes comprehensive staff training sessions focused on the Indian Child Welfare Act, as outlined in the Workforce Development and Human Resource Management Policy and Procedures, page 2.
b. In a commitment to culturally inclusive practices, the HFW Facilitator actively reaches out to local tribal partnerships and representatives, fostering collaborative engagements that weave together traditions and ceremonies into the HFW process; see Workforce Development and Human Resource Management Policy and Procedures, page 2, for further information.
9.3 Flexible and Creative Work Environment
The HFW program embraces a “Whatever It Takes” philosophy, emphasizing adaptability to meet the unique needs of each youth and their families. This innovative approach allows for creativity and flexibility in service delivery.
a. To uphold high standards of program quality, the Fidelity Coach provides in-depth training focused on methods of continuous improvement; see Training Curriculum, pages 4-6.
b. Additionally, the Fidelity Coach facilitates training on building Cohesion within teams; see Training Curriculum, pages 4-6 for more insights.
c. Open Communication is another crucial focal point of the training provided by the Fidelity Coach; see Training Curriculum, pages 4-6.
d. Lastly, trainings on Mission Alignment and Compliance with HFW Philosophy ensure that all staff members are oriented towards a shared vision; refer to Training Curriculum, pages 4-6 for details.
9.4 Hiring, Performance Evaluation, and Job Descriptions
To maintain an exceptional standard of care and professionalism, every employee participates in a thorough 90-day performance evaluation. This assessment is crucial in determining whether staff members meet the evolving expectations and basic requirements of their positions.
a. The HFW program boasts uniquely defined roles, complete with clear descriptions and responsibilities; refer to the HFW Manager Supervisor Job Description, pages 1-2, for more information.
b. Job descriptions within the HFW framework detail the purpose, functions, and key qualities expected of each role; further specifics can be found in the HFW Facilitator Job Description, pages 1-2.
c. Following state guidelines, the HFW job descriptions are tailored specifically to the needs of the HFW program; see HFW Family Specialist Job Description, pages 1-2, for further reference.
d. The HFW Manager Supervisor provides valuable opportunities for staff to showcase their skills, as indicated in the Workforce Development and Human Resource Management Policy and Procedures, pages 3-4.
e. Ongoing feedback on performance is a regular practice, ensuring constructive dialogue between the HFW Manager, Supervisor, and team members, as emphasized in the Workforce Development and Human Resource Management Policy and Procedures, page 5.
9.5 Workforce Stability
The Human Resources Department at Casa Esperanza is dedicated to building a robust, stable workforce by providing essential resources that enhance overall effectiveness.
a. To ensure competitive compensation, the HFW Manager Supervisor aligns wages with the cost of living and comparable agency salaries within the community, as detailed in the Workforce Development and Human Resource Management Policy and Procedures, page 6.
b. The HFW Manager Supervisor ensures that staffing levels are adequate to manage workloads effectively, promoting a balanced and supportive work environment as illustrated in the Organizational Chart, page 1.
c. Opportunities for professional growth, promotions, and advancement are actively announced, affirming a clear pathway for career development; see the Workforce Development and Human Resource Management Policy and Procedures, page 6.
d. Furthermore, the HFW Manager Supervisor offers avenues for leadership development and wage increases that do not necessitate a job change, fostering sustained employee engagement and satisfaction, as outlined in the Workforce Development and Human Resource Management Policy and Procedures, page 6.
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 has a crucial role in supervising data collection and reporting initiatives at Casa Esperanza, ensuring that program practices are both effective and transparent.
a. Utilizing insights from outcomes data, the HFW Manager Supervisor will proactively implement strategies to enhance service delivery, as detailed in the Treatment Tracker, Outcomes Tracker tab.
b. By analyzing data from the Outcomes Tracker, the HFW Manager Supervisor is equipped to identify any program deficits and take swift action to enhance program performance, whether through additional training or adjustments to existing procedures; further information can be found in the Treatment Tracker, Outcomes Tracker tab.
c. The HFW Manager Supervisor will harness data from the Outcomes Tracker to pinpoint systemic issues and convey these insights to the Community Leadership Team, fostering a culture of continuous improvement and accountability, as referenced in the Treatment Tracker, Outcomes Tracker tab.
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)
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) Other funding is regularly explored with families including scholarships, reduced rates, natural supports, and unrestricted funds available through the agency.
C) There are no funding source requirements that a family accesses that would prohibit their ability to also access flex funds.
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. 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
(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 family engagement meeting, the Wraparound Facilitator along with Wraparound team members- Parent Partner, Clinician, and Child family Specialist meet with the family and guides a discussion on Family Goals, wherein the client and family are 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 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)
(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 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). The 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).
(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.
(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)
(b) Development of the Safety Plan is initially created by the Wraparound team at the onset of treatment. It is then constantly updated and revised during Child and Family Team Meetings occur (Wraparound Policy, policy 10, page 25)
(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, p 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: surveys_DMH family-English, Survey_DMH youth-English). 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
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
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 outcomes measures (i.e.: CANS) to identify individualized strengths, prioritize and track client’s goals and projected outcomes. Planning: 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. 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.
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) Clinicians utilize the CANS to identify, prioritize, and track treatment goals and outcomes; CANS data informs planning and service delivery. 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
d) Transition is a formal Wraparound phase focused on preparing the family for conclusion of services through individualized transition planning and celebration of success; exits require planned transition support. 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
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) Tools are utilized to monitor quality of services and provide feedback to the HFW team 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 ProceduresProgram Monitoring (Policy 20) p.42 Chart Review Audit Tool, Masada’s Consumer Satisfaction Surveys
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. See Masada Admission Procedure-INTAKE-Wrap
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 engages in activities to promote a positive and collaborative CFT culture. Child and Family Engagement and Team Preparation – This step focuses on engaging the family and build ownership, emphasizing family voice and choice, addressing and planning for non-negotiables and focusing on safety, using the Quality Service Review (QSR) table to reflect on practice, promoting cross system collaboration, and identifying and following up with team members. Specifically, the HFW Facilitator and other team members prepare the family for the CFTM. They explain the team process, show and review the CFTM Agenda. 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
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) 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. See County of Los Angeles Department of Mental Health Child Welfare Division-Wraparound Program Policies and Procedures, Criteria and Target Population pg5
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
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
Vista del Mar is committed to timely engagement of youth and families, initiating first contact as soon as possible and no later than 10 calendar days, including Tribal outreach when applicable. HFW teams complete the Plan of Care within 30 calendar days, review it at least every 30–45 days, and update it as needed. The Plan of Care is distributed to all team members at least every 90 days or more frequently when changes occur. Vista del Mar shall use recognized fidelity tools (e.g., Wraparound Fidelity Index, Team Observation Measure, document review) to monitor adherence to HFW standards.
Supporting Documentation:
o DMH Policy and Procedure Manual, p. 7
o DMH Policy and Procedure Manual, p. 34
o DMH Policy and Procedure Manual, p. 21
o Case Review Questionnaire; Facilitator Training Binder, p.19
o Facilitator Training Binder, p.166; HFW Persistence Policy
1.2 Led by Youth and Families
Vista del Mar ensures Family Voice and Choice by centering youth and families as primary decision-makers in the Wraparound process. Facilitators actively honor each family’s values, culture, strengths, and preferences, using their input to guide planning and problem-solving. When serving an Indian child, the Tribe is engaged as an equal partner, and the voices of the youth, family, and Tribe are prioritized in all decisions.
(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) (Facilitator Training Binder, p.36)
(b) Family values, culture, expertise, capabilities, interests and skills are elicited and clearly documented in the youth’s case file (Facilitator Training Binder, p. 183)
(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. (Family Facilitator Supervisor Job Description, 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. At Vista del Mar, we uphold the Outcome Based Principle of Wrapround by tying the needs and strategies to observable and measurable indicators of success and eliciting feedback from families during the CFT meetings. (Facilitator Training Binder, p. 37).
Observable and measurable indicators of success and eliciting feedback from families during the CFT meetings. (Facilitator Training Binder, p. 37).
1.3 Strength-Based
Vista del Mar upholds the Strength-Based principle by identifying and building upon the functional strengths of youth, families, team members, and their communities. Strengths are documented through engagement and the IP-CANS assessment and are used to guide decision-making, strategy development, and service planning. Teams maintain a solution-focused approach, using strengths as the foundation for promoting resilience, progress, and positive outcomes.
(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. VDM’s HFW teams inventory the child and families’ strengths and community resources in the Plan of Care, which is posted and reviewed at each CFT meeting, and updated as needed. (Family Meeting Worksheet, Facilitator Training Binder, p.170)
(b) The identification of individualized strengths must include, but not be limited to, the strengths identified in the CANS (DMH Policy and Procedure Manual, p.15)
(c) Staff receive ongoing coaching and training in providing strengths-based, solution-focused services. Utilizing a strengths-based approach is integral to the work we do at Vista del Mar. HFW employees are trained and coached to understand their work with families through strength-based lens. The word strengths appear 76 times in our Facilitator Training Binder! We formally review strengths using the CANS and informally coach to strengths throughout our work with families. (Facilitator Training Binder, pgs. 24-25, 75, 160.)
(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. VDM’s HFW program conducts routine Caregiver and Youth or Child Satisfaction Surveys reviews the outcomes to understand trends and adjust service delivery, as need ed. (DMH Policy and Procedure Manual, p.42)
1.4 Needs Driven
Vista del Mar ensures services are driven by the identification and understanding of the youth’s and family’s underlying needs. Needs are identified through every stage of the Wraparound process in collaboration with the team and family, including using the IP-CANS assessment. Identified needs reflect the root causes of challenges rather than symptoms alone. These needs guide planning and service delivery, and the Wraparound process continues until priority needs are adequately addressed.
(a) Underlying needs are identified and prioritized before goals and strategies are established for the youth and family. All HFW employees take the Underlying Needs; A strengths/needs based service crafting approach, which reviews how to identify underlying needs and instructs staff to identify underlying needs as the first step, before creating goals or strategies. (Facilitator Training Binder, p. 11)
(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. HFW Staff receive individualized supervision and group supervision to receive coaching in addition they engage in monthly problem solving during Case Reviews. (Family Facilitator Job Description, p. 1; Case Review Questionnaire.)
(c) The identification of individualized needs must include, but not be limited to, the needs identified in the IP-CANS. Needs are identified early on in the engagement and throughout the Wraparound Process, routinely reviewed in the CFT meetings. (LA County DMH CFT Policy, Facilitator Training Binder, pgs. 21-23)
(d) Transition is planned according to team and family agreement that needs are sufficiently met. Each stage of Wrapround is reviewed and planned during the CFT process. Teams review the stages as outlined in the Wraparound Process User’s Guide (Facilitator Training Binder, p. 45).
1.5 Individualized
Vista del Mar ensures services are individualized by developing creative, customized strategies that reflect each youth and family’s unique needs, strengths, values, culture, and preferences. Plans of Care are tailored to the family and incorporate natural supports, community resources, and informal networks. When serving an Indian child, the Tribe is engaged as a key partner in planning and support.
(a) Forms/documentation allow for sufficient flexibility in creating individualized plans for each child/youth and family. Documents have flexibility within their structure. For example, items such as preferred names or pronouns are not fixed and can be updated to meet the needs of the client. (Facilitator Training Binder, p. 183-188)
(b) Staff receive ongoing training and coaching in providing flexible, creative, and highly individualized services and strategies. All HFW staff are required to take Child and Family Team Agenda and Planning Matrix, which instructs staff on how to create individualized services and strategies (Facilitator Training Binder, p. 14) and staff receive individualized supervision, group supervision (Family Facilitator Job Description) and review cases routinely during Case Reviews for coaching and guidance. (Case Review Questionnaire)
(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. All HFW staff are required to take Child and Family Team Agenda and Planning Matrix, which instructs staff on how to create individualized services and strategies (Facilitator Training Binder, p. 14) and staff receive individualized supervision, group supervision (Family Facilitator Job Description) and review cases routinely during Case Reviews for coaching and guidance. (Case Review Questionnaire.)
(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. HFW teams review cases routinely during Case Reviews to ensure that family’s needs are being met in a strength-based, individualized way. (Case Review Questionnaire.)
(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. VDM’s HFW program conducts routine Caregiver and Youth or Child Satisfaction Surveys and reviews the outcomes to understand trends and adjust service delivery, as needed. (DMH Policy and Procedure Manual, p.42.)
1.6 Use of Natural and Community Based Supports
Vista del Mar prioritizes the use of natural and community-based supports as essential partners in the Wraparound process. Facilitators actively engage individuals identified by the family and incorporate community resources into the Plan of Care. Strategies emphasize strengthening natural supports to promote long-term stability and reduce reliance on formal services and are routinely reviewed in CFT meetings.
(a) A natural and community supports inventory is developed and updated for every family. (Facilitator Training Binder, p.36.)
(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. (Case Review Questionnaire, 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. (Case Review Questionnaire, p.1.)
(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. (DMH Policy and Procedure Manual, p.42.)
1.7 Culturally Respectful and Relevant
Vista del Mar provides culturally respectful and relevant services by honoring each family’s traditions, values, and heritage as strengths. Facilitators ensure strategies and supports reflect the family’s cultural identity and connect families to culturally relevant community resources. When serving an Indian child, the Tribe is engaged as an essential partner throughout the Wraparound process and transition planning.
(a) A strength, 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. (Facilitator Training Binder, p.71.)
(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. (Case Review Questionnaire, p.1.)
(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. (DMH Policy and Procedure Manual, p.42.)
1.8 High-Quality Team Planning and Problem Solving
Vista del Mar ensures high-quality team planning and problem solving through the CFT process by convening teams of formal and natural supports who collaborate to develop, implement, and monitor individualized Plans of Care. Team members share responsibility for action steps and work together to address identified needs. Facilitators promote an environment of collaboration, shared ownership, and optimism to support positive outcomes for youth and families.
(a) Team agreements are created for each HFW team and documented in the youth’s file. (Team Agreement)
(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.). (DMH Policy and Procedure Manual, p.42.)
(c) This feedback is used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes. (HFW Persistence Policy, p.2.)
(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. (Case Review Questionnaire, p.1.)
1.9 Outcomes Based Process
Vista del Mar ensures services are outcomes-based by routinely monitoring progress toward identified needs, strategy implementation, and action step completion. Facilitators use measurable outcomes and data, including the IP-CANS, to guide team review and decision-making. The Plan of Care is updated as needed to reflect progress and ensure strategies remain effective and responsive to the youth and family.
(a) The HFW plan of care includes specific, measurable strategies and action items with timeframes. (Facilitator Training Binder, p.186.)
(b) Action item completion is tracked by facilitators and updated at HFW team meetings, or more often as needed. (Facilitator Training Binder, p.14.)
(c) Forms and processes allow strategies and action items to be adjusted or changed as needed. These changes are communicated to all team members. (Facilitator Training Binder, p.186.)
(d) Vista’s policy is for Clinical Supervisors or Program Managers to complete the IP-CANS with team members then the team reviews the IP-CANS with client & caregivers. (Facilitator Training Binder, p.134 – 137.)
(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. (Facilitator Training Binder, p.134 – 137.)
1.10 Persistence
Vista del Mar upholds the principle of persistence by viewing setbacks as opportunities to strengthen and revise the Plan of Care rather than reasons to end services. Facilitators support teams in identifying new strategies and maintaining engagement, even when progress is limited, or system barriers exist. Services continue until the youth’s and family’s priority needs are addressed and sustainable supports are in place.
(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. ( HFW Persistence Policy, p1.)
(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. (HFW Persistence Policy, p1.)
(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. (HFW Persistence Policy, p2.)
1.11 Transitions as a part of the Fourth Phase of HFW
Vista del Mar ensures transitions are thoughtfully planned and guided by the youth and family, with preparation occurring throughout the Wraparound process. Transition occurs only when priority needs have been met and sustainable supports are in place, not due to administrative timelines or adverse events. Facilitators support teams in celebrating progress and ensuring continuity of care within the family’s natural and community supports.
(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. (Facilitator Training Binder, p.45.)
(b) Transitions out HFW are celebrated according to the child or 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. (Facilitator Training Binder, p.45.)
Expected Outcomes
2.1 Youth and Family Satisfaction
Vista del Mar maintains comprehensive policies, procedures, and data monitoring processes to routinely evaluate the effectiveness and fidelity of its High Fidelity Wraparound (HFW) program in alignment with Standard 10.2 Evaluation Metrics and Outcomes. Program effectiveness is assessed through multiple methods, including regular completion and review of the IP-CANS to measure needs and strengths, structured documentation review, and supervisory oversight to ensure fidelity to Wraparound principles and timely implementation of Plans of Care.
Vista del Mar also gathers qualitative and quantitative feedback through family and team satisfaction surveys, quality assurance phone calls, and post-meeting feedback to assess engagement, team collaboration, and family voice and choice. Fidelity tools such as the Wraparound Fidelity Index (WFI), Team Observation Measure (TOM), and Document Assessment Review Tool (DART) may be used, as applicable, to evaluate adherence to Wraparound standards and inform coaching and quality improvement. Vista del Mar will finalize which fidelity tools will be implemented once we receive guidance from the Los Angeles County Department of Mental Health.
Supervisors and fidelity coaches review outcome data, service timelines, and team functioning through routine supervision, case consultation, and program-level quality assurance reviews. Findings are used to guide continuous quality improvement, including staff training, coaching, and program development. These processes ensure that services remain effective, individualized, culturally responsive, and aligned with the needs and outcomes of youth and families served.
2.1 Youth and Family Satisfaction
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. At Vista del Mar, we uphold the Outcome Based Principle of Wrapround by eliciting feedback from families. VDM’s HFW program conducts routine Caregiver and Youth or Child Satisfaction Surveys, reviews the outcomes to understand trends and adjust service delivery, as needed. Finally, outcome measures are tracked by the Quality Assurance Department and quarterly reports are shared with the program managers to view trends, find areas of need for coaching and quality improvement.
Supporting Documentation:
o DMH Policy and Procedure Manual, p.42
2.2 Improved School Functioning
School behavior, achievement and functioning are routinely assessed through the completion of the IP-CANS, and in collaboration with the caregivers during the CFT process through collection of grade and attendance reports, when indicated. The Clinical Supervisor conducts the CANS. The Facilitator tracks the CANS to ensure that it is completed at intake, every 6 months and at termination Monthly Case Reviews are also held and review school functioning. Case reviews are facilitated by Managers and Clinical Supervisors with the HFW team, to provide feedback on fidelity to the HFW model and strength-based coaching to the staff. Finally, CANS data is reviewed quarterly by the Quality Improvement Committee. Reports are shared with the program managers to view trends, find areas of need for coaching and quality improvement.
Supporting Documentation:
o Facilitator Training Binder, p.227-228
o IP-CANS Questions 16, 17, 18 & 34
o Facilitator Training Binder, p. 134-137
o Case Review Questionnaire
o QIC Guidelines pg. 11 & 18
2.3 Improved Functioning in the Community
Functioning in the community is routinely assessed through the completion of the IP-CANS and in collaboration with the caregivers during the CFT process. Monthly Case Reviews are also held and review how the client is functioning in the community. Case reviews are facilitated by Managers and Clinical Supervisors with the HFW team, to provide feedback on fidelity to the HFW model and strength-based coaching to the staff. Finally, CANS data is tracked by the Quality Assurance Department and quarterly reports are shared with the program managers to view trends, find areas of need for coaching and quality improvement.
Supporting Documentation:
o Facilitator Training Binder, p.227-228, IP-CANS, Questions 12, 14, 15 & 38
o Case Review Questionnaire
o QIC Guidelines pg. 11 & 18
2.4 Improved Interpersonal Functioning
Interpersonal functioning is routinely assessed through the completion of the IP-CANS and in collaboration with the caregivers during the CFT process. Monthly Case Reviews are also held and review interpersonal functioning. Case reviews are facilitated by Managers and Clinical Supervisors with the HFW team, to provide feedback on fidelity to the HFW model and strength-based coaching to the staff. Finally, CANS data is tracked by the Quality Assurance Department and quarterly reports are shared with the program managers to view trends, find areas of need for coaching and quality improvement.
Supporting Documentation:
o Facilitator Training Binder, p.227-228
o IP-CANS Questions 10, 12, 14, 15, 33 & 39
o Case Review Questionnaire
o QIC Guidelines pg. 11 & 18
2.5 Increased Caregiver Confidence
Caregiver confidence is routinely assessed through the completion of the IP-CANS, and in collaboration with the caregivers during the CFT process. Monthly Case Reviews are also held and review caregivers’ strengths, needs and overall confidence. Case reviews are facilitated by Managers and Clinical Supervisors with the HFW team, to provide feedback on fidelity to the HFW model and strength-based coaching to the staff. Finally, CANS data is tracked by the Quality Assurance Department and quarterly reports are shared with the program managers to view trends, find areas of need for coaching and quality improvement.
Supporting Documentation:
o Facilitator Training Binder, p.227-228
o IP-CANS, Questions 41a – 45a
o Case Review Questionnaire
o QIC Guidelines pg. 11 & 18
2.6 Stable and Least Restrictive Living Environment
The HFW Team is committed to family reunification and/or placement in the least restrictive environment (contract?). Placement is reviewed during Case Reviews (Case Review Questionnaire). Case reviews are facilitated by Managers and Clinical Supervisors with the HFW team, to provide feedback on fidelity to the HFW model and strength-based coaching to the staff.
Supporting Documentation:
o Case Review Questionnaire
o QIC Guidelines pg. 11 – 12
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
At Vista del Mar, we uphold the Outcome Based Principle of Wrapround by collecting and analyzing outcome data, including inpatient hospitalizations and/or emergency room visits for behavior health needs. VDM uses the Special Incident Report to document behavioral health admissions to the emergency room or hospitals. Data is reviewed in the Quality Improvement Committee meetings and reports are shared with program managers to view trends, find areas of need for coaching and quality improvement.
Supporting Documentation:
o QIC Guidelines pg. 11 – 12
o Facilitator Training Binder pg. 264
2.8 Reduction in Crisis Visits
At Vista del Mar, we uphold the Outcome Based Principle of Wrapround by collecting and analyzing outcome data, including use of the On-Call support team for in person Crisis Visits. VDM uses the On-Call Log Sheet to document client and family utilization of the On-Call support team. Data is reviewed in the Quality Improvement Committee meetings and reports are shared with program managers to view trends, find areas of need for coaching and quality improvement.
Supporting Documentation:
o QIC Guidelines pg. 15
o Wraparound On-call Policy & Procedures pg. 1 – 5
2.9 Positive Exit from HFW
At Vista del Mar, we uphold the Outcome Based Principle of Wrapround by eliciting feedback from families. Feedback from families is elicited at the time of graduation or when clients and families exit from the Wraparound program. VDM’s HFW program conducts an exit interview with the caregiver and youth or child. In addition, the Caregiver and Youth or Child Satisfaction Surveys are completed routinely and at the end of the program (DMH Policy and Procedure Manual, p.42). Finally, outcome measures are tracked by the Quality Assurance Department and quarterly reports are shared with the program managers to view trends, find areas of need for coaching and quality improvement.
Supporting Documentation:
o DMH Policy and Procedure Manual, p.42
o QIC Guidelines pg. 11 & 18
Engagement
3.1 Orientation
3. Engagement
Vista del Mar operationalizes the Four Phases of High Fidelity Wraparound—Engagement, Plan Development, Implementation, and Transition—through clear policies, procedures, supervision, and documentation standards that guide direct service delivery with youth, families, and Tribes when applicable.
During Engagement, facilitators prioritize timely outreach, family voice and choice, cultural humility, and strengths and needs identification, including Tribal engagement for Indian children. In Plan Development, teams create individualized Plans of Care grounded in underlying needs, measurable outcomes, natural supports, and IP-CANS data. During Implementation, teams meet regularly to monitor progress, track action steps, revise strategies, and maintain persistence despite challenges. In Transition, planning begins early, with teams ensuring needs are met, sustainable supports are in place, and transitions are family-driven and celebrated.
Supervision, fidelity review tools, documentation monitoring, and ongoing training ensure consistent practice across all four phases, supporting high-quality, culturally responsive Wraparound services that reflect HFW principles and improve outcomes for youth and families.
3.1 Orientation.
Vista del Mar ensures that youth and families receive a clear orientation to the High Fidelity Wraparound process, including an overview of the HFW principles and phases, team member roles, and the importance of family voice, natural supports, and collaboration. Facilitators review legal and ethical considerations and, when serving an Indian child, engage the Tribe as an equal partner and explain its role within the Wraparound team.
Procedures Ensure:
(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. (Facilitator Training Binder, pg. 74-80)
At a minimum the explanation provided to the family includes:
(b) an overview of the principles and phases (Facilitator Training Binder, pg. 36-37 & 41)
(c) legal and ethical considerations (Facilitator Training Binder, pg. 75 & 183)
(d) the role of each team member including the family and natural supports and Tribes in the case of an Indian child (Facilitator Training Binder, pg. 21-28)
3.2 Safety and Crisis stabilization
Vista del Mar ensures that urgent needs are addressed promptly so youth and families can fully engage in the Wraparound process. Facilitators coordinate immediate interventions as needed, develop written crisis and safety plans with the team, and ensure families have access to our 24/7, On Call Crisis Response Team.
Procedures Ensure:
(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. (Facilitator Training Binder, pg. 175)
(b) The crisis plan is used to inform, but not replace, the HFW Safety Plan developed during the Plan Development phase. (Facilitator Training Binder, pg. 175)
(c) All families are provided with information regarding how to access 24/7 crisis response when needed. (Facilitator Training Binder, pg. 74)
3.3 Strengths, Needs, Culture and Vision Discovery
The HFW team facilitates intentional conversations with youth and families to identify strengths, underlying needs, and each family’s unique culture, values, and vision for the future. Vista del Mar honors and celebrates the individuality of every family’s cultural background and lived experience, ensuring these perspectives guide planning and support strategies. Facilitators prepare a written summary to share with all team members, orient new participants, and inform development of the initial Plan of Care.
Procedures Ensure:
(a) A Family Vision is completed with every family and documented in the youth’s chart during the Engagement phase. (Facilitator Training Binder, pg. 175)
(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. (Facilitator Training Binder, pg. 21)
3.4 Engage All Team Members
The HFW team actively engages formal and natural supports across all Children’s System of Care partners—and Tribes when serving an Indian child—to build a strong, collaborative team around the youth and family. Facilitators clarify roles, encourage shared responsibility, and use structured activities to promote respectful communication, positive team culture, and meaningful participation from all members.
Procedures Ensure:
(a) A natural supports inventory is completed with all youth and families and is documented in the child or youth’s case file. (Facilitator Training Binder, pg. 36, 79, 170-171 & 253)
(b) Children’s System of Care partners who should be included on the HFW team are identified and engaged. (Facilitator Training Binder, pg. 22 & 39)
(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. (Facilitator Training Binder, pg. 153)
(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). (Facilitator Training Binder, pg. 18 & 173-176)
3.5 Arrange Meeting Logistics
The Vista del Mar HFW team schedules Wraparound meetings at times and locations that prioritize family voice and choice and are accessible to all team members. Facilitators consider family schedules, culture, and trauma history, and coordinate needed supports—such as transportation, interpretation, childcare, or telehealth—to ensure equitable participation for youth and families.
Procedures Ensure:
(a) Staff are flexible in working hours and scheduling meeting times and locations to accommodate family and HFW team needs. (Facilitator Training Binder, pg. 36)
(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. (Facilitator Training Binder, pg. 67)
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
Vista del Mar facilitators guide teams to develop and document team agreements, identify additional strengths, and create a shared mission statement aligned with the family’s vision. Agreements clarify respectful communication and decision-making, strengths from youth, family, team members, and community are recorded, and the team mission is documented in the Plan of Care to guide collaboration and accountability.
Procedures Ensure:
(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.
(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.
Supporting Documentation:
o Facilitator Training Binder, pg. 14, 36-40 & 43
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
Vista del Mar facilitators lead their teams in reviewing and prioritizing identified underlying needs, ensuring family voice and choice guide the discussion. The team develops specific, measurable goals linked to those needs, then engages in structured brainstorming to generate multiple creative strategies. Selected strategies are translated into clear action steps with assigned responsibilities and timelines, documented in the Plan of Care.
Procedures Ensure:
(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.
(b) Measurable goals and outcomes are developed from these identified needs (as opposed to behavior or deficit-based goal development)
(c) These goals and outcomes are developed collaboratively with the youth, family, and the rest of the HFW team.
(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.
(e) Facilitators are trained to lead teams in identifying, prioritizing, and selecting strategies and developing action items.
(f) These steps are utilized to develop the individualized HFW Plan of Care in a team-based, collaborative environment.
Supporting Documentation:
o Facilitator Training Binder, pg. 14, 36-40, 43 & 183
4.3 Develop an Individualized Child or Youth and Family Plan
Vista del Mar facilitators lead the development of a comprehensive, individualized Plan of Care grounded in the family’s vision, team mission, strengths, needs, and culture. Through a collaborative team process—including all relevant system partners and Tribes when applicable—the team prioritizes needs across life domains and develops clearly documented strategies and action steps with assigned responsibilities and timelines. Plans emphasize culturally relevant supports, coordinated services, and increasing reliance on natural and community resources over time. Transition planning is integrated from the outset, with benchmarks that support gradual movement toward less formal supports at a pace aligned with family readiness.
Procedures Ensure:
(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.
(b) The Plan of Care comprehensively integrates goals and objectives identified by all Children’s System of Care partners. (SOC link https://www.chhs.ca.gov/home/system-of-care/)
(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)
(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.
Supporting Documentation:
o Facilitator Training Binder, pg. 14, 36-40 & 43
o Case Review Questionnaire
4.4 Develop a Crisis and Safety Plan
Vista del Mar facilitators guide the team in creating a written crisis and safety plan that identifies safety needs, potential risks, and individualized proactive and reactive strategies. The facilitator ensures youth and family voice and choice guide strategy selection, that plans are culturally relevant, and that natural supports are included whenever possible, with roles and response steps clearly documented and shared with all team members.
Procedures Ensure:
(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.
(b) The development of the plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process.
(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.
Supporting Documentation:
o Facilitator Training Binder, pg. 14, 36-40, 42-43, 238, 249 & 253
o Case Review Questionnaire
Implementation
5.1 Implement The Plan of Care
Vista del Mar HFW teams implement the Plan of Care by tracking action steps, reviewing progress toward needs and outcomes at each team meeting, and updating strategies as needed in alignment with Wraparound principles. Teams recognize and celebrate successes with youth and families to reinforce strengths, motivation, and continued engagement.
Procedures Ensure:
(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.
(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.
Supporting Documents:
o Facilitator Training Binder, pg. 14, 21-22 & 40
5.2 Review and Update The Plan of Care
Vista del Mar facilitators lead regular team reviews of the Plan of Care to assess progress, evaluate strategy effectiveness, and revise goals or actions as youth and family needs change. Facilitators document meeting outcomes, task completion, attendance, use of natural supports and flex funds, and communicate updates to all team members. The Plan of Care is updated in team meetings and shared at least every 90 days, or more often as needed.
Procedures Ensure:
(a) Reviews of strategies, progress, and action items occurs in a HFW team meeting setting.
(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.
(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.
(d) Forms are able to be updated and individualized to meet the youth, family, and team’s changing needs.
Supporting Documents:
o Facilitator Training Binder, pg. 44, 183-188 & 206-211
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
Vista del Mar facilitators regularly check in with team members to strengthen trust, clarify roles, and address barriers to collaboration. Facilitators help identify and engage additional natural supports identified by the family and ensure all new members are oriented to the Wraparound process, team agreements, and Plan of Care to support strong, cohesive teamwork.
Procedures Ensure:
(a) Team agreements are utilized, reviewed regularly, and present at HFW team Meetings.
(b) Facilitators receive ongoing training and coaching on building, engaging, and maintaining effective teams.
(c) Use of natural supports are monitored over time and teams are provided feedback through coaching and supervision.
(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.
Supporting Documentation:
o Team Agreement
o Case Review Questionnaire
o Facilitator Training Binder, pg. 11
Transition
6.1 Develop a Transition Plan
Vista del Mar facilitators initiate transition planning when agreed-upon benchmarks are met and the youth, family, and team determine readiness. The facilitator leads the team in creating a written, individualized transition plan outlining ongoing needs, services, and natural supports that will remain after formal Wraparound ends. Responsibilities are gradually shifted from HFW staff to sustainable supports, and adoptive families using Adoption Assistance Program (AAP) funding are educated about available post-adoptive services to ensure continuity of care.
Procedures Ensure:
(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.
(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.
(c) The development of the individualized transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process.
(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.
Supporting Documentation:
o Facilitator Training Binder, pg. 45 & 183
6.2 Develop a Post-Transition Safety Plan
Vista del Mar facilitators guide the team in developing or revising a crisis and safety plan prior to transition. The plan identifies potential post-transition risks and outlines culturally relevant, proactive and reactive strategies selected by the youth and family. Emphasis is placed on strengthening natural and community supports who will remain involved, ensuring clarity of roles and access to resources after HFW services conclude.
Procedures Ensure:
(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.
(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.
(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.
Supporting Documentation:
o Facilitator Training Binder, pg. 14, 38 &42
o Case Review Questionnaire
6.3 Create a Commencement and Celebrate Success
The Vista del Mar HFW teams celebrate successes throughout the Wraparound process as this is a core value of highlighting the family and client’s strengths and accomplishments. The team works alongside the family to plan a commencement that is meaningful to the family and client, culturally relevant and provides respect and recognition that the client and family deserve.
Procedures Ensure:
(a) Transitions out of the Wraparound process are celebrated according to the family’s culture, values, and preferences.
(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.).
Supporting Documentation:
o Facilitator Training Binder, pg. 45
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
Vista Del Mar Child and Family Services ensures that youth and families are meaningfully engaged as partners in High Fidelity Wraparound (HFW) service delivery and program improvement. Youth and family voice and choice are embedded in service planning through the Child and Family Team (CFT) process and reinforced through structured opportunities for feedback and participation.
Families are informed of their right to provide feedback regarding their experiences with HFW services, and participation is encouraged throughout engagement, implementation, and transition. These mechanisms support youth and family participation in decisions that impact service delivery and program quality.
Supporting Documentation
• Youth & Family Participation & Feedback Framework
Vista Del Mar routinely collects and uses youth and family feedback to inform service planning, service implementation, and continuous quality improvement. The HFW program administers regular Caregiver and Youth or Child Satisfaction Surveys and reviews aggregated results to identify trends, strengths, and areas for improvement. Survey findings are reviewed by program leadership and supervisory staff and are used to guide adjustments to service delivery, engagement strategies, and staff coaching as needed.
Vista Del Mar will implement additional fidelity and outcome measures, including the Wraparound Fidelity Index (WFI) and/or Team Observation Measure (TOM), as required and directed by Los Angeles County Department of Mental Health (LAC DMH). Implementation of these tools will align with County guidance to ensure consistency with countywide expectations and reporting requirements.
Supporting Documentation
• Youth and Family Participation & Feedback Framework
• Caregiver and Youth/Child Satisfaction Survey Process
• LA County DMH Wraparound Policy & Procedure Manual, Policy 20, p. 42
7.2 Community Leadership Team
Community Leadership Teams (CLTs) are established and convened by Los Angeles County Department of Mental Health (LAC DMH) to provide system level leadership and coordination for High Fidelity Wraparound. Vista Del Mar Child and Family Services participates in the CLT as a contracted HFW provider.
Vista Del Mar has designated the Director of Wraparound as the organization’s official representative to the Community Leadership Team. The representative participates in CLT meetings as convened by LAC DMH, provides provider level input, and communicates relevant information back to Vista Del Mar leadership and program staff to support alignment with countywide priorities and implementation guidance.
Supporting Documentation
• Community Leadership Team Participation Statement
7.3 Eligibility and Equal Access
Description of Practice
Vista Del Mar Child and Family Services provides High Fidelity Wraparound services in accordance with eligibility and referral requirements established by Los Angeles County Department of Mental Health (LAC DMH). Eligibility and referral processes are defined in the Children and Youth Full Service Partnership High Fidelity Wraparound Program Service Exhibit #1700.
Vista Del Mar does not exclude youth based on the severity or nature of their needs. Eligibility determinations are guided by County defined criteria and clinical decision making tools, including the Child and Adolescent Needs and Strengths (CANS) and Level of Care Utilization System (LOCUS), as applicable. Vista Del Mar implements County defined referral, outreach, engagement, enrollment, transfer, and disenrollment procedures to ensure equitable access to services.
Supporting Documentation
• Eligibility, Referral, and Equal Access Policy
• LAC DMH Program Service Exhibit #1700
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
The 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 of 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.
Procedures ensure contracts outline rates that reflect the inclusion of:
(a) High fidelity direct services and supports to meet the immediate individualized needs of youth and families. LACDMH Contract for HFW services is still pending.
(b) Required workforce development and staffing including required roles or functions from Workforce Development standard 9.3. LACDMH Contract for HFW services is still pending.
(c) Required data collection and/or data management systems.
Vista Del Mar maintains established data collection and data management processes to support High Fidelity Wraparound operations and contract reporting requirements. Program and outcome data are collected through standard program workflows and compiled for reporting and quality monitoring. Vista Del Mar uses Power BI dashboards to manage, analyze, and report key data elements across programs, including required outcome measures.
Outcome data reviewed through the organization’s CQI process and is reviewed at least quarterly through the Quality Improvement Committee using Power BI to monitor trends, assess performance, and inform improvement actions. Data processes are designed to support timely reporting, internal monitoring, and continuous quality improvement.
Supporting Documentation
o VDM Data Collection & Data Management System Overview
o Vista Del Mar Continuous Quality Improvement Plan
8.2 Equitable Funding Across System Partners
The HFW Program must ensure that federal, state, local, or private resources available across the Children’s System of Care are leveraged to the maximum extent to meet the needs of youth and families served by HFW so that the service is funded adequately. Collaboration and equitable contribution across systems partners are principles of HFW services. Medi-Cal may be leveraged for youth who are eligible.
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.
Vista del Mar maintains a structured process to review, approve, and monitor the use of flexible funds in alignment with High Fidelity Wraparound principles and Los Angeles County Department of Mental Health (LACDMH) guidelines. Structures are in place to ensure youth and families participating in High Fidelity Wraparound (HFW) have timely access to flexible funds to meet urgent and individualized needs when those needs cannot be met through existing services or resources. Flexible funds are used to support individualized strategies identified by the HFW team and documented in the Plan of Care.
Supporting Documents
o DMH Policy and Procedure Manual, Policy #27, p. 52 (Flex Funds/CRSS)
o Wraparound Flex Fund Procedure
8.5 Collaborative Oversight of Flex Funds
Vista del Mar maintains collaborative oversight of flexible funds through clear tracking, transparent reporting, and coordination with funding partners. Flexible fund requests—whether approved or denied—are documented to include the amount requested, purpose, and the HFW team’s recommendation. Funds are pooled and managed centrally to ensure equitable availability for all families served. Program leadership monitors utilization and regularly communicates fund availability and usage trends with funders and system partners to ensure responsible stewardship and alignment with Wraparound principles.
Supporting Documents
o DMH Policy and Procedure Manual, Policy #27, p. 55 (Flex Funds/CRSS)
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
Vista del Mar’s HFW will work with LACDMH who ensures the requirements of any single funding source (e.g., BHSA, Title IV-E, CalWORKs, etc.) 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.
Supporting Documents
o DMH Policy and Procedure Manual, Policy #27, p. 52 (Flex Funds/CRSS)
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
Vista Del Mar Child and Family Services monitors the demographic composition of the youth and families served and uses this information to guide culturally responsive recruitment and hiring practices. The organization’s mission, values, and explicit commitment to equity establish a foundation for employment practices that promote racial, cultural, and linguistic representation while ensuring equal opportunity and non discrimination.
Program leadership reviews available demographic information regarding the populations served and collaborates with Human Resources to identify workforce needs and recruitment priorities. Recruitment strategies include community based outreach and internal referrals designed to attract candidates who reflect the diversity of the communities served. Vista Del Mar’s Referral Incentive Payment Program further supports recruitment of qualified and culturally diverse candidates. All hiring, promotion, and compensation decisions are made in alignment with Equal Employment Opportunity and non discrimination policies outlined in the Employee Handbook.
Supporting Documentation
• Culturally Responsive Workforce & Recruitment Plan, pp. 1–3
• Vista Del Mar Child and Family Services Employee Handbook:
o Mission, Values, and Commitment to Equity, pp. 8–9
o Discrimination, Harassment, and Retaliation Free Workplace, pp. 9–10
o Referral Incentive Payment Program, p. 43
9.1(b) Alternative strategies for cultural representation when staff matching is not possible
Description of Practice
When it is not possible to assign a staff member who directly matches a family’s cultural, racial, or linguistic background, Vista Del Mar implements alternative strategies to ensure culturally responsive support. Youth and families are engaged as equal partners in identifying culturally relevant supports that align with their values, traditions, and preferences.
Alternative strategies may include engaging family identified natural supports, culturally relevant community based or formal service providers, and consultation with culturally knowledgeable staff or supervisors. These strategies are incorporated into service planning and team processes in a manner consistent with Vista Del Mar’s mission, values, and standards for respectful client relations. Use of alternative cultural representation strategies is documented as appropriate, and staff utilize supervision and consultation to ensure fidelity to culturally responsive practices.
Supporting Documentation
• Cultural Representation & Support Procedures, pp. 1–2
• Vista Del Mar Employee Handbook:
o Mission, Values, and Commitment to Equity, pp. 8–9
o Client Relations, p. 34
9.1(c) Language access and interpretation
Description of Practice
Vista Del Mar ensures meaningful access to services for youth and families with limited English proficiency or language needs. Language needs are identified during referral, intake, engagement, and ongoing service delivery and are documented in the case record or service documentation.
When staff who speak the family’s primary language are not available, Vista Del Mar utilizes professional interpretation services, qualified bilingual staff, or family identified natural supports when appropriate and with family consent. Interpretation services are provided in a manner that maintains confidentiality, dignity, and respect. Staff are trained to avoid reliance on children or youth as interpreters and to ensure that families fully understand information shared throughout the Wraparound process. These practices are consistent with Vista Del Mar’s non discrimination and reasonable accommodation policies.
Supporting Documentation
• Language Access and Interpretation Policy, pp. 1–2
• Vista Del Mar Employee Handbook:
o Discrimination, Harassment, and Retaliation Free Workplace, pp. 9–10
9.2 Tribally Responsive Workforce
Vista del Mar ensures a tribally responsive workforce by providing staff training on tribal sovereignty, traditions, values, and culturally respectful communication and collaboration. When serving an Indian child, facilitators actively partner with tribal representatives, honor the Tribe as an equal voice on the team, and support youth and families in accessing tribal traditions, ceremonies, and culturally rooted services. These practices promote positive outcomes through meaningful integration of Tribal supports and advocacy grounded in respect and sovereignty.
Supporting Documents:
o Los Angeles County Department of Mental Health Training Policy Draft – Policy #6, Page 2
9.3 Flexible and Creative Work Environment
Vista del Mar fosters a flexible and creative work environment by promoting shared responsibility for program quality, staff cohesion, and fidelity to High Fidelity Wraparound principles. Leadership engages staff in continuous quality improvement through regular supervision, team meetings, fidelity reviews, and data-informed discussions. Managers cultivate a positive and collaborative team culture, encourage open communication across roles, and provide structured opportunities for feedback and innovation. Ongoing training and reflective supervision reinforce a clear mission and alignment with HFW values, principles, phases, and activities.
Supporting Documentation:
(a) QIC Guidelines, p. 3
(b) Facilitator Supervisor Job Description, Overall Function Section
(c) Facilitator Job Description, Facilitator Supervisor Job Description, #4 Collaboration & Communication, #5 Equity & Inclusion.
9.4 Hiring, Performance Evaluation, and Job Descriptions
Vista del Mar ensures the High Fidelity Wraparound workforce standards are met through structured hiring practices, clearly defined role expectations, and ongoing performance management aligned with HFW principles.
Vista maintains clearly written HFW-specific job descriptions for all required roles or functions. Roles are fulfilled through distinct positions and, in some cases, thoughtfully combined positions, with responsibilities explicitly defined to prevent role confusion and ensure all required functions are met. Each job description outlines the role’s purpose, core functions, and required competencies, including Wraparound values, family engagement skills, cultural humility, collaboration, and strengths-based practice.
Hiring processes are rigorous and competency based. Candidates participate in structured interviews and practical exercises (e.g., scenario responses, role plays, case discussions) designed to assess skills in engagement, facilitation, conflict resolution, teamwork, and alignment with HFW philosophy.
Once hired, staff receive clear performance expectations tied to fidelity standards, documentation quality, collaboration, and outcomes. Employees participate in regular supervision, coaching, and formal performance evaluations that include meaningful feedback, professional development planning, and corrective action when necessary. This structured approach ensures role clarity, workforce competency, and ongoing alignment with HFW best practices.
Supporting Documentation
• Vista Del Mar Employee Handbook:
o Performance Evaluation, p. 40
o Family Facilitator Job Description
o Vista del Mar is working closely with the Los Angeles County Department of Mental Health (LACDMH) to align our job descriptions with their contract requirements. We have included the current Family Facilitator Job Description for reference to our agency values and the standards that we believe will remain constant during the delivery of HFW services. We will wait for further guidance from LACDMH to finalize the job descriptions for the HFW team.
9.5 Workforce Stability
9.5(a) Matching wages to cost of living in the service area
Description of Practice
Vista Del Mar Child and Family Services implements structured compensation practices to ensure wages are aligned with job responsibilities, professional norms, and labor market conditions in the communities served. Job descriptions are formally evaluated based on required skills, responsibility, effort, and working conditions, and are placed into appropriate salary ranges that reflect education, experience, and professional standards.
Compensation practices are reviewed and managed through Human Resources to support equitable pay and workforce retention. Salary determinations and adjustments are informed by role expectations, internal equity, and market considerations, which supports Vista Del Mar’s ability to recruit and retain qualified staff while remaining responsive to cost of living considerations in the service area.
Supporting Documentation
• Vista Del Mar Employee Handbook:
o Salary Evaluation, p. 17
9.5 (b) Maintaining manageable workloads for staff
Description of Practice
Vista del Mar ensures that HFW caseloads are flexible to meet the needs of the families and clients being served. VDM will also adhere to the recommended ratios put forth by Los Angeles County Department of Mental Health and CDSS.
Supporting Documentation:
DMH Policy and Procedure Manual
9.5(c) Clearly communicated and accessible promotion / advancement structures
Description of Practice
Vista Del Mar maintains clearly defined and accessible promotion and advancement structures that support workforce stability and professional growth. The organization prioritizes internal promotion when possible and posts open positions to ensure transparency and equitable access. Employees are encouraged to pursue advancement opportunities based on demonstrated competencies, experience, and performance rather than formal credentials alone.
Promotion and transfer processes are documented and standardized, including eligibility criteria, application requirements, and supervisory approvals. Performance evaluations are conducted on an ongoing and annual basis to provide staff with clear expectations, feedback, and guidance related to professional development and advancement opportunities. These structures are designed to be inclusive and not prohibitive for staff with lived experience.
Supporting Documentation
• Vista Del Mar Employee Handbook:
o Promotions, pp. 39–40
o Performance Evaluation, p. 40
9.5(d) Wage increases or leadership opportunities that do not require a position change
Description of Practice
Vista Del Mar supports workforce stability by providing opportunities for professional growth, skill development, and leadership that do not require employees to leave their current role. Compensation structures account for skill, responsibility, and experience, and performance evaluations are used to recognize growth and increased contribution over time.
In addition, Vista Del Mar invests in employee development through training, conference attendance, and reimbursement for licensure and certification costs. These opportunities allow staff to deepen expertise, assume informal leadership or mentoring functions, and increase professional value while remaining in their existing positions. This approach supports retention and acknowledges professional advancement without requiring a formal position change.
Supporting Documentation
• Vista Del Mar Employee Handbook:
o Salary Evaluation, p. 17
o Performance Evaluation, p. 40
o Conference, Training, and License Certification, pp. 22–23
9.6 High Fidelity Training Plan
Vista del Mar maintains a comprehensive High Fidelity Wraparound training plan that includes onboarding, annual refresher, booster, and ongoing skill-based trainings. The plan provides core HFW training for all staff and role-specific training for Youth Partners, Parent Partners, Facilitators, Family Specialists, Fidelity Coaches, Clinical Supervisors, and Supervisors/Managers. Training also includes ICWA and Tribal sovereignty, cultural humility, and specialized content to support populations with unique or complex needs. Participation is tracked and reinforced through supervision, and coaching, to ensure sustained fidelity to HFW principles and practice.
Procedures Ensure:
(a) All staff receive an initial HFW training using one of three options (select option that applies to your organization):
Select Option: Vista del Mar selects option one. HFW staff are trained externally by attending the Statewide Standardized Foundational HFW training through the UC Davis RCFFP.
(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.
(c) All staff receive booster trainings at least annually in general Wraparound and in their specific roles.
(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.
(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.
Supporting Documentation for b-e:
o Los Angeles County Department of Mental Health Training Policy Draft
9.7 Community-based Training Program
Vista del Mar administers its High Fidelity Wraparound training plan in partnership with Los Angeles County Department of Mental Health. At Vista del Mar, we value the input and voices of youth, families, and peer partners who have lived Wraparound experience. Once the county provides guidelines, Vista del Mar will work with LA County so that individuals with lived Wraparound experience are meaningfully involved as co-trainers, panelists, and advisors to ensure training reflects authentic family voice and practical application of HFW principles.
Supporting Documentation
Vista del Mar is waiting for the LA County has requested information regarding the creation of this committee and subsequent guidance. Vista del Mar will follow LA County Department of Mental Health guidelines regarding Sections 9.7 – Community-based Training Program (a) and (b).
9.8 Coaching and Supervision
Vista del Mar provides structured initial apprenticeship for all HFW staff, covering Wraparound values, principles, phases, activities, and appropriate use of flex funds. Staff receive ongoing reflective supervision, fidelity coaching, and case consultation to reinforce high-quality practice. Leadership ensures access to supervisory support and consultation 24/7 to address crises and urgent needs, consistent with the flexible and responsive nature of Wraparound services.
Supporting Documentation:
(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.
o Facilitator Job Description, p. 2 “On the Job Training”
o Facilitator Training Binder pgs. 5-9
o Wraparound On Call Policies & Procedures, p. 3
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
Vista Del Mar maintains an established Continuous Quality Improvement (CQI) process through its Quality Improvement Committee. The Committee routinely reviews demographic, fidelity, and outcome data to monitor program quality and effectiveness. Outcome data reviewed include Child and Adolescent Needs and Strengths (CANS) and Pediatric Symptom Checklist (PSC) measures, which are reviewed at least quarterly as part of the CQI process.
Supporting Documentation for Section 10.1, #s 1-3:
o Vista Del Mar Continuous Quality Improvement Plan (attached)
o Quality Improvement Committee Guidelines (attached)
Regarding County Procedures, Vista del Mar will collaborate with LACDHM CQI protocols pending guidance from the updated contract. Currently, VDM HFW teams follow the guidance from the LACDMH Wraparound Policy & Procedure Manual.
10.2 Evaluation Metrics & Outcomes
Data reviewed through the CQI process is used to inform program practice, supervision, and quality improvement efforts. Quarterly review of CANS and PSC outcome data by the Quality Improvement Committee supports identification of trends, informs coaching and training priorities, and guides program level improvement activities.
Supporting Documentation for Section 10.2 a-c:
o Vista Del Mar Continuous Quality Improvement Plan
o Quality Improvement Committee Guidelines
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 and 26.
(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:
(1) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 1.1 p. 3.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 4.1.3 and
Program Manual Appendix 3 Section 2.3-2.3.4 p. 4-5..
(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 4.1.10.1 p. 29-31 and Program Manual Appendix 2 p. 52-57 and 37.
(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.
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.
(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.
(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.
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.
(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.
(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 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 Wellnest has not yet received contract rates from the Los Angeles County Department of mental Health or the Department of Health Care Services of that reflect contract rates.
(a) Wellnest Emotional Health and Wellness is waiting for further guidance from the Los Angeles County Department of mental Health or the Department of Health Care Services on contract rates for high fidelity direct services and supports to meet the immediate individualized needs of youth and families.
(b) Wellnest Emotional Health and Wellness is waiting for further guidance from the Los Angeles County Department of mental Health or the Department of Health Care Services on contract rates for required workforce development and staffing.
(c) Wellnest Emotional Health and Wellness is waiting for further guidance from the Los Angeles County Department of mental Health or the Department of Health Care Services on contract rates for required data collection and/or 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
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.
(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.
(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.
(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.
(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
Program Manual Appendix 45.
(2) Attachment 1 (Wellnest Emotional Health and Wellness High-Fidelity Wrapround Program Manual) Section 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 p. 83-85.
Fidelity Indicators
1.1 Timely Engagement and Planning
At Smiles and Tears Children and Family Services, we firmly prioritize effective engagement by adhering to California’s High-Fidelity Wraparound (HFW) fidelity indicators, which guide our interactions with families and enhance the overall coherence of our organization. This commitment is reflected through a structured set of processes and comprehensive documentation:
a. The HFW Manager-Supervisor meticulously oversees the initial contact following a referral, as delineated in the Treatment Tracker on page 1. This ensures that families receive prompt support from the outset.
b. The completion of the Plan of Care is a critical milestone monitored by the HFW Manager-Supervisor; this documentation, referenced in the Treatment Tracker, serves to confirm that families possess a clear and actionable plan.
c. Regular reviews of the Plan of Care during team meetings are documented by the HFW Manager-Supervisor, ensuring that all team members remain aligned and actively engaged in the youth’s care process (see Treatment Tracker, page 1).
d. Updates to the Plan of Care are systematically tracked by the HFW Manager-Supervisor, reinforcing our commitment to adapt to the evolving needs of each family (see Treatment Tracker, page 1).
e. To foster transparency and collaboration, the HFW Manager-Supervisor engages in weekly discussions regarding the Treatment Tracker with staff and supervisors; these discussions reference Treatment Tracker, page 1.
f. Our dedicated staff members receive specialized training from the Fidelity Coach, focusing on impactful engagement and team-building exercises designed to enhance interpersonal connections; details are available in Engagement and Team Building Activities, pages 1-2.
1.2 Led by Youth and Families
We believe that the effective implementation of the HFW model hinges on integrating family perspectives that honor their values, cultural backgrounds, and unique expertise. This input is actively solicited during meetings and visits, with comprehensive documentation maintained within the youth’s case file, evidenced by the following processes:
a. The HFW Facilitator actively solicits valuable insights from youth and families through the Strengths-Needs-Culture-Discovery Form, pages 1-2, ensuring their voices are central to the care process.
b. The HFW Facilitator diligently works to understand the family’s core values and perspectives, creating a holistic understanding of their needs as represented in the Strengths-Needs-Culture-Discovery Form, pages 2-3.
c. Observations made by the HFW Fidelity Coach during meetings are systematically documented to provide constructive feedback to staff, ensuring continual growth and adherence to best practices (see Coaching Observation Form, page 1).
d. Feedback from youth and families is collected through satisfaction surveys, overseen by the HFW Manager-Supervisor, allowing for the assessment of the effectiveness of our approaches and facilitating necessary adjustments (see Youth and Family Satisfaction Surveys, page 1).
1.3 Strength-Based
Our methodology is grounded in the belief that every individual possesses inherent strengths. The Manager leads the development of a strengths inventory form reflective of the unique strengths identified through the IP-CANS assessment.
a. The HFW Facilitator conducts a thorough strengths inventory for each team member, as recorded in the Team Strengths Inventory, page 1, fostering a culture of recognition and empowerment.
b. The HFW Family Specialist applies insights gained from the IP-CANS assessment to underscore the family’s strengths, as outlined on page 1 of the IP-CANS.
c. Staff members participate in specialized training that emphasizes solution-focused, strength-based methodologies; further details are available in our Training Curriculum, page 1.
d. The HFW Manager-Supervisor consistently collects feedback from the youth and family through satisfaction surveys, ensuring that our services effectively resonate with those we support (see Youth and Family Satisfaction Surveys, page 1).
1.4 Needs Driven
At Smiles and Tears Children and Family Services, we prioritize a needs-driven approach, using insights from the Strengths Inventory and the IP-CANS to identify and document families’ perceived needs collaboratively.
1. The HFW Facilitator utilizes the identified needs to set and prioritize objectives, as delineated in the Strengths-Needs-Culture-Discovery Form (page 3), ensuring a focused and effective strategy for support.
2. The HFW Fidelity Coach provides targeted training centered on needs-focused planning, which enhances the expertise of our staff (refer to Training Curriculum, page 1).
3. The HFW Facilitator meticulously reviews the documented needs from the IP-CANS (noted on page 1) to ensure these needs remain central to our planning efforts.
4. Transition planning is developed with precision based on feedback gathered during Team meetings, highlighting the importance of collaborative engagement (see Wraparound Team Meeting Template, page 1).
1.5 Individualized
We are committed to creating individualized plans that reflect the distinct circumstances and aspirations of each youth and their family.
1. The HFW Facilitator employs the Plan of Care to identify personalized strategies tailored to the unique needs of the youth and family (see Plan of Care, page 2).
2. Continuous training provided by the HFW Fidelity Coach emphasizes the implementation of flexible and individualized strategies to ensure responsiveness to family preferences (see Training Curriculum, page 1).
3. The HFW Fidelity Coach offers ongoing coaching to staff, reinforcing the significance of customizing the HFW process and the Plan of Care to foster a supportive environment (see Coaching Observation Form, page 1).
4. Monthly chart audits conducted by the HFW Clinical Supervisor rigorously assess the elements of the Plan of Care, upholding our standards of care and quality assurance (see HFW Chart Audit, page 1).
5. We consistently gather feedback from youth and families through satisfaction surveys, overseen by the HFW Manager-Supervisor, which underscores our commitment to continuous improvement and responsiveness (see Youth and Family Satisfaction Surveys, page 1).
1.6 Use of Natural and Community Based Supports
The HFW Manager-Supervisor plays a critical role in developing a comprehensive inventory of natural and community support resources available to families. This detailed catalog encompasses various types of support that families may currently utilize or may require over time, covering essential domains such as health, housing, recreation, financial assistance, nutrition, legal affairs, communication, spiritual needs, education, and other crucial life areas.
1. The HFW Facilitator is tasked with compiling and updating the support inventory for each family every month, documented through the Natural Supports Inventory Form, providing a clear overview of available resources.
2. To empower staff, the HFW Fidelity Coach offers specialized training focused on the engagement and integration of natural supports, as detailed in the Training Curriculum (page 2).
3. To maintain high standards of care, the HFW Clinical Supervisor conducts monthly chart audits to thoroughly review various elements of the Plan of Care, ensuring compliance with best practices (refer to the HFW Chart Audit on page 1 for further information).
4. The HFW Manager-Supervisor actively solicits feedback from youth and families through satisfaction surveys designed to capture their experiences and perspectives, facilitating ongoing improvements (see Youth and Family Satisfaction Surveys, page 1).
1.7 Culturally Respectful and Relevant
In developing a personalized Plan of Care, the HFW Facilitator collaborates closely with the youth and their family members to explore their distinct cultural perspectives. This in-depth dialogue covers various dimensions, including language, spirituality, religion, rituals, customs, dietary preferences, hobbies, traditions, beliefs, and values, ensuring that every aspect of their identity is respected.
a. The HFW Facilitator actively gathers information that captures the cultural perspectives of the youth and family, utilizing the Strengths-Needs-Culture-Discovery Form (page 3) to facilitate these discussions.
b. To enhance staff competencies, the HFW Fidelity Coach provides comprehensive training on effectively eliciting and integrating family and cultural insights into both planning and service delivery, as outlined in the Training Curriculum (page 2).
c. Continuous improvement is emphasized through feedback mechanisms, where the HFW Manager-Supervisor collects valuable input from youth and families via satisfaction surveys; please refer to the Youth and Family Satisfaction Surveys (page 1).
1.8 High-Quality Team Planning and Problem Solving
The team planning process is characterized by collaboration, as team agreements are developed in partnership with each youth and their family. The HFW Facilitator works closely with them, integrating feedback from the youth, their family, and their support network to create meaningful agreements.
a. As part of the engagement process, the HFW Facilitator formulates team agreements for each client’s HFW team, as documented in the Team Agreement form (page 1).
b. Feedback is critical for growth, and the HFW Manager-Supervisor gathers insights from youth and families through satisfaction surveys; see Youth and Family Satisfaction Surveys (page 1) for further details.
c. The HFW Manager-Supervisor also plays a vital role in providing monthly updates on family feedback to the staff, utilizing the CQI Indicators Form (page 1).
d. To uphold accountability and quality, the HFW Clinical Supervisor conducts thorough monthly chart audits, reviewing both the components of the Plan of Care and the minutes from team meetings; refer to the HFW Chart Audit (page 1).
1.9 Outcomes Based Process
Demonstrating a commitment to measurable progress, the Facilitator meticulously crafts a Plan of Care (POC) featuring clear, measurable, achievable, relevant, and time-bound strategies. To ensure accountability, action items are assigned to team members along with specific deadlines, which are systematically tracked in HFW meetings until full completion.
a. The HFW Facilitator incorporates quantifiable strategies, benchmarks, time-oriented results, and individual strengths into the Plan of Care, as exemplified on pages 2-3.
b. Weekly tracking of action items is standard practice for the HFW Facilitator, ensuring that progress is monitored, and necessary adjustments are made promptly; see the Plan of Care (pages 2-3) for further details.
c. The HFW Facilitator is empowered to adjust and tailor the Plan of Care form, adapting to any significant changes in circumstances, as noted on pages 2-3.
d. The HFW Family Specialist diligently completes the IP-CANS assessment and shares its findings during the team meeting; see IP-CANS (page 1) for details.
e. Information derived from the IP-CANS assessment is thoughtfully integrated into the Plan of Care to enhance its relevance; refer to the Plan of Care (pages 2-3) for further clarification.
1.10 Persistence
The HFW team remains committed to collaborating with youth and families, particularly in the face of setbacks or limited progress. The HFW Manager-Supervisor conducts weekly staff meetings to review the status and progress of each family, fostering a culture of accountability and support. For those experiencing challenges, the HFW staff performs a comprehensive analysis of the underlying causes and formulates actionable plans to address these barriers.
a. The HFW Fidelity Coach observes team dynamics and provides constructive feedback in response to challenges, utilizing insights collected in the Coaching Observation Form referenced on page 2.
b. To facilitate access to essential resources, the HFW Manager-Supervisor offers protocols for engaging with services that can assist families, as detailed in the Fidelity Indicators policy on page 4.
c. Staff training is paramount; the HFW Fidelity Coach equips team members with skills in safety planning, conflict resolution, and brainstorming techniques as outlined in the Training Curriculum on pages 2-3.
1.11 Transitions as a part of the Fourth Phase of HFW
Recognizing the importance of seamless transitions, HFW staff proactively work to prevent service disruptions. If a youth or family misses a meeting or activity, the HFW Family Specialist or HFW Parent Partner promptly reaches out to re-establish connection and reschedule, ensuring ongoing support.
a. The HFW team is dedicated to facilitating smooth transitions, characterized by warm hand-offs to ongoing service providers as described in the Transition Plan on page 1.
b. In collaboration with the active participation of the youth and family, the HFW team acknowledges successes through thoughtfully developed plans for recognition, as documented in the Commencement and Celebration of Success Plan on page 1.
Expected Outcomes
2.1 Youth and Family Satisfaction
The HFW Family Specialist will play a crucial role in collecting insights and feedback concerning the satisfaction levels of youth and their families. This data will be meticulously documented and reviewed in the Treatment Tracker (Tab 2), as outlined in the Expected Outcomes policy on page 1.
2.2 Improved School Functioning
The HFW Family Specialist bears the significant responsibility for tracking and assessing the functioning of youth in academic settings. Relevant data will be systematically accessible in the Treatment Tracker (Tab 2), along with the guidelines detailed in the Expected Outcomes policy on page 1.
2.3 Improved Functioning in the Community
Under the supervision of the HFW Manager-Supervisor, the HFW Facilitator and Family Specialist will diligently assess the engagement and functioning of youth in community settings. Comprehensive information pertinent to this assessment can be found in the Treatment Tracker (Tab 2), supplemented by the Expected Outcomes policy outlined on page 2.
2.4 Improved Interpersonal Functioning
The HFW Family Specialist will be responsible for gathering detailed information on interpersonal functioning using the IP-CANS assessment. Key data and documentation should be referenced in the Treatment Tracker (Tab 2) and in the directives specified in the Expected Outcomes policy on page 2.
2.5 Increased Caregiver Confidence
The HFW Family Specialist will actively collect insights reflecting increased caregiver confidence, a vital element in supporting youth. This information should be systematically cataloged in the Treatment Tracker (Tab 2), in conjunction with the guidelines detailed in the Expected Outcomes policy on page 2.
2.6 Stable and Least Restrictive Living Environment
The HFW Manager-Supervisor will conduct monthly monitoring and evaluation of the youth’s placement status to ensure it supports a stable, least restrictive living environment. Updates or changes regarding new placements will be promptly documented in the Treatment Tracker (Tab 2) and reinforced in the Expected Outcomes policy on page 3.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
To enhance the quality of care, the HFW Manager-Supervisor will meticulously track youth admissions to inpatient facilities monthly. This ongoing monitoring will be documented in the Treatment Tracker (Tab 2) and supported by the criteria outlined in the Expected Outcomes policy on page 3.
2.8 Reduction in Crisis Visits
The HFW Manager-Supervisor will consistently oversee and evaluate the frequency of crisis visits experienced by the youth, ensuring a proactive approach to crisis management. Insights into these visits can be found 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 will closely monitor the youth’s progress and transition dates to ensure a smooth and positive exit from the HFW program. This critical information about the exit process can be effectively tracked in the Treatment Tracker (Tab 2) and detailed in the Expected Outcomes policy on page 3.
Engagement
3.1 Orientation
When a youth joins the High-Fidelity Wraparound (HFW) program, both the youth and their family are introduced to the program through a detailed orientation. This session acts as a key introduction, highlighting the program’s main principles and important legal and ethical issues related to the family’s well-being. It also explains the roles of each team member, emphasizes the significance of natural supports, including tribal resources when relevant, and covers other vital aspects for a successful experience in the HFW program.
a. At the start of the engagement phase, the HFW Manager-Supervisor personally leads the orientation, explaining the core principles and stages of development in HFW. For detailed information, see the Orientation Format on pages 1-3.
b. During this initial phase, the Manager-Supervisor discusses the legal and ethical considerations relevant to HFW, with more details in the Orientation Format on pages 1-3.
c. For cases involving Indian children, the Manager-Supervisor provides additional orientation on specific team roles. Refer to the Orientation Format on pages 1-3 for comprehensive details.
3.2 Safety and Crisis stabilization
Considering that youths entering HFW may face various safety issues, such as potential runaway behavior, suicidal or homicidal thoughts, or other high-risk factors, a proactive crisis plan is developed before formal crisis and safety plans are put in place.
a. During the engagement phase, the HFW Facilitator or a designated team member discusses potential crisis and safety concerns openly, according to procedures outlined in the Crisis Plan on page 1.
b. The Facilitator or designee creates a thoughtful crisis plan that provides the youth and their family with essential resources and strategies to handle challenges effectively during engagement. Detailed guidance is available in the Crisis Plan on page 1.
c. The Facilitator or designee also shares key information about the crisis plan, including how to access 24/7 response services, ensuring support is always accessible when needed. See the Crisis Plan on page 1 for details.
3.3 Strengths, Needs, Culture and Vision Discovery
Throughout engagement, the Facilitator spends time with the family to create a safe environment to discuss their strengths, needs, cultural values, and family vision.
a. The Facilitator works with each family to collaboratively develop a compelling Family Vision that reflects their hopes and goals. For more information, see the Strengths-Needs-Culture-Discovery form on page 3.
b. Within 90 days of entering the program, the Facilitator prepares a detailed plan that includes the family’s strengths, needs, cultural background, and broader vision. More details can be found in the same form on page 5.
3.4 Engage All Team Members
During engagement, the Facilitator completes the Natural Supports Inventory, involving the youth, family, and team members to identify natural supports within their networks and determine their contribution potential.
a. Each youth and family receives a tailored Natural Supports Inventory from the Facilitator, covering all relevant supports, see page 1 for details.
b. The Facilitator identifies key partners from the Children’s System of Care to be part of the HFW team. More information is available in the Natural Supports Inventory on page 1.
c. The Facilitator carefully identifies potential team members and clarifies their roles to ensure clarity and purpose, details are in the Natural Supports Inventory on page 1.
d. All team-building activities are well documented by the Facilitator, promoting transparency and cohesion. Records can be found in the Wraparound Team Minutes on page 1.
3.5 Arrange Meeting Logistics
Meetings are scheduled thoughtfully, considering the availability of the youth and their families. Smiles and Tears Children and Family Services encourages flexibility, prompting staff to adapt hours, including evenings or weekends, to ensure participation.
a. Staff recognize their responsibility to remain flexible and adaptable, as detailed in the Facilitator Job Description on page 1.
b. All staff receive training in strategies for flexible and inclusive engagement with youth and families. More information is available in the Training Curriculum on page 1.
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
Before formulating the HFW Plan of Care, it is essential to engage in a series of collaborative tasks, including establishing team agreements, conducting a thorough inventory of team strengths, and formulating a clear mission statement, in partnership with each family. These documents are systematically recorded in the youth’s file to accurately reflect and update the unique strengths identified throughout the engagement process.
a. The HFW Facilitator will lead the development of team agreements, the strengths inventory, and the mission statement in collaboration with the youth and their family. For detailed guidance, please refer to the Team Strengths Inventory, Team Agreement Form, and Team Mission Statement found on page 1.
b. Throughout the HFW process, the HFW Facilitator will remain attentive to updating 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 the HFW Plan of Care, it is crucial to identify, articulate, and prioritize the underlying needs specific to each family. These identified needs will be documented in the youth’s file. From these needs, measurable goals and outcomes will be established, focusing on a strength-based rather than a deficit-focused approach.
a. The HFW Facilitator is tasked with elucidating the underlying needs of the youth and family, utilizing the Strengths-Needs-Culture-Discovery Form found on page 3 as a key resource.
b. The measurable goals and outcomes will be grounded in the recognized needs of the youth and family, as outlined on page 1 of the Measurable Goals and Outcomes Form.
c. Engaging the entire HFW team in the goal-setting process is a vital aspect of the approach, as documented in the Measurable Goals and Outcomes Form on page 1.
d. The HFW Facilitator will conduct brainstorming sessions aimed at fostering creativity and collaboration in the identification of impactful goals and outcomes, as noted in the Wraparound Team Minutes on page 1.
e. To enhance the team’s skills in Needs Focused Planning, the HFW Fidelity Coach will provide targeted training, detailed in the Training Curriculum on page 1.
f. The development of the Plan of Care will be a collaborative team-based effort, emphasizing input and cooperation as documented in the Wraparound Team Minutes on page 1.
4.3 Develop an Individualized Child or Youth and Family Plan
The Plan of Care is a comprehensive document that integrates the goals and objectives established by team members, ensuring it is tailored to the specific needs of the youth and family. This plan will be meticulously documented in the youth’s file and circulated to all team members, in accordance with established effectiveness criteria.
a. The HFW Fidelity Coach will provide training and coaching on effective team engagement to enhance the collaborative process, as referenced in the Coach Observation notes on page 2 and the Training Curriculum on page 1.
b. The HFW Facilitator will ensure that the goals and objectives align with the standards set forth by the Children’s System of Care, as detailed in the Plan of Care on page 1.
c. A complete version of the Plan of Care, including all requisite elements, will be shared with team members, as referenced in the Plan of Care on page 1 and the Strengths-Needs-Culture-Discovery Form on page 5.
d. To maintain high standards of care, the HFW Manager-Supervisor will conduct monthly audits of the chart for updates to the Plan of Care, as outlined in the HFW Chart Audit on page 1.
4.4 Develop a Crisis and Safety Plan
In preparation for potential challenges, individualized Crisis and Safety Plans will be developed and documented in the youth’s file. These plans are specifically designed to address safety concerns, identify high-risk situations, and outline crises while incorporating proactive and reactive strategies selected collaboratively with family members. Additionally, the plans will include clear guidance on who to contact for 24/7 support.
a. The development of the Crisis and Safety Plan will be conducted by the HFW Facilitator or a designated team member, based on insights from the initial Crisis Plan, as indicated in the Crisis and Safety Plan on page 1.
b. Input and feedback from the HFW team will be instrumental in crafting this plan, ensuring it reflects the collective knowledge and perspectives of all members, as documented in the Crisis and Safety Plan on page 1.
c. To ensure ongoing relevance and effectiveness, the HFW Facilitator will review the Crisis and Safety Plan monthly or as necessary, confirming its adaptability to the family’s evolving needs, as noted in the Crisis and Safety Plan on page 1.
Implementation
5.1 Implement The Plan of Care
The HFW Facilitator plays a critical role in overseeing the execution of the Plan of Care, ensuring that each component is implemented effectively. Following a comprehensive review and approval of the plan, and upon distributing individual copies to each team member, the HFW Facilitator diligently monitors the associated assignments and action items arising from this detailed plan.
a. The HFW Facilitator fosters a collaborative environment where team members can engage in substantive discussions regarding the strategies outlined in the Plan of Care. This process includes facilitating adjustments to action items as necessary, as documented in the Wraparound Team Minutes, page 1.
b. Training sessions conducted by the HFW Fidelity Coach provide the team with the knowledge and skills essential for effective implementation and adaptation of the Plan of Care. This training ensures that all members are aligned and prepared for their respective roles, as described in the Training Curriculum, page 1.
5.2 Review and Update The Plan of Care
During a structured team meeting, the HFW team conducts a comprehensive review of the Plan of Care. This includes evaluating strategies, assessing progress, and addressing action items. The HFW Facilitator plays a pivotal role in identifying emerging needs during this collaborative session, allowing for necessary adjustments to the Plan of Care and the development of new strategies and action items.
a. During these meetings, the HFW Facilitator thoroughly evaluates strategies, progress, and action plans, ensuring that all team members remain informed and engaged, as recorded in the Wraparound Team Minutes, page 1.
b. The HFW Facilitator takes the initiative in adapting the plan to accommodate newly identified needs and acknowledges achievements of established goals, as noted in the Wraparound Team Minutes, page 1.
c. A comprehensive record of task completions and newly assigned responsibilities is meticulously maintained by the HFW Facilitator, ensuring accountability and clarity, as outlined in the Wraparound Team Minutes, page 1.
d. To address changing circumstances, the HFW Facilitator updates necessary documentation, ensuring alignment with the current needs of the team, as referenced in the Wraparound Team Minutes, page 1.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
The HFW Facilitator actively promotes a sense of unity and trust within the team by consistently applying team agreements throughout all phases of the HFW process. These agreements are regularly revisited with team members to incorporate necessary updates and are prominently displayed during team meetings.
a. The team agreements serve as a foundational tool during HFW Team Meetings, reinforcing shared values and expectations, as indicated in the Team Agreement Form, page 1.
b. The HFW Fidelity Coach provides training on the development of high-functioning teams, equipping team members with the skills needed to enhance collaboration and cohesion, as detailed in the Training Curriculum, pages 3 and 4.
c. The HFW Facilitator closely monitors the engagement and involvement of natural supports, ensuring their effective integration into the team process, as documented in the Natural Supports Inventory, page 1.
d. To facilitate the onboarding of new team members, the HFW Facilitator employs the Orientation Format, ensuring that all newcomers are adequately informed and integrated into the HFW process, as specified in the Orientation Format, page 1.
Transition
6.1 Develop a Transition Plan
The High-Fidelity Wraparound (HFW) team, comprising the youth, family members, and a combination of formal and informal support systems, collaborates to assess whether the youth and family have successfully achieved the goals outlined in the HFW Plan of Care. This assessment is rooted in specific benchmarks and indicators previously identified and agreed upon by the youth and family within the Plan of Care.
a. The HFW Facilitator utilizes these established benchmarks to evaluate the readiness of the youth and family for transition; please consult the Plan of Care on page 2 for further details.
b. Drawing upon insights from the family and the youth’s ongoing needs after the program, the HFW Facilitator develops a comprehensive Transition Plan; see Transition Plan on page 1 for specifics.
c. In a collaborative team meeting, the HFW Facilitator leads the development of the Transition Plan, ensuring that input from all team members is actively integrated; refer to the Wraparound Team Minutes on page 1 for additional context.
d. The HFW Facilitator is tasked with identifying specific services and supports that have been confirmed as available to the youth and family following their transition out of the program; detailed information can be found in the Transition Plan on page 1.
6.2 Develop a Post-Transition Safety Plan
The existing Crisis and Safety Plan, initially created during the HFW process, will serve as a strong foundation for the HFW Facilitator to modify and adapt in response to the evolving needs of the youth and family during and after the transition. If necessary, a new Crisis and Safety Plan may be developed to better address these needs.
a. The HFW Facilitator or a designated team member will update the existing Crisis and Safety Plan to ensure it accurately reflects any new requirements or contacts; for a detailed outline, refer to the Crisis and Safety Plan on page 1.
b. The HFW Facilitator or designee will engage in a collaborative process to develop or modify the Crisis and Safety Plan during team meetings, gathering valuable insights and contributions from all team members involved; see Wraparound Team Minutes on page 1 for further details.
c. Utilizing the team meeting as a critical platform, the HFW Facilitator or designee will conduct a thorough review of the Crisis and Safety Plan with the youth, family, and team members to ensure a collective understanding and collaboration; consult the Wraparound Team Minutes on page 1 for a recap of discussions.
6.3 Create a Commencement and Celebrate Success
The transitions experienced by youth and families represent significant milestones in their journey, indicating profound progress. Throughout their participation in the HFW process, these individuals have attained notable goals that warrant thoughtful acknowledgment and celebration.
a. The HFW Facilitator will utilize the Commencement and Celebration of Success framework to engage with the family, openly discussing their envisioned approach to celebrating these accomplishments; see the Commencement and Celebration of Success Plan on page 1 for guidance.
b. To ensure an appropriate tribute to their journey, the HFW Facilitator will actively involve staff and team members to align with the family’s needs while planning the celebration; refer to the Commencement and Celebration of Success Plan on page 1 for further instructions.
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
In our ongoing commitment to enhance the well-being of our community, Smiles and Tears Children and Family Services is pleased to announce the formation of a dynamic advisory board for the Healing Families and Youth (HFW) program. This board will consist of dedicated volunteers, including youth and their families who have either completed the HFW process or are currently engaged in it.
a. The HFW Manager-Supervisor will facilitate regular advisory group meetings, fostering a collaborative environment to gather valuable insights and perspectives from families. Please refer to the Advisory Group Agenda on page 1 for further details.
b. These advisory group meetings will serve as critical forums for the HFW Manager-Supervisor to solicit constructive feedback from families regarding the decision-making process, with the aim of refining and enhancing our services, workforce implementation, and policy frameworks. Additional details can be found in the Advisory Group Agenda on page 1.
7.2 Community Leadership Team
In an essential role within our organization, the HFW Manager, Supervisor, or an appointed representative will function as a key liaison on the HFW Community Leadership Team.
a. The HFW Manager, Supervisor, or designated representative will actively engage in Community Leadership Meetings. A comprehensive overview of responsibilities is detailed in the Manager Job Description on page 2.
7.3 Eligibility and Equal Access
At Smiles and Tears Children and Family Services, we understand the importance of maintaining a well-equipped and resourceful HFW team capable of delivering exceptional services to all youth and their families transitioning from the Foster Family Agency (FFA).
a. The HFW Manager-Supervisor conducts thorough evaluations of each youth and family to assess their eligibility, ensuring that we are inclusive in accepting individuals regardless of the severity or nature of their needs. Specifics can be referenced in the Eligibility Criteria on page 2.
b. Furthermore, the HFW Manager-Supervisor is dedicated to staffing the organization with a competent and skilled team, ensuring that we provide the appropriate intensity and frequency of services necessary to effectively support our families. For additional information, please see the Organizational Chart on page 1.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
Our contracts are purposefully structured to incorporate high-fidelity direct services and supports designed to meet the immediate and unique needs of both youth and their families. For further details, please refer to the Fiscal Supports Policy on page 1. These contracts also mandate comprehensive workforce development and staffing, clearly delineating specific roles and functions that are critical to our mission (as outlined in the Fiscal Supports Policy on page 1). Moreover, they emphasize the necessity for robust data collection and management systems to enhance service delivery.
a. The HFW Manager-Supervisor conducts diligent reviews of all contracts to ensure that adequate funding is earmarked to support the diverse needs of youth and families, as highlighted in the Fiscal Supports Policy on page 1.
b. To cultivate a stable and effective environment for HFW activities, the HFW Manager-Supervisor evaluates contracts to guarantee sufficient hiring and retention of qualified staff in accordance with the guidelines outlined in the Fiscal Supports Policy on page 1.
c. Additionally, the HFW Manager-Supervisor assesses contracts to ensure that necessary resources are allocated for data collection and management systems, as referenced in the Fiscal Supports Policy on 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, specifically designated for the vulnerable youth and families served by Smiles and Tears Children and Family Services, represent a crucial and adaptive component of the program’s financial framework.
a. The HFW Manager-Supervisor is responsible for the careful allocation of flex funds, ensuring that resources are distributed in a manner that effectively meets the needs of those we serve; please refer to the Fiscal Supports Policy on pages 1-2 for additional information.
b. To facilitate the effective utilization of these funds, the HFW Manager-Supervisor undertakes the responsibility of training staff on the processes involved in disbursing flex funds and maintaining accurate documentation, as detailed in the Fiscal Supports Policy on pages 1-2.
8.5 Collaborative Oversight of Flex Funds
The overarching approval process for all flex fund requests falls under the meticulous oversight of the HFW Manager-Supervisor.
a. The HFW Manager-Supervisor ensures that each flex fund request is thoroughly documented, maintaining transparency and accountability, as outlined in the Fiscal Supports Policy on page 2.
b. To promote equitable access, the HFW Manager-Supervisor manages the flex funds as a collective pool, making them available to all families in need, as emphasized in the Fiscal Supports Policy on page 2.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
To uphold the accessibility of flex funds for every family, the Executive Director collaborates closely with the HFW Manager and Supervisor.
a. Together, they conduct a thorough review of the program’s funding and actively seek to secure additional flex funds to address any shortfalls, as outlined in the Fiscal Supports Policy on pages 2-3.
b. In the event of funding constraints, the Executive Director and HFW Manager-Supervisor proactively engage with the Community Leadership Team and their county liaison to explore viable solutions, as detailed in the Fiscal Supports Policy on pages 2-3.
c. Through their collaborative efforts, the Executive Director and HFW Manager-Supervisor ensure that sufficient flex funds remain accessible to all families, fostering a supportive environment for those we serve, as specified in the Fiscal Supports Policy on pages 2-3.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
At Smiles and Tears Children and Family Services, the Executive Director meticulously compiles comprehensive statistical data to create insightful profiles of the youth in our care. This data serves as a foundational framework for developing a workforce that reflects the diverse demographics of our clientele.
a. The HFW Manager-Supervisor plays a crucial role in ensuring that our staff composition mirrors the vibrant tapestry of the community’s demographics; please refer to the Workforce Development and Human Resource Management Policy and Procedures, page 1, for additional details.
b. When necessary, the HFW Manager-Supervisor actively identifies and leverages natural community supports to enhance cultural representation, reinforcing the values outlined in the Workforce Development and Human Resource Management Policy and Procedures, page 1.
c. Understanding the significance of effective communication, the HFW Manager-Supervisor also provides essential translation services to overcome language barriers, as detailed in the Workforce Development and Human Resource Management Policy and Procedures, page 1.
9.2 Tribally Responsive Workforce
At Smiles and Tears Children and Family Services, HFW staff participate in specialized training focusing on the Indian Child Welfare Act (ICWA). This training not only enhances their understanding of relevant legal frameworks but also deepens their appreciation for Native American culture and heritage.
a. The HFW Manager-Supervisor organizes comprehensive staff training sessions centered on the Indian Child Welfare Act, as outlined in the Workforce Development and Human Resource Management Policy and Procedures, page 2.
b. Committed to culturally inclusive practices, the HFW Facilitator actively engages with local tribal partnerships and representatives, fostering collaborative efforts that integrate traditions and ceremonies into the HFW process. Further information can be found in the Workforce Development and Human Resource Management Policy and Procedures, page 2.
9.3 Flexible and Creative Work Environment
The HFW program adopts a “Whatever It Takes” philosophy, emphasizing adaptability to meet the unique needs of each youth and their families. This innovative approach promotes creativity and flexibility in service delivery.
a. To maintain high standards of program quality, the Fidelity Coach provides in-depth training focused on methods of continuous improvement; please refer to the Training Curriculum, pages 4-6 for more details.
b. The Fidelity Coach also facilitates training on building cohesion within teams; see Training Curriculum, pages 4-6 for further insights.
c. Open communication is another critical aspect of the training provided by the Fidelity Coach; refer to Training Curriculum, pages 4-6 for more information.
d. Additionally, training on mission alignment and compliance with HFW philosophy ensures that all staff members are oriented towards a shared vision; see Training Curriculum, pages 4-6 for details.
9.4 Hiring, Performance Evaluation, and Job Descriptions
To uphold exceptional standards of care and professionalism, all employees undergo a comprehensive 90-day performance evaluation. This assessment is vital in determining staff members’ adherence to evolving expectations and essential requirements of their roles.
a. The HFW program features clearly defined roles, complete with detailed descriptions and responsibilities; refer to the HFW Manager-Supervisor Job Description, pages 1-2, for more information.
b. Job descriptions within the HFW framework articulate the purpose, functions, and key attributes expected of each role; further specifics can be found in the HFW Facilitator Job Description, pages 1-2.
c. In accordance with state guidelines, HFW job descriptions are tailored to meet the specific needs of the HFW program; see HFW Family Specialist Job Description, pages 1-2 for further reference.
d. The HFW Manager-Supervisor provides valuable opportunities for staff to showcase their skills, as indicated in the Workforce Development and Human Resource Management Policy and Procedures, pages 3-4.
e. Ongoing feedback on performance is a regular practice, ensuring constructive dialogue between the HFW Manager, Supervisor, and team members, as emphasized in the Workforce Development and Human Resource Management Policy and Procedures, page 5.
9.5 Workforce Stability
The Human Resources Department at Smiles and Tears Children and Family Services is committed to fostering a robust and stable workforce by providing essential resources that enhance overall organizational effectiveness.
a. To ensure competitive compensation, the HFW Manager-Supervisor aligns salaries with the cost of living and comparable agency wages within the community, as outlined in the Workforce Development and Human Resource Management Policy and Procedures (page 6).
b. The HFW Manager-Supervisor ensures that staffing levels are sufficient to manage workloads effectively, promoting a balanced and supportive work environment, as illustrated in the Organizational Chart (page 1).
c. Opportunities for professional growth, promotions, and advancement are actively communicated, affirming a clear pathway for career development; additional details can be found in the Workforce Development and Human Resource Management Policy and Procedures (page 6).
d. Furthermore, the HFW Manager-Supervisor provides avenues for leadership development and wage increases that do not require a job change, fostering sustained employee engagement and satisfaction, as specified in the Workforce Development and Human Resource Management Policy and Procedures (page 6).
9.6 High Fidelity Training Plan
The HFW Manager-Supervisor plays a crucial role in coordinating a comprehensive staff training calendar, meticulously aligning HFW courses with offerings from UC Davis RCFFP. This alignment ensures that all staff receive high-quality, relevant training necessary for their roles within the HFW framework. Upon hiring, the HFW Manager-Supervisor will carefully assess 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 (page 1).
b. The HFW Fidelity Coach will facilitate continuous professional development by providing specialized training in courses focused on Wraparound services and the essential skills associated with them; further information is available in the Training Curriculum (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 (page 1).
d. Both the HFW Manager-Supervisor and the Clinical Supervisor are required to participate in general training, along with initial, ongoing, and booster training specific to their responsibilities, as specified in the HFW Manager-Supervisor Job Description (page 3).
e. Additionally, the HFW Fidelity Coach will provide essential training on the Indian Child Welfare Act (ICWA), as noted in the Training Curriculum (page 6).
9.7 Community-based Training Program
While training courses are mandatory for HFW employees, those offered by UC Davis RCFFP provide invaluable opportunities for all individuals involved in the HFW process to enhance their understanding and skills.
a. The HFW Fidelity Coach will enrich training sessions by incorporating 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 comprehensive access to these development opportunities; please refer to the Workforce and Human Resource Management policy (page 6) for more information.
9.8 Coaching and Supervision
The HFW Fidelity Coach, along with the HFW Manager, Supervisor, and HFW Clinical Supervisor, provides staff with numerous opportunities for both initial and ongoing coaching and supervision to enhance 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 at all times, reflecting their dedication to staff development and well-being; please refer to the HFW Manager-Supervisor Job Description (page 3) for further details.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
The HFW Fidelity Coach, along with the HFW Manager, Supervisor, and HFW Clinical Supervisor, provides staff with numerous opportunities for both initial and ongoing coaching and supervision to enhance 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 at all times, reflecting their dedication to staff development and well-being; please refer to the HFW Manager-Supervisor Job Description (page 3) for further details.
Fidelity Indicators
1.1 Timely Engagement and Planning
Krista Foster Homes prioritizes early and consistent engagement with youth, families, caregivers, and support networks in order to ensure timely and effective service planning. Upon receipt of a referral, staff initiate contact with the youth and family as soon as possible and no later than 10 calendar days after referral.
Initial engagement focuses on building rapport, explaining the Wraparound process, and identifying the youth and family’s strengths, needs, culture, and immediate priorities. During this early phase, staff work collaboratively with the youth and family to begin identifying members of the Child and Family Team (CFT), including family members, natural supports, caregivers, service providers, and other individuals identified by the family as important to the youth’s support network.
A Wraparound Plan of Care is developed within 30 calendar days of service initiation. The plan is reviewed regularly during Child and Family Team meetings, which occur at least every 30–45 days, and is updated and distributed to team members at least every 90 days or more frequently as needed.
When a child is identified as an Indian child under ICWA/FICWA, Krista Foster Homes actively engages tribal representatives early in the process and invites them to participate in Child and Family Team meetings to ensure culturally appropriate planning and services.
This early engagement and planning process ensures services are family-centered, culturally responsive, and aligned with Wraparound fidelity principles.
• Krista Foster Homes Wraparound Program Overview (Sections: Wraparound Services Overview; Identifying and Accessing Services; Collaboration and Child and Family Team Process)
• Krista Foster Homes Policy Manual – Needs and Services Plan Procedures
1.2 Led by Youth and Families
Description of Practice
Krista Foster Homes ensures that youth and families are central decision-makers throughout the Wraparound process. Staff prioritize the voices, preferences, and perspectives of youth and their families when developing and modifying the Wraparound Plan of Care. During the initial engagement phase, staff work collaboratively with the youth and family to identify their strengths, cultural values, goals, and priorities.
Youth and families actively participate in identifying members of their Child and Family Team (CFT) and are encouraged to invite natural supports, extended family members, and community supports who they believe will help them achieve their goals. Team meetings are structured to ensure youth and family members have meaningful opportunities to share their perspectives, guide decision-making, and participate in developing strategies that address their needs.
When a child is identified as an Indian child under ICWA/FICWA, tribal representatives are invited to participate as equal members of the Child and Family Team. Feedback from youth and families regarding their experience with services is regularly solicited and used to improve service delivery and support continuous quality improvement.
Supporting Documentation
• Krista Foster Homes Wraparound Program Overview
• Child and Family Team Collaboration Procedures
• Needs and Services Plan Policy
1.3 Strength-Based
Description of Practice
Krista Foster Homes utilizes a strength-based approach to service planning and delivery. Staff work with youth and families to identify strengths, talents, interests, cultural values, and existing support systems that can be leveraged to support positive outcomes. Strengths are identified through engagement conversations, assessment tools, family interviews, and information shared by the Child and Family Team.
These strengths are documented in the youth’s case record and incorporated into the Wraparound Plan of Care. Strategies and interventions are developed to build upon existing strengths and to empower youth and families to use their capabilities and support networks in achieving their goals.
Staff receive training and coaching in strength-based practice and solution-focused engagement. Family feedback is routinely gathered through surveys, meetings, and quality assurance processes to ensure services continue to reflect strength-based principles.
Supporting Documentation
• Krista Foster Homes Wraparound Services Overview
• Needs and Services Plan Policy
• Staff Training and Coaching Procedures
1.4 Needs Driven
Description of Practice
Krista Foster Homes ensures that Wraparound services are driven by the underlying needs of the youth and family rather than solely by presenting problems or behaviors. Staff collaborate with the youth, family, caregivers, and Child and Family Team members to identify and prioritize the youth’s most important needs.
Needs identification occurs through engagement meetings, review of historical records, and standardized assessment tools including the Child and Adolescent Needs and Strengths (CANS) assessment when available through the county placing agency. Identified needs guide the development of goals, strategies, and action steps within the Wraparound Plan of Care.
The Child and Family Team regularly reviews progress toward meeting identified needs during team meetings, and the plan is updated as necessary to ensure strategies remain responsive to the youth and family’s evolving circumstances.
Supporting Documentation
• Needs and Services Plan Policy
• Wraparound Program Overview
• Assessment and Case Planning Procedures
1.5 Individualized
Description of Practice
Krista Foster Homes develops individualized Wraparound Plans of Care that reflect each youth and family’s unique strengths, needs, culture, preferences, and circumstances. Service planning is flexible and creative, allowing staff and Child and Family Teams to identify strategies that best match the youth and family’s specific situation.
Plans are developed collaboratively with the youth, family members, caregivers, and identified supports. Strategies may include formal services, informal supports, community resources, and culturally relevant supports identified by the family.
Plans are reviewed regularly during Child and Family Team meetings to assess progress and make adjustments as needed. Staff receive ongoing coaching and supervision to support individualized planning and problem-solving that reflects Wraparound fidelity principles.
Supporting Documentation
• Wraparound Services Policy
• Child and Family Team Procedures
• Needs and Services Plan Documentation
1.6 Use of Natural and Community Based Supports
Description of Practice
Krista Foster Homes emphasizes the use of natural and community-based supports as essential components of the Wraparound process. During the engagement and planning phases, staff work with youth and families to identify individuals and resources within their natural support network such as relatives, mentors, faith-based supports, community organizations, and other trusted individuals.
These natural supports are invited to participate in Child and Family Team meetings when appropriate and are incorporated into the Wraparound Plan of Care to promote sustainability and long-term success beyond formal services.
Staff maintain awareness of community resources and collaborate with local organizations to support youth and families in accessing educational, recreational, cultural, and supportive services within their communities.
Supporting Documentation
• Community Engagement and Resource Coordination Procedures
• Wraparound Program Overview
• Child and Family Team Collaboration Policy
1.7 Culturally Respectful and Relevant
Description of Practice
Krista Foster Homes is committed to providing culturally responsive and respectful services that honor the traditions, values, and identities of youth and families served. Staff engage families in discussions about cultural identity, language, traditions, and community connections in order to ensure services reflect the family’s cultural context.
When serving youth identified as Indian children under ICWA/FICWA, tribal representatives are invited to participate in planning and decision-making processes, and tribal customs and preferences are respected throughout service delivery.
Staff receive ongoing training in cultural humility, trauma-informed care, and inclusive service practices. Feedback from families regarding cultural relevance of services is incorporated into continuous quality improvement efforts.
Supporting Documentation
• Agency Philosophy and Mission Statement
• Cultural Responsiveness Policy
• ICWA/FICWA Compliance Procedures
1.8 High-Quality Team Planning and Problem Solving
Description of Practice
Krista Foster Homes utilizes the Child and Family Team (CFT) as the primary structure for collaborative planning and problem-solving. The CFT includes the youth, family members, caregivers, social workers, service providers, natural supports, and other individuals identified by the family.
Team meetings provide a structured opportunity to review progress, identify barriers, celebrate successes, and adjust strategies within the Wraparound Plan of Care. Team members share responsibility for implementing action steps and supporting the youth and family in achieving identified goals.
Meeting summaries and updates to the Wraparound Plan of Care are documented in the youth’s record and shared with team members as appropriate.
Supporting Documentation
• Child and Family Team Meeting Procedures
• Needs and Services Plan Policy
• Wraparound Services Overview
1.9 Outcomes Based Process
Description of Practice
Krista Foster Homes utilizes an outcomes-based planning process in which each youth’s individualized service plan includes measurable goals, strategies, and action steps. Progress toward goals is reviewed regularly during team meetings and documented by case managers. Action steps are monitored and updated as needed to ensure strategies remain responsive to the youth and family’s needs. Standardized assessment tools, including the IP-CANS when applicable, are used to inform planning and evaluate outcomes. Information gathered through assessments, team discussions, and case documentation is used to guide service adjustments and transition planning.
Supporting Documentation:
Individualized Service Plan; Assessment Procedures; Case Documentation; Team Meeting Records.
1.10 Persistence
Description of Practice
Krista Foster Homes staff demonstrate persistence in working with youth and families even when challenges or setbacks occur. The Wraparound process views difficulties as opportunities to reassess strategies and identify new approaches rather than as reasons to discontinue services prematurely.
Child and Family Teams collaboratively problem-solve when progress is limited, revising strategies and identifying additional supports when necessary. Staff receive supervision, coaching, and consultation to support effective problem-solving and maintain engagement with families.
Services continue until the Child and Family Team agrees that identified needs have been sufficiently addressed and the youth and family are prepared for transition from Wraparound services.
Supporting Documentation
• Wraparound Services Policy
• Staff Supervision and Coaching Procedures
• Needs and Services Plan Review Process
1.11 Transitions as a part of the Fourth Phase of HFW
Description of Practice
Krista Foster Homes plans transition collaboratively with youth, caregivers, and service providers to ensure continuity of support when services conclude. Transition planning begins prior to case closure and focuses on connecting youth and families with ongoing community resources, educational supports, and behavioral health services when appropriate. Transitions are conducted in a manner that respects the youth and family’s culture, values, and preferences, and may include recognition of accomplishments achieved during services.
Supporting Documentation:
Transition Planning Procedures; Case Closure Documentation; Individualized Service Plan.
Expected Outcomes
2.1 Youth and Family Satisfaction
Description of Practice
Krista Foster Homes gathers feedback from youth and caregivers regarding their experiences with services through direct communication, team meetings, and periodic satisfaction surveys. Feedback is reviewed by program leadership to identify strengths in service delivery and opportunities for improvement. Youth and family input is valued and incorporated into service planning and program development.
Supporting Documentation:
Family Satisfaction Surveys; Quality Assurance Review Documentation.
2.2 Improved School Functioning
Description of Practice
Krista Foster Homes supports youth in achieving improved school functioning by coordinating with school personnel, caregivers, and service providers to monitor attendance, academic progress, and behavioral needs. Educational goals are incorporated into each youth’s service plan, and staff work with families and schools to ensure youth receive appropriate educational supports and resources.
Supporting Documentation:
Individualized Service Plan; Education Coordination Documentation; Case Notes.
2.3 Improved Functioning in the Community
Description of Practice
Krista Foster Homes supports youth in developing positive community connections and engagement in pro-social activities. Staff work with youth and caregivers to identify community resources, recreational activities, and supportive services that promote healthy development and positive peer relationships. Community engagement is monitored through case documentation and team discussions.
Supporting Documentation:
Individualized Service Plan; Case Notes; Community Resource Coordination Documentation.
2.4 Improved Interpersonal Functioning
Description of Practice
Krista Foster Homes supports the development of healthy relationships between youth, caregivers, and peers. Staff assist youth and families in strengthening communication skills, conflict resolution, and positive relationship building through service planning and collaboration with behavioral health providers when appropriate. Progress is reviewed during team meetings and documented in case records.
Supporting Documentation:
Individualized Service Plan; Case Notes; Behavioral Health Collaboration Documentation.
2.5 Increased Caregiver Confidence
Description of Practice
Krista Foster Homes provides caregivers with ongoing guidance, resources, and support to strengthen their ability to meet the needs of youth in their care. Staff collaborate with caregivers to address challenges, connect them with services, and develop strategies that promote stability and effective parenting. Caregiver confidence and capacity are reviewed during regular case contacts and team meetings.
Supporting Documentation:
Caregiver Support Documentation; Case Notes; Training Records.
2.6 Stable and Least Restrictive Living Environment
Description of Practice
Krista Foster Homes prioritizes maintaining youth in stable, family-based placements whenever possible. Staff work closely with caregivers, child welfare representatives, and service providers to address challenges early and prevent placement disruptions. Placement stability and changes are documented and reviewed to ensure youth remain in the least restrictive and most supportive environment appropriate to their needs.
Supporting Documentation:
Placement Stability Documentation; Case Management Records; Individualized Service Plan.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Description of Practice
Krista Foster Homes works collaboratively with behavioral health providers, caregivers, and youth to support emotional and behavioral stability. Staff assist families in accessing appropriate behavioral health services and developing strategies that reduce the likelihood of behavioral health crises requiring hospitalization or emergency services. Behavioral health concerns and service utilization are documented and reviewed as part of ongoing case management.
Supporting Documentation:
Behavioral Health Coordination Documentation; Case Notes; Crisis Intervention Procedures.
2.8 Reduction in Crisis Visits
Description of Practice
Krista Foster Homes supports youth and caregivers in developing strategies to prevent and manage crises. Staff collaborate with families and service providers to identify triggers, develop safety plans when necessary, and connect youth to appropriate behavioral health supports. Crisis incidents are documented and reviewed to inform adjustments to service plans and strengthen prevention strategies.
Supporting Documentation:
Crisis Intervention Policy; Case Notes; Individualized Service Plan.
2.9 Positive Exit from HFW
Description of Practice
Youth and families exit services at Krista Foster Homes when goals outlined in the service plan have been substantially achieved and stability has been demonstrated. Staff work collaboratively with youth, caregivers, and service providers to ensure that families remain connected to community resources and supports following case closure. Exit decisions and outcomes are documented and reviewed as part of program quality assurance.
Supporting Documentation:
Case Closure Documentation; Transition Planning Procedures; Quality Assurance Records.
Engagement
3.1 Orientation
Description of Practice
Krista Foster Homes provides orientation to youth and caregivers at the beginning of services to explain the Wraparound process, including the principles and phases of High Fidelity Wraparound. Staff review the roles of team members, including caregivers, natural supports, and service providers. Legal and ethical considerations, including confidentiality and youth rights, are discussed. This information is documented in the youth’s case file and reviewed during the engagement phase to ensure youth and families understand the process and their role in the team.
Supporting Documentation
Orientation Procedures; Individualized Service Plan; Case Management Notes.
3.2 Safety and Crisis stabilization
Description of Practice
Krista Foster Homes works collaboratively with youth, caregivers, and service providers to identify safety concerns and develop strategies to prevent and manage crises. During the engagement phase, staff assess immediate safety needs and develop an initial crisis response plan when necessary. Ongoing safety planning is incorporated into the youth’s individualized service plan, and families are provided with information regarding how to access emergency or crisis response services if needed. Crisis concerns and responses are documented in the youth’s case record.
Supporting Documentation
Crisis Intervention Procedures; Individualized Service Plan; Case Management Notes.
3.3 Strengths, Needs, Culture and Vision Discovery
Description of Practice
Krista Foster Homes engages youth and families in a strengths-based discovery process to identify the youth’s strengths, needs, cultural considerations, and vision for the future. This information is gathered through conversations with youth, caregivers, and service providers during the engagement phase and documented in the youth’s case file. The information collected is used to guide development of the individualized service plan and inform team members of the youth and family’s goals and priorities.
Supporting Documentation
Strengths and Needs Assessment; Individualized Service Plan; Case Management Notes.
3.4 Engage All Team Members
Description of Practice
Krista Foster Homes works collaboratively with youth and caregivers to identify individuals who can provide meaningful support to the youth and family. Team members may include caregivers, extended family members, behavioral health providers, school personnel, and other community supports. Staff encourage participation of both formal and natural supports and document team engagement activities in case notes and team meeting documentation.
Supporting Documentation
Team Meeting Documentation; Case Management Notes; Individualized Service Plan.
3.5 Arrange Meeting Logistics
Description of Practice
Krista Foster Homes coordinates team meetings in a manner that is convenient and accessible for youth, caregivers, and other team members. Staff work with families to schedule meetings at times and locations that support participation and consider the needs, schedules, and preferences of the youth and family. When necessary, staff assist with arranging transportation or virtual participation to ensure team members can attend and participate effectively.
Supporting Documentation
Team Meeting Documentation; Case Management Notes; Individualized Service Plan.
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
Description of Practice
Krista Foster Homes works with youth, caregivers, and team members to establish team agreements that guide how meetings are conducted and how decisions are made collaboratively. During the engagement and planning phases, staff document the strengths of the youth, family, and other team members and incorporate them into the individualized service planning process. As additional strengths are identified through ongoing engagement, they are documented and used to support development of strategies and goals that reflect the youth and family’s vision.
Supporting Documentation
Individualized Service Plan (ISP); Strengths Assessment Documentation; Case Management Notes.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
Description of Practice
Krista Foster Homes collaborates with youth, caregivers, and team members to review and prioritize the needs identified during engagement. Measurable goals and outcomes are developed based on these needs and reflect the strengths and vision of the youth and family. Team members work together to brainstorm strategies and assign responsibilities to support achievement of these goals. The identified needs, goals, strategies, and assigned action steps are documented in the individualized service plan and reviewed regularly during team meetings.
Supporting Documentation
Individualized Service Plan (ISP); Team Meeting Documentation; Case Management Notes.
4.3 Develop an Individualized Child or Youth and Family Plan
Description of Practice
Krista Foster Homes develops individualized service plans for each youth and family that reflect the youth’s strengths, needs, culture, and family vision. Plans are developed collaboratively with caregivers, service providers, and other team members and include clearly defined goals, strategies, and assigned responsibilities. The plan coordinates services across providers and emphasizes the use of natural supports whenever possible. Plans are documented in the youth’s case file, shared with appropriate team members, and reviewed periodically to ensure services remain aligned with the youth and family’s needs.
Supporting Documentation
Individualized Service Plan (ISP); Team Meeting Documentation; Case Management Notes; Quality Assurance Review.
4.4 Develop a Crisis and Safety Plan
Description of Practice
Krista Foster Homes collaborates with youth, caregivers, and team members to develop individualized crisis and safety plans when safety concerns are identified. These plans outline potential risk situations, proactive prevention strategies, and specific response actions for caregivers and team members. Crisis and safety plans are developed through team discussion, documented in the youth’s case record, and reviewed periodically to ensure the strategies remain appropriate and effective for supporting youth safety and stability.
Supporting Documentation
Crisis and Safety Plan; Individualized Service Plan (ISP); Case Management Notes.
Implementation
5.1 Implement The Plan of Care
Description of Practice
Krista Foster Homes implements the individualized service plan through ongoing collaboration with youth, caregivers, and team members. Staff monitor progress toward goals and completion of action steps during regular team meetings and case contacts. Responsibilities for strategies are clearly assigned to team members, and progress is documented in the youth’s case record. Staff receive training and supervision to support effective implementation of service plans and to ensure that services remain aligned with the needs and strengths of the youth and family.
Supporting Documentation
Individualized Service Plan (ISP); Team Meeting Documentation; Case Management Notes; Staff Training Documentation.
5.2 Review and Update The Plan of Care
Description of Practice
Krista Foster Homes regularly reviews the individualized service plan with youth, caregivers, and team members to assess progress toward goals and determine whether strategies remain effective. Updates to goals, strategies, and assigned action steps are made collaboratively during team meetings as the needs of the youth and family evolve. Staff document progress, team participation, and updates to the plan in the youth’s case record and communicate relevant changes to team members to ensure coordinated service delivery.
Supporting Documentation
Individualized Service Plan (ISP); Team Meeting Documentation; Case Management Notes; Plan Review Documentation.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
Description of Practice
Krista Foster Homes promotes strong collaboration among youth, caregivers, and team members by encouraging open communication, shared decision-making, and consistent participation in team meetings. Staff work to strengthen relationships among team members and identify natural supports that can assist the youth and family. When new team members join, staff provide orientation to the service plan and team process to ensure continuity of care. Team functioning and engagement are supported through ongoing supervision and training.
Supporting Documentation
Team Meeting Documentation; Individualized Service Plan (ISP); Case Management Notes; Staff Training Records.
Transition
6.1 Develop a Transition Plan
Description of Practice
Krista Foster Homes collaborates with youth, caregivers, and team members to determine when the youth and family are ready to transition from formal Wraparound services. When progress toward identified goals has been achieved, staff work with the team to develop an individualized transition plan that identifies ongoing supports, services, and resources that will remain available after services conclude. Transition planning is conducted collaboratively and documented in the youth’s case record to ensure continuity of care and support for the youth and family.
Supporting Documentation
Transition Plan Documentation; Individualized Service Plan (ISP); Team Meeting Documentation; Case Management Notes.
6.2 Develop a Post-Transition Safety Plan
Description of Practice
Krista Foster Homes works with youth, caregivers, and team members to review and update crisis and safety planning prior to transition from services. The post-transition safety plan identifies potential risk situations and outlines proactive and reactive strategies that youth, caregivers, and natural supports can use to maintain safety and stability. These strategies are developed collaboratively with the youth and family and documented in the youth’s case file to ensure families are prepared to manage future challenges after services conclude.
Supporting Documentation
Crisis and Safety Plan; Transition Plan Documentation; Case Management Notes.
6.3 Create a Commencement and Celebrate Success
Description of Practice
Krista Foster Homes recognizes the accomplishments of youth and families as they complete services and transition from the Wraparound process. Staff work with youth, caregivers, and team members to acknowledge progress and celebrate successes in ways that are meaningful and culturally appropriate for the family. These celebrations may occur during final team meetings or through other supportive activities that highlight the strengths and achievements of the youth and family.
Supporting Documentation
Team Meeting Documentation; Case Management Notes; Transition Plan Documentation.
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
Description of Practice
Krista Foster Homes values youth and family voice as an essential part of service planning and program development. Youth and caregivers are actively involved in decision-making throughout the Wraparound process, including identifying goals, developing strategies, and evaluating progress. Feedback from youth and families is encouraged during team meetings and through ongoing communication with staff. This feedback is used to strengthen services, inform program improvements, and ensure that services remain responsive to the needs of the families served.
Supporting Documentation
Team Meeting Documentation; Individualized Service Plan (ISP); Case Management Notes.
7.2 Community Leadership Team
Description of Practice
Krista Foster Homes participates in community collaboration efforts that support coordinated services for youth and families. Agency representatives engage with community partners, service providers, and system stakeholders to support effective service coordination and shared problem-solving. Participation in collaborative meetings and partnerships helps ensure that services provided to youth and families align with community resources and broader system-of-care practices.
Supporting Documentation
Community Partnership Documentation; Agency Collaboration Records; Case Management Notes.
7.3 Eligibility and Equal Access
Description of Practice
Krista Foster Homes provides services in accordance with established referral and eligibility criteria to ensure that youth and families have equitable access to services. Staff work collaboratively with referral sources and community partners to ensure that youth who meet eligibility requirements are able to receive services appropriate to their needs. Caseloads are managed to support effective service delivery and ensure staff are able to provide appropriate levels of support for youth and families.
Supporting Documentation
Referral and Intake Procedures; Case Management Policy; Staffing and Caseload Guidelines.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
Description of Practice
Krista Foster Homes allocates program resources to support the implementation of High Fidelity Wraparound services for youth and families. Funding supports essential program functions including staffing, service coordination, workforce development, and documentation systems. These resources ensure staff are able to provide individualized services, coordinate care across providers, and maintain accurate documentation necessary for effective service delivery.
Supporting Documentation
Program Budget Documentation; Staffing Plan; Workforce Training Records; Case Management Documentation.
8.2 Equitable Funding Across System Partners
Description of Practice
Krista Foster Homes collaborates with referral sources and community partners to ensure youth and families are connected with appropriate services and resources available through the broader system of care. The agency works with partner organizations to coordinate services and ensure that youth and families receive appropriate supports through available programs and community resources.
Supporting Documentation
Community Partnership Documentation; Referral Procedures; Case Management Notes.
8.3 Cost Savings are Reinvested
Description of Practice
Krista Foster Homes focuses on providing effective and coordinated services that support positive outcomes for youth and families. Program resources are used to support service delivery, staff training, and coordination of care. The agency maintains financial oversight processes to ensure resources are used responsibly to support the needs of youth and families served.
Supporting Documentation
Program Budget Documentation; Financial Oversight 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.
Description of Practice
Krista Foster Homes works collaboratively with team members and referral partners to identify resources that support the individualized needs of youth and families. When available, flexible funding or community resources may be utilized to address urgent or individualized needs that support the youth’s care plan. Requests for resources are reviewed collaboratively to ensure they support the goals identified in the youth’s individualized service plan.
Supporting Documentation
Individualized Service Plan (ISP); Team Meeting Documentation; Case Management Notes.
8.5 Collaborative Oversight of Flex Funds
Description of Practice
Krista Foster Homes maintains documentation regarding the use of resources that support youth and families served through the program. Staff collaborate with team members and referral partners when identifying resources to support individualized needs. Documentation of these decisions is maintained within the youth’s case record to ensure transparency and accountability.
Supporting Documentation
Case Management Notes; Resource Coordination Documentation; Individualized Service Plan (ISP).
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
Description of Practice
Krista Foster Homes collaborates with community partners and referral sources to identify resources that support the individualized needs of youth and families. When specific funding limitations exist, staff work with the team to identify alternative resources or services available within the community to ensure youth and families receive appropriate support aligned with their individualized service plan.
Supporting Documentation
Community Resource Coordination Documentation; Individualized Service Plan (ISP); Case Management Notes.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
Description of Practice
Krista Foster Homes works to ensure that staff are able to respond to the cultural, racial, and linguistic needs of youth and families served. Hiring practices consider the cultural and community context of the youth served, and staff work to ensure services are respectful and responsive to family culture and preferences. When language barriers exist, interpretation services or natural supports are utilized to ensure youth and families are able to participate fully in service planning and decision-making.
Supporting Documentation
Hiring and Recruitment Policies; Staff Training Records; Case Management Notes.
9.2 Tribally Responsive Workforce
Description of Practice
Krista Foster Homes recognizes the importance of respecting tribal sovereignty and culturally responsive practices when serving Native youth and families. Staff work collaboratively with tribal representatives and community partners when appropriate to support culturally relevant services. Training and supervision emphasize respectful communication, collaboration, and advocacy that honor tribal traditions and values.
Supporting Documentation
Cultural Competency Training Documentation; Staff Training Records; Case Management Notes.
9.3 Flexible and Creative Work Environment
Description of Practice
Krista Foster Homes promotes a collaborative and supportive work environment that encourages open communication, teamwork, and continuous program improvement. Leadership works with staff to maintain a positive team culture and ensure that services reflect the principles and values of the Wraparound model. Staff are encouraged to share feedback, participate in program improvement efforts, and collaborate in supporting youth and families.
Supporting Documentation
Staff Meeting Documentation; Staff Training Records; Program Policy Documentation.
9.4 Hiring, Performance Evaluation, and Job Descriptions
Description of Practice
Krista Foster Homes maintains job descriptions and hiring practices that reflect the responsibilities and competencies necessary to support youth and families through the Wraparound process. Staff receive clear expectations regarding their roles and responsibilities and participate in ongoing supervision and performance evaluation. Coaching and feedback are provided to support professional development and ensure staff are able to effectively implement Wraparound principles.
Supporting Documentation
Job Descriptions; Performance Evaluation Documentation; Staff Training Records.
9.5 Workforce Stability
Description of Practice
Krista Foster Homes works to maintain a stable workforce by supporting manageable workloads, providing supervision and professional development opportunities, and encouraging staff growth within the organization. Leadership focuses on maintaining a supportive work environment that promotes staff retention and ensures staff are able to effectively support youth and families.
Supporting Documentation
Human Resources Policies; Staffing Plan; Staff Supervision Documentation.
9.6 High Fidelity Training Plan
Description of Practice
Krista Foster Homes provides staff with training and supervision related to the principles and practices of High Fidelity Wraparound. Staff receive initial training and ongoing professional development to strengthen their ability to work collaboratively with youth, families, and service providers. Training may include coaching, supervision, team meetings, and continuing education opportunities to support effective implementation of the Wraparound model.
Supporting Documentation
Staff Training Records; Training Curriculum Documentation; Supervision Records.
9.7 Community-based Training Program
Description of Practice
Krista Foster Homes collaborates with community partners, youth, and families to strengthen services and support system-of-care practices. Training opportunities and collaborative meetings support communication between service providers and community partners and promote shared understanding of the Wraparound approach. These efforts support coordinated services and strengthen collaboration across the community.
Supporting Documentation
Training Records; Community Partnership Documentation; Staff Meeting Documentation.
9.8 Coaching and Supervision
Description of Practice
Krista Foster Homes provides staff with supervision and coaching to support effective implementation of the High Fidelity Wraparound model. Staff receive orientation and training related to Wraparound principles, phases, and team-based service planning. Ongoing supervision and coaching are provided through regular meetings, consultation with supervisors, and collaborative problem solving to support staff in responding effectively to the needs of youth and families.
Supporting Documentation
Staff Supervision Records; Staff Training Documentation; Program Policy Documentation.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
Description of Practice
Krista Foster Homes participates in ongoing program monitoring and quality improvement efforts to ensure services meet the needs of youth and families. Data collected through case documentation, service planning, and team meetings are reviewed by program leadership to identify opportunities for program improvement. These processes support continuous evaluation of service delivery and ensure that services remain aligned with the principles of the High Fidelity Wraparound model.
Supporting Documentation
Case Management Notes; Individualized Service Plans; Team Meeting Documentation.
10.2 Evaluation Metrics & Outcomes
Description of Practice
Krista Foster Homes reviews information gathered through service documentation, individualized service planning, and team meetings to evaluate outcomes for youth and families. This information is used to support staff development, improve service delivery, and identify program needs. Program leadership reviews data trends to strengthen services and support continuous improvement of Wraparound implementation.
Supporting Documentation
Individualized Service Plans; Case Management Notes; Program Review Documentation.
Fidelity Indicators
1.1 Timely Engagement and Planning
(a) Kern County is committed to providing timely services to families, understanding that it is critical to have an immediate response to minimize any urgent concerns and quickly support family in their journey of recovery. Initial contact with families is a prime opportunity to connect with family and allow them to share their story. These initial efforts help to foster trust and a welcoming environment, offer an initial opportunity to understand culture, including if the family is Native American, and evaluate values, needs and preferences that are important to understand as we are joining with the family to support them. As part of the Mental Health Plan, Kern Behavioral Health and Recovery Services (KernBHRS) maintains systems to monitor and report on the timeliness of all providers through our Timeliness Application (Timeliness of initial request report) that is managed through KernBHRS’ Performance Management Team. Additionally, this timeliness standard is incorporated into our High-Fidelity Wraparound policy and Exhibit A of the Wraparound provider contracts, which is monitored quarterly. When providers do not meet contract standards the department does follow up with the provider and implements Plans of Correction to assist with meeting the standard. Kern will be utilizing the Wraparound Fidelity Assessment System (WFAS) and through this system specific instruments will be used to gather data. The Document Assessment and Review Tool (DART) will also be used to provide data on this standard. Lastly, The HFW provider team has a short daily check-in meeting and a weekly staff meeting where review of Timeliness tracking is a standing agenda item for the providers. Evidence: Timeliness of initial request report: slide 2 (Submitted first 1.1a) HFW Policy: Page 3:II Timeliness of Services: A (Submitted first 1.1a); HFW Exhibit A:Page 2: 3. Referral Process: D (Submitted first 1.1a) HFW Provider Meeting Agenda: VI timeliness tracking (Submitted first 1.1a); CQI Plan: Page 5 Goals & Objectives (Submitted first 1.1a)
(b) All KernBHRS teams and contract providers are expected to meet timeliness standards. These standards and expectations are included in the provider contract exhibit A as well as in the High-Fidelity Wraparound policy. This standard will also be measured by the DART Tool and tracked in the weekly HFW provider team meeting. Evidence: HFW Exhibit A: Page 2: 5. Service Delivery Phases: B Phase2 Plan of Care Development (filed in 1.1a); HFW Policy: Page 3: II Timeliness of Services: B (submitted 1.1a); HFW Provider Meeting Agenda: page 1: VI timeliness tracking. (submitted 1.1a)
(c) Kern County’s High Fidelity Wraparound providers will embed the practice of reviewing each plan of care no less than every 30 to 45 days into the HFW provider meeting, as well as, into Child and Family Team (CFT) meeting agendas as a standing item. This will be required by the HFW policy and monitored through HFW provider contract (Exhibit A). Evidence: HFW Policy: Page 9: V Coordination of Wraparound Services: B Plan of Care Development: 4f (filed 1.1a) HFW Provider Meeting Agenda: page 1: VI: a: Timeliness tracking; (submitted 1.1a) HFW Exhibit A: Page 2: 5 Service Delivery Phases: B. Phase 2: Plan of Care Development (submitted in 1.1a)
(d) In order to ensure continuous quality improvement, the family is supported within the CFT meeting to provide feedback and update the plan of care no less than every 90 days. This standing item will be tracked in the provider team’s minutes to ensure timely completion, will be monitored by utilizing provider contract standards Exhibit A, and will align with HFW policy. The KernBHRS’ Performance Management Team in alignment with the Continuous Quality Improvement Plan will utilize the WFAS to produce quarterly reports for provider teams to help monitor this standard. Evidence: HFW Provider Meeting Agenda: Page 1: VI: a (submitted in 1.1a); HFW Exhibit A: Page 2:5 Service Delivery Phases: B. Phase 2: Plan of Care Development (filed in 1.1a) HFW Policy: Page 9: V:Coordination of Wraparound Services: B Plan of Care Development: 4g (submitted 1.1a)
(e) Through the Performance Management Team, KernBHRS has established performance improvement projects. Specifically, the Key Performance Indicator Committee (KPIC), a subcommittee of the Quality Improvement Committee (QIC), responsible for providing oversight, monitoring, and evaluation of compliance efforts and performance outcomes. All monitoring activities are strategically designed to enhance access to services, improve the quality of care, and optimize outcomes within the Behavioral Health Plan (BHP). KPIC drives system-level improvements by applying evidence-based methodologies such as Lean Six Sigma and the Plan-Do-Study-Act (PDSA) cycle. This committee is tasked with the following responsibilities: collecting and analyzing data to assess progress toward established goals and prioritized improvement areas, identifying and prioritizing, opportunities for performance enhancement, designing and implementing targeted interventions to address identified gaps, and evaluating the effectiveness of implemented strategies. The KPIC team meets quarterly with agencies/divisions to provide outcomes on specific standards, one of which is timeliness data. On a quarterly basis there is a meeting with executive staff to review key performance measures and quality improvement initiatives for the entire department. As HFW implements the outcomes and data reporting will be integrated into a similar process that will monitor timeliness as well as other outcomes. Kern will be utilizing the WFAS outcome tools and the DART to capture timeliness with this information being provided to wraparound providers through the CQI process. Evidence: Kern County FY 24-25 Workplan page 7; page 8; and page 9 (first submitted 1.1e); CQI Plan: Page 5 Data Collection & Monitoring (First submitted 1.1e)
(f) Engagement is pivotal and it is through our first conversations that we can provide support to a family who are often in the midst of challenging situations. Also, understandably the family could be experiencing stigma or hesitation to share this personal information with others. Staff are trained to approach families in a respectful and non-judgmental approach that fosters trust and is critical to rapport building. Staff are provided with support while learning to customize their strategies and interventions to engage families in a way that is comfortable for the family. This occurs through ongoing training, one example is the Listen, Empathize, Agree and Partner (LEAP) training that teaches an evidence-based communication approach to engage individuals in treatment. The HFW Policy also reflects the importance of these first engagement efforts. Evidence: Leap Training Flier (first submitted 1.1f) HFW Policy: Page 5: V Coordination of Wraparound Services: A Engagement:2 and 3 (first submitted 1.1a)
1.2 Led by Youth and Families
(a) Kern strongly believes that recovery happens best when families and young people are the main voices in decisions about their lives. It is with intention that when developing the child and family team the selection of who is on the team is in alignment with recognizing the family’s preferences. During the initial Wraparound Child and Family Team meetings the family is invited to develop the family vision statement in their own words and The Child and Family Team to develop a Team Mission statement. These two processes are foundational to developing the larger high fidelity wraparound plan of care. Worksheets are utilized during the CFT meeting and then scanned into the youth’s file and the service is documented as a progress note in the electronic health record. The family vision and team mission will appear on the standing agenda for all CFT meetings as an ongoing reminder to the team. In our process we will utilize the HFW CFT Agenda’s in the CFT meeting to ensure all member have a concrete document that guides the meeting. Upon completion of the meetings behavioral health staff will document in the EHR which is demonstrated in the Mock Kern County Progress note. The action step of completing the family vision process is referenced in the HFW Policy. Evidence: Family Vision Discovery worksheet (first submitted 1.2a) Team Mission Worksheet (first submitted 1.2a); Mock Kern County progress note ICC-Assessment plan: Page 1 Family Vision( first submission 1.2a); HFW CFT agenda engagement phase: family vision (first submitted 1.2a); HFW Policy: Page 7:V Coordination of Wraparound Services: A Engagement:8a and 8b (first submitted 1.1a); HFW Policy:Page7: V. Coordination of Wraparound Services: A Engagement:9 a, b and c (first submitted 1.1a)
(b) Healing and recovery are achieved through support and care that align with the family’s culture, values, aspirations, strengths and needs. The family is recognized as the expert on their family. In our interactions with the family, we work to empower them to engage in decisions and planning that align with their values, culture, capabilities, interests, and skills. This information is carefully elicited through thoughtful conversations and documented in the youth’s case file taking into account the family’s culture and preferred language. By sharing their vision of how they want their family to be, the child and family team can use this detailed understanding to support the development of a unique and personalized wraparound plan. This is documented in the Mock Kern County Progress note. Evidence: Mock Kern County progress notes ICC-Assessment plan: Page 1: Family Vision; and Page 2 cultural discovery and strengths/IP-CANS (first submission 1.2a): HFW Policy: Page 7: V Coordination of Wraparound Services: A Engagement:8a and 8b (first submission 1.1a)
(c) KernBHRS policy requires regularly occurring supervision for staff. Our supervisors employ various methods, such as shadowing staff, reviewing documentation, and coaching on clinical interventions. It is the standard and the norm that supervisors join CFT meetings (and other clinical services) to observe and provide feedback for both higher level Intensive Care Coordination/Wraparound youth, as well as youth that have less need in order to provide coaching to team members and ensure quality services. This practice will continue with the implementation of HFW to ensure the fidelity of the wraparound model and the TOM 2.0 will be used to assess the quality of the meeting. In addition, supervisors routinely review staff’s documentation with them. The DART will be utilized by the supervisor and feedback will be given to staff during coaching and supervision meetings with guidance on how to enhance their clinical skills and grow professionally. The use of coaching and supervision is also referenced in the Training Plan. Clinical supervision is documented in the Clinical supervision Form. Evidence: Policy 2.1.9 Supervision of Mental Health Staff; page2: Definitions: Page 2: Procedure:1 (first submitted 1.2c); Kern BHRS Direct service staff supervision form: page 2: Agenda items for current supervision and Page 3: Discussion notes and issues (submitted 1.2c) Training Plan: Page 2: Supervision and Page 3: Coaching (first submitted 1.2c)
(d) Incorporated into our Child and Family Team (CFT) meetings, our teams work to create opportunities for families to share their perspectives about the process. This happens both formally and informally, for instance in an intimate one-on-one conversation between a parent partner or in a formal child and team meeting. Creating the Family Vision offers a foundational structure that guides the team’s direction and can be built on to consolidate the work of the team. As noted in above utilizing the standardized outcome measure of the TOM 2.0 will provide information about the family’s experiences of their wraparound plan. Family and CFT members will receive feedback about the results of the TOM 2.0 through the CQI process as outlined in the plan and this information will be used for supervisors to provide coaching to staff in providing individualized approaches that will improve the overall process for families and ensure that the family’s voice is central. Evidence: Kern BHRS Direct service staff supervision form: Page 2: Agenda items for current supervision, and Page 3: Discussion notes and issues and Page 4: Action Plan (First Submitted 1.2c); CQI Plan: Page 3 CQI Philosophy & Approach (Submitted 1.1a)
1.3 Strength-Based
(a) In our CFT meetings, we identify and document strengths from the family, team members, and community supports. This process serves as a fundamental building block first documented in the service note for the CFT and later as the plan of care is developed it will be documented into the family’s plan of care in the Plan of care development phase. Recognizing the strengths of the family, team and community aids our teams in navigating both rewarding and challenging situations and conversations throughout the wraparound process. By understanding the family’s resources and strengths, we can enhance confidence, support decision-making, and foster commitment to the process. As reflected in the HFW policy, our facilitator collaborates with the family and CFT members to conduct a strengths discovery, which is recorded in the HFW Child and Family Team (CFT) agenda meeting and documented in the youth file. A strength discovery worksheet is available for facilitators to use to help guide and make the process more family friendly. Kern BHRS is certified in the Transition to Independence Process (TIP) Model, incorporating its principles across our children’s system of care. This model includes a strengths discovery for all youth. TIP training is available to all community members, and we integrate this practice into our cross-system coordination efforts. As HFW implements this principle is already embraced by providers and our larger system. Evidence: Strength discovery worksheet: page 1 (Submitted 1.3a) Mock Kern County Progress Note ICC-Assessment plan: Page 2:Strengths/IP CANS (first submitted 1.2a) Mock Plan of Care: page 2 and 3: Strengths and need summary (first submitted 1.3a) HFW Policy: Page 8:V Coordination of Wraparound Services: A Engagement:10a and 10b (submitted 1.1a); HFW CFT agenda engagement phase: Page 1: Strengths/IP-CANS: Natural and Community Supports (submitted in 1.2a) TIP Strengths Discovery Review: page 1; (First Submitted 1.3a) TIP strength discovery worksheet: page 1 (first submitted 1.3a)
(b) The IP-CANS is utilized in the CFT meetings and is an ongoing assessment that is updated as new information is discovered. The discussion of IP-CANS outcomes is used to propel the family and CFT members into opportunities for deeper conversations and activities that identify newly uncovered strengths. In addition, team members are invited to share their perspectives in relation to additional strengths they have noted that are added to the discovery. These processes are outlined in both the IP-CANS policy and HFW policy. Evidence: HFW Policy: Page 8: V Coordination of Wraparound Services: A Engagement:10a; (first submitted 1.1a) 5.1.30 IP-CANS Policy: Page 1: Policy and Purpose and Page 4: Strength Inventory (first submitted 1.3b)
(c) Kern BHRS uses the Transition into Independence (TIP) model, which includes a strength inventory similar to the HFW model. We will build on this practice as we implement HFW to ensure all HFW staff attend this training. Additionally, the department invites internal providers, system partners including schools, social workers, probation officers and community and natural supports to attend a 2-day TIP training. Part of the agenda for this training includes training in the strength discovery processes. The training promotes this value within our community as we serve our youth together. The High-Fidelity Wraparound providers will be trained to complete strength-based discoveries as noted in the training plan for HFW. In addition, our staff are trained and supported in both motivational interviewing and solution-focused interventions, which provide skills for staff to utilize evidence-based approaches that focus on family strengths. This training enhances team effectiveness and continually improves staff skills and tools to address high-priority needs. In addition, Kern County Superintendent of Schools through the Dream Center, a resource hub for TAY youth, hosted motivational interviewing training for all partners. More recently, KernBHRS hosted a Motivational Interviewing training course for all staff. Staff also receive coaching and supervision on ways to increase effectiveness of strength base intervention as noted in the training plan. To support ongoing learning, the department provides a weekly KernBHRS learning skills series that is shared throughout the agency. Lastly, Supervisors incorporate coaching on Strength-based approaches into ongoing supervision. Evidence: TIP Training Agenda: page 2 (first submitted 1.3c) Training plan: Page 2:Supervision; (first submitted 1.2c) Training plan: Page 3: Coaching; (first submitted 1.2c) Learning skills solution focused Treatment: page 1 (first submitted 1.3c) KCNC introduction to Motivational interviewing: entire doc (first submitted 1.3c); Introduction to MI for SUD: entire document: (first submitted 1.3c) Kern BHRS Direct service staff supervision form: Discussion notes and issues (submitted 1.2c)
(d) Collecting family feedback on strength-based services is essential for improving the delivery of services. As reflected in the CQI plan, Kern will use the WFAS outcomes to gather information on family experiences and perspectives with the WFI EZ and TOM 2.0 tools being used for this standard. Results of these administered outcomes and fidelity instruments will be analyzed by our Performance Management Team and reports provided to HFW provider teams. These results will be used by fidelity coaches and supervisors to provide training and coaching to staff in how to increase strengths-based interventions and improve service delivery as reflected in coaching log and supervision documentation. Evidence: CQI Plan: Page 8 Staff Training & Supervision (Submitted 1.1a); Training plan; page 2: Supervision; (First submitted 1.2c) Training Plan; page 3 Coaching ; (First submitted 1.2c); Training Plan; page 3; booster training; (First submitted 1.2c); HFW Coaching log; page 1: (first submitted 1.3d) Kern BHRS Direct service staff supervision form: page 4:Action Plan (first submitted 1.2c)
1.4 Needs Driven
(a) Understanding the needs of the youth and family is essential in developing a comprehensive approach that will be beneficial to the family. This process starts at engagement, and the facilitator leads the group in the development of a needs inventory using tools like the HFW needs discovery worksheet. Prior to the CFT, Initial needs are identified through a behavioral health assessment and the IP-CANS assessment to determine the needs of the youth and family. This information and other collaborative information with the family’s permission is brought forward to the CFT meeting. During the CFT meeting following the HFW CFT agenda, the facilitator helps the family share assessment information with the team, including the initial IP-CANS. The CFT members discuss needs and update the IP-CANS until everyone agrees on ratings. Additional needs not on the CANS may be added for overall planning. Most importantly, the CFT members listen closely to understand and confirm the family’s needs and ensure that the team has a clear understanding of the family’s perspective. It is important to note that the IP-CANS is a dynamic tool, updated in the CFT meeting as new information arises. It is not until the needs are clearly identified that the group can begin to discuss options and strategies and how the family would like the team to support them. Both the IP-CANS Policy and HFW Policy provides guidance. Evidence: HFW CFT Agenda engagement phase: page 1: needs/ IP CANS and Initial transition planning (first submitted 1.2a); HFW Needs Discovery worksheet (first submitted 1.4a) 5.1.30 IP-CANS Policy: Page 2: Principles (submitted 1.3b); HFW Policy: Page 8: V Coordination of Wraparound Services: A Engagement: 10c (submitted 1.1a).
(b) Kern County places strong emphasis on continuous professional development, ensuring that all staff members are supported in ongoing learning and skill development. All staff will attend the UC Davis Wraparound 101: Foundations of Fidelity training for initial implementation and annually thereafter. All therapists receive initial training on completing the clinical assessment. We train clinicians to support families to share their stories, identify needs and barriers, and use motivational interviewing techniques to encourage hope and needs focused planning. Kern is certified in the TIP model which also includes training in future-focused planning. This promising practice similarly conducts a needs discovery and works to focus on a solution versus focusing on behavior. Most direct service children’s staff attend this training which helps to develop needs discovery skills. Similar skills will be utilized as HFW completes needs discoveries with our families. In addition, all children’s behavioral health staff are trained and certified through the Praed Foundation in the IP-CANS tool, which is utilized to prioritize and address the most pressing needs. Additional support to develop effectiveness of identifying needs is provided through regular meetings with supervisors and fidelity coaches as referenced in training plan. Evidence: Tip Training Agenda: Page 2: futures planning and needs assessment (submitted in 1.3c) Praed Foundation Collaborative Training for IP-CANS certification (first submitted 1.4b); 5.1.30 IP-CANS Policy: Page 2: Background (submitted 1.3b); Training Plan: Page 3: Coaching (First submitted 1.2c)
(c) In identifying the needs first and foremost the family is supported in sharing their priorities, needs and perspectives. In addition, the team utilizes the IP-CANS but also relies on other strategies to identify needs. The clinical assessment provides important information about the needs of the family as well as their family’s history, strengths, and traditions that can be utilized to address the needs. Peers who engage with families may have lived experience that helps to bridge connections that allow disclosure of pertinent information that may not otherwise have been provided and with family permission may be able to be shared with the CFT. In addition, through the integrated core practice model cross system coordination services with partners working with the family often provide information that helps to inform other CFT members of additional needs. For foster youth, Kern’s IPC committee, Special Multi-Agency and Referral Team (SMART) which includes KernBHRS, Community Behavioral Health providers, Kern Child Welfare and Kern Probation that meets weekly and serves as a system hub to consult about specific needs and concerns and employ other higher system resources including accessing flex funding. The information from SMART is dispersed to the youth’s CFT to rapidly address needs and further informs the path of treatment. Per the HFW policy as the needs discovery is completed, any new information that is shared in the CFT will further support planning and will be reflected in an updated IP-CANS. Evidence: SMART Program Description: page 2: agency specific procedures and page 3: multi-agency intervention plan: (first submitted 1.4c) HFW Policy: Page 8: V Coordination of Wraparound Services: A Engagement:10c (First Submitted 1.1a)
(d) Effective treatment starts with an initial transition plan that helps to ensure that the family and team are in agreement about the needs that will be worked on and what successful resolution and celebration looks like. The team mission agreement remains on all of the HFW CFT agendas to remind the team of our commitment to the Family. The CFT members and the family proactively plan the transition process through collaboration initially in the engagement phase and with more specific transition readiness markers being developed in the Plan of Care Development Phase. This approach ensures that all needs are thoroughly identified with a plan to address the need. In our CFT meetings we discuss progress, review and update IP-CANS, review goals, and update the individual plan of care. Within the plan of care there is a transition plan. It is important to us that we continuously listen to and assess the family’s needs, making informed decisions about transitions based on their feedback on whether their needs have been met or for ongoing needs natural or community supports are in place. Evidence: HFW CFT Agenda Engagement Phase: page 1: Team mission and transition planning(submitted 1.2a) HFW Policy: Page 9: V Coordination of Wraparound Services: B Plan of Care Development: 4d; HWF Policy: Page 10: V Coordination of Wraparound Services: D Transition (submitted 1.1a) Mock Plan of Care: page 8: Transition Plan (first submitted 1.3a)
1.5 Individualized
(a) Forms that are used are designed to allow for family and youth driven responses, by utilizing text boxes that the writer can complete based on family’s response that captures the unique picture of the family including values, culture and preferences. In addition, forms typically include prompts within the EHR service note to help guide staff as they capture the interaction that they had with the youth and family. Forms in the EHR are also easily amended and updated as the treatment path unfolds. Evidence: How to amend a signed document: Page 2 (first submitted 1.5a)
(b) In order to ensure that staff are responsive to the individual needs of each family we ensure that aside from the basic Wraparound 101: Foundations of Fidelity training that there are continuous opportunities for staff to engage in ongoing trainings, coaching and booster trainings that will expand the ability to attend to specific needs of youth and families. Our training division which supports both internal KernBHRS and contracted providers, will offer both wraparound specific practices as well as additional training courses that are not reflected in the HFW training plan. KernBHRS has routinely developed specific consultation groups with the aim of improving skills and effectiveness of staff to provide imaginative tools and individualized interventions that can enhance knowledge and skills of staff. Examples of consult groups that are available to direct service staff include ten (10) skills building consult group for Recovery Specialists that teaches and roleplays skills within the group, Zero Suicide consultation groups, eating disorder consultation groups, and dialectical behavior therapy (DBT) consultation groups. Other strategies that KernBHRS has implemented is the distribution of skill-building ideas through weekly email blasts that further expands our direct services staff skills toolbox. Lastly, our teams that are Full-Service Partnership Teams have daily morning meetings to ensure coordination across the team and provide daily coaching as needed. KernBHRS TAY team, for instance, takes this opportunity to integrate coaching and booster trainings into the daily morning meeting to sharpen TIP specific skills. HFW providers will adopt this practice of daily morning meetings. Evidence: Training plan: page:3: Booster training (first submitted 1.2c); Recovery Specialist Consult Group Workshop: page 1 (first submitted 1.5b); CBT-SP Consultation: Page 1 and 2 (first submitted 1.5b); Eating Disorder Consultation and resources flier: page 1 (first submitted 1.5b); Weekly Email Blasts: Solution Focus Techniques Page 1 and 2 and Learning Skill Cognitive Reframing: Page 3 (first submitted 1.5b); Tay team minutes: page 2:TAY Booster training: SODAS and SODAS: skill handout: Page 3 (first submitted 1.5b)
(c) In addition to Wraparound 101: Foundations of Fidelity training, facilitators will receive role-specific training. As a part of the training plan the facilitator will attend as available the training offered by UC Davis, Child and Family Team Meetings: Facilitation Training for Wraparound Practitioners. In addition, through supervision and coaching sessions facilitators will be supported and coached to create goal-oriented, individualized plans of care that reflect each youth and family’s preferences, values, cultures, traditions, and strengths. They will also receive training on WFAS outcome tools, in this case the TOM 2.0 (Team Observation Measure) to ensure processes of fidelity and skill improvement tailored to individual families and overall team dynamics. Supervisors and coaches will undergo similar training to provide consistent direction in line with the high-fidelity wraparound model. Evidence: Training plan: Page 4: matrix: Child and Family Team Meetings Facilitation Training for Wraparound Practitioners, and Page 4: WFAS Evaluation tools-CQI plan (first submitted 1.2c)
(d) KernBHRS and providers ensure quality plans of care through regular youth record reviews by supervisors. Using the DART tool, supervisors will ensure effective, tailored plans based on the strengths and needs of youth and their families are being provided, that natural and community supports are being used and strategies and outcomes are reviewed for effectiveness. Staff receive feedback from supervisors on how to customize each plan of care that can occur in supervision but also will occur in the provider team meetings to ensure the provider team places the review on the HFW CFT agenda. In regard to ensuring community and natural supports are used, Kern County is a very collaborative community, through ongoing partnership we are able to become aware of a multitude of services and community events that are integrated into the youth and family’s plan that will meet individualized needs. The Family Advocate will be assigned to attend collaborative meetings such as the Kern County Network for Children through Kern County Superintendent of Schools, to maintain awareness about new community resources that can be shared with the provider team and new supports added to the Plan of care as applicable. Evidence: HFW provider Meeting agenda: page 1: VI: d (submitted 1.1a); Training plan: Page 4: Matrix: KCSOS Network for Children (submitted 1.2c); Mock Plan of Care: page 2: strength and needs summary (First submitted 1.3a)
(e) Kern aims to ensure services are tailored to each youth and family, responding to their feedback. We will use TOM 2.0 through observation of the CFT meetings to gather necessary information. Our Performance Management Team through the CQI process will analyze information gained from the TOM 2.0 and distribute it to the HFW supervisors and staff. The information received will be reviewed in the provider team meeting as well as utilized by fidelity coaches and supervisors with individual staff to suggest recommendations to improve individualized strategies that will support a meaningful path to guide the family’s journey. Evidence: HFW provider Meeting agenda: page 1: VI:b (submitted 1.1a) CQI Plan: Page 7: Analysis & Reporting (Submitted 1.1a)
1.6 Use of Natural and Community Based Supports
(a) To ensure the HFW model’s effectiveness, it is essential to help families identify and establish community and natural supports. Our facilitator utilizes tools such as the natural and community support worksheet to guide the CFT in discovering these supports to meet family needs and ensure sustainability post-wraparound. This information will later be used to develop strategies to support the family’s goals during the Plan of Care Development stage, as referenced in the HFW policy. Evidence: Natural and Community support discovery worksheet: entire document (first submitted 1.6a) HFW Policy: Page 8: V Coordination of Wraparound Services: A Engagement:10b (first submitted 1.1a); Mock Plan of care: page 2; strength and needs summary (first submitted 1.3a)
(b) Staff are trained to identify and incorporate community and natural supports into the HFW process, using various mechanisms to ensure these supports are engaged and integrated into the wraparound plan of care. Some strategies include but are not limited to providing coaching that reviews and teaches ways to enhance engagement skills of natural and community support. Our facilitators will be trained in leading the CFT in identifying and developing natural supports that can be invited to join the CFT. It is important in this process that the facilitator connects the development of these relationships to the family’s success and self-sufficiency and the goal of their transition to natural and community supports. Our Family Specialist will also assist the family to strengthen these newly identified natural supports and explore specific relationships they wish to nurture. All staff will receive specific training by attending the Natural Support Skill Lab provided by UC Davis, as part of their training plan. In addition, Kern DHS and Probation are trained in Family Finding processes with DHS having a dedicated unit to conduct family finding searches to further identify, develop and foster reliance on extended family supports. Trainings that are attended are DHS Family Finding Training: KinnectU CA Strengthening Kinship Kin First and Foremost. In addition, there is an embedded probation officer and Child Welfare Social Worker on our Wraparound Team that will assist in providing this information to the CFT members. Evidence: Training plan: Page 2:Supervision (first submitted 1.2c); Training Plan: page 3: Coaching (first submitted 1.2c); Training Plan: page 4:Matrix: Natural Support Skill Lab (first submitted 1.2c); DHS Family Finding Training: KinnectU CA: page 1 and 2 (submitted 1.6b); Strengthening Kinship in Kern County: page 1-6 (first submitted 1.6b); Kin First and Foremost: Page 1 and 2 (first submitted 1.6b)
(c) As the wraparound plan of care is developed community and natural supports are explored based on family preferences and integrated into the plan. Reviewing all documentation, including the plan of care, is a standard part of our supervisory processes systemwide. The DART includes an item that specifically reviews the natural, and community supports that will be utilized to ensure these are integrated within the plan of care. In addition, through the CFT meetings and further review from supervisor, strategies and action steps are assigned with attention to roles of team members and who would best assist in completing actions steps that are associated with integration of community and natural supports. Community and Natural supports are standard items that are built into the CFT agenda. These community and natural supports are then integrated into the plan of care. Evidence: Mock plan of care: page 2: strengths and needs summary (first submitted 1.3a); Mock plan of care: Page 6: additional notes for this need (first submitted 1.3a); Mock plan of care: page 7: selected strategies: action steps (first submitted 1.3a)
(d) Receiving feedback from families is an ongoing effort to ensure that we are aligned with their needs and are providing services to fidelity of the ten (10) principles. In regard to exploring their experience of having natural supports engaged on their team this will occur in several ways. The TOM 2.0 data would be valuable information to gain an understanding of the effectiveness of inclusion of natural supports on their team. Additionally, measuring the family’s satisfaction by using the WFI EZ would be critical information to guide the planning. WFAS tools will be administered quarterly as well as when additional feedback is needed as reflected in the CQI plan. Furthermore, as part of the CQI plan, the information obtained will be shared with the team and supervisor during regularly scheduled meetings. These meetings will review data and provide opportunities for coaching and training on strategies that can be used to amend the plan of care to ensure it is responsive to the individual needs and preferences of families. Evidence: CQI Plan: Page 5 Data Collection & Monitoring, Page 8 Staff Training & Supervision (Submitted 1.1a)
1.7 Culturally Respectful and Relevant
(a) Kern County recognizes that values, traditions, and culture are crucial to the identity of young people and families. They provide roots that anchor us in customs and communities, forming a foundation for our very identity. Building on the family’s cultures, traditions and histories and asking permission for the wraparound team to enter this part of who they are with cultural humility, sensitivity and respect fosters an atmosphere that can expand the success of the recovery process. Prior to developing a plan of care, the strengths, needs and culture preferences are explored as a team. The process involves inviting the family to share important information about their culture, eliciting strengths and addressing all needs expressed by both the youth and the family. In addition, a vital component is ongoing team engagement and being attentive to what the family shares as rapport is established. Throughout services the team remains on track to embrace and allow the family’s voice regarding strengths, needs and cultural preferences that guide the work of the services provided throughout the process. To stay in fidelity with this principle team agreements are created that document not only the commitment to support the family’s vision but also reinforce the vital need to follow the family’s lead of how to do so with culturally relevant support. Utilizing this information as well as information from the IP-CANS, the facilitator supports the family in creating formalized strengths, needs and cultural discoveries. Facilitators use tools like strengths, needs, and cultural discovery worksheets to guide the team and integrate this information into the EHR. The facilitator sets the pace for each phase with all discoveries typically taking several meetings to complete. Information is then documented into youth’s file as reflected in the Mock Kern County Progress Note. Information from worksheets will be used once team begins the POC development phase. Evidence: Strength discovery worksheet: Page 1 (first submitted 1.3a); HFW Needs discovery worksheet: Page 1 (submitted 1.4a); Cultural Discovery Worksheet: page 1 (first submitted 1.7a); Mock Kern County progress notes ICC-Assessment plan: page 2 Cultural Discovery: Strengths/IP-CANS: Needs/IP CANS (first submitted 1.2a); HFW Policy: Page 8: V Coordination of Wraparound Services: A Engagement:11a (first submitted 1.1a)
(b) The Kern County Wraparound providers will receive ongoing coaching and training designed to prepare staff with strategies to respectfully engage families in sharing their cultural backgrounds during the engagement phase, the planning phase and throughout service delivery. To promote cultural humility and competence, Kern BHRS’ training plan mandates a minimum of hours of continuous education in culturally relevant training. Evidence: Cultural Competence plan: page 13: Strategy 1(first submitted 1.7b); Training plan: page 3: Coaching; and Training plan: page 4: Matrix: Cultural competence (6 hours) (submitted 1.2c)
(c) The DART and the TOM 2.0 will be used to gather feedback from families regarding cultural relevance of services. Through the CQI process the fidelity coaches and supervisor will use this information to improve and inform the delivery of services. The youth and family care plan and all other documentation are regularly reviewed to ensure that services align with the family’s preferences, traditions, and values. Information that is gathered is brought forward for instance, in coaching sessions, but also integrated into provider team meetings and supervision through the CQI process. Evidence: CQI Plan: Page 3: Last paragraph, and Page 8 Staff Training & Supervision (Submitted 1.1a); HFW Coaching log: Page 2 (First Submitted 1.3d)
1.8 High-Quality Team Planning and Problem Solving
(a) Essential to the wraparound process is the ongoing engagement and commitment of the CFT members to support the family and value their preferences. The effectiveness of the CFT is largely determined by cohesion of the group and their commitment to embrace and respect each other and the process. To remain faithful to the principles of HFW and, most importantly, to honor the family’s voice, the team, led by the facilitator, and using the team mission worksheet to establish the team’s commitment to the family. This document not only commits to supporting the family’s vision but also emphasizes the crucial need to follow the family’s lead. This team agreement is created, provided to the team and documented into the EHR. Evidence: Team Mission Worksheet (submitted 1.2a); HFW Policy: Page 7: V Coordination of Wraparound Services: A Engagement: 9a, b, c (First submitted 1.1a)
(b) Feedback for this standard will be accomplished through systematic administration of the WFAS measures in addition to other satisfaction surveys, and quality assurance feedback. Feedback from families and HFW team members is gathered using both the TOMS to complete observations and the WFI EZ satisfaction surveys. The TOMS will provide information that reflects the team dynamic in relation to engagement and the WFI EZ satisfaction surveys will provide information about the effectiveness of the teamwork as well as measure fidelity to principles such as Led by Families and Strength Driven principles. Results from the administration of tools will be gathered and used in ongoing continuous quality improvement through supervision and coaching sessions. Evidence: CQI Plan: Page 8: Staff Training & Supervision (Submitted 1.1a)
(c) The Feedback obtained through outcome surveys about the team’s experience with engagement and collaboration will be shared with the provider team and supervisors as part of the CQI process through regularly scheduled meetings that review the findings of the WFAS. The Performance Management Team will consolidate information in a similar way where we currently review our Key Performance Indicator Reviews with teams as well as with higher management. Results will be used to determine what specific skills staff need and are integrated into supervision, coaching sessions and booster sessions. Evidence: CQI plan: Page 3: Last paragraph and Page 7: Analysis & Reporting (Submitted 1.1a)
(d) Prior to the CFT meeting, the fidelity coach will review the plan of care to provide feedback to the supervisor and provider team of any areas that may need attention to ensure that fidelity standards are met. The facilitator adds any clarification or strengthening of the plan of care to the standing CFT agenda for further review in the CFT meeting. The details of the meeting are documented into the EHR as an ICC assessment/plan service. During each CFT meeting the plan of care is reviewed with attention to how the team is working together to meet goals, which includes report from team members of the actions steps that have been assigned to specific team members, review of strategies and if they were effective in completing assigned actions steps. Progress is documented and if other strategies or other individuals need to assist with these to complete action steps an amendment is documented in the CFT documentation and updated in the plan of care. Evidence: HFW CFT Agenda plan of care development phase: Page 1: plan of care section (first Submitted 1.8d); Mock Plan of Care: page 5: Selected Strategy and Action Steps (first submitted 1.3a); HFW Exhibit A: page 2: B Plan of care development: entire section (first submitted 1.1a)
1.9 Outcomes Based Process
(a) The Wraparound teams will utilize the standardized plan of care form that documents the specific measurable goals, strategies and action steps with timelines, assigned responsible team members, and needs priorities that were established as a result of the needs discovery and review of IP-CANS. The DART will serve to assess the quality of the documentation within the plan of care, enabling our provider to implement quality improvement updates accordingly. Evidence: Mock Plan of care: page 5: Selected strategy and action steps (submitted 1.3a); HFW Provider Meeting Agenda: Page 1: VI: d (submitted in 1.1a); HFW Policy: Page 9: V Coordination of Wraparound Services: B Plan of Care Development: 4b, c (submitted 1.1a)
(b) The review of the plan of care and progress of strategies is a standing agenda item for the CFT meeting agenda. All updates to the action items are documented in the HFW CFT meeting agenda note, as well as the plan of care. These documentation processes will be monitored utilizing the DART tool and feedback given to provider team as indicated. Evidence: Mock Plan of care: page 5: Selected strategy and action steps (first submitted 1.3a); HFW CFT Implementation phase agenda: page 1: plan of care review (first submitted 1.9b); HFW Policy: Page 9: V Coordination of Wraparound Services: B Plan of Care Development: 4e (submitted 1.1a)
(c) As changes are needed there are formalized processes in the EHR of how to amend documentation. All new information will be updated on the HFW plan of care, and CFT documentation which the team will have distributed to the family and CFT Members in the CFT meetings. Evidence: How to Amend a Signed Note Final: page 2 (submitted 1.5a)
(d) The initial IP-CANS is completed by the clinician during the behavioral health assessment and there after the facilitator will update the IP-CANS no less than every six (6) months and when new information arises in the CFT meeting. The peer partner will ensure that IP-CANS is shared with the CFT members, as well as emailed to placing agencies drop boxes. Evidence: 5.1.30 IP-CANS Policy: Page 3: I Administration of IP-CANS: A Kern BHRS Staff will: 1a, b and f (first submitted 1.3b); 5.1.30 IP-CANS Policy: Page 5: III IP-CANS and Cross System Coordination: A KernBHRS Staff will: 5 (first submitted 1.3b); Foster youth meeting agenda: page 2: Send all CANS to (first submitted 1.9d)
(e)The IP-CANS is reviewed and used to guide decisions at every CFT meeting. This discussion provides an opportunity for the family and CFT members to share information about any new needs or progress toward existing goals that may not yet be reflected on the IP-CANS. Both IP CANS and other information guide treatment and are integrated into the overall care plan. Goals, needs, strategies, and action steps are tracked to monitor transition readiness. Additionally, completed items are discussed and celebrated with the family, marking a step of success that leads to transition planning and, importantly, recognizes the family’s enhanced well-being. These processes are referenced in HFW policy and IP-CANS Policy. Evidence: Mock Plan of Care: page 5: action steps (submitted 1.3a); 5.1.30 IP-CANS Policy: Page 2: Principles (first submitted 1.3b) 5.1.30 IP-CANS Policy: Page 5: III IP-CANS and Cross-System Coordination: A KernBHRS Staff will: 4a: iii (first submitted 1.3b)
1.10 Persistence
(a) All attempts to engage and contact youth and family are reflected in the youth’s record. Very frequently youth and families that are enrolled in Wraparound are familiar with other service providers in our system of care. It is common practice in Kern’s system of care to leverage existing relationships to help build trust and bridge to more effective engagement. In the recovery processes, “relapse” is viewed as a normal and expected part of recovery. Challenges and setbacks are part of our shared experiences and are seen by our wraparound teams as powerful opportunities to learn, grow, overcome, and help the family explore how they would like to be supported through any obstacles. Building on our relationship with the family we work to present families with a non-judgmental approach encouraging families and offering hope. Evidence: Exhibit A: Page 3: Service Delivery Phases: D Phase 4 Transitions (first submitted 1.1a); HFW Policy: Page 7: V Coordination of Wraparound Services: A Engagment:9a (first submitted 1.1a)
(b) KernBHRS’ universal expectations requires supervision is regularly occurring with all staff. The provider’s team meetings includes a regular agenda item for coaching and consultation. Requests can be discussed with the supervisor either in a team setting or one-on-one. Furthermore, supervisors are housed on site with the rest of the wraparound team for easy access. If for any reason the supervisor is off or not available for urgent need there is always an alternative supervisor of the day that is able to step in and assist. In regard to flexible funds for youth that are in foster care these requests are directed to the social worker and subsequently reviewed and documented in the SMART committee. Evidence: HFW Provider meeting agenda: page 1: IIb (Final 1.1); Universal Expectations: page 1: supervision (first submitted 1.10b); SMART Program Description: page 3: (first submitted 1.4c); Flex fund availability and request: entire document and DHS flex fund request (first submitted 1.10b)
(c) The Department provides training in Motivational Interviewing and Listen, Empathize, Agree and Partner (LEAP) which aims to enhance staff’s ability to build trust and effectively engage with families. All staff have access to these training courses, with Motivational Interviewing being a part of the wraparound teams training plan. In addition, through the Zero Suicide framework all staff receive annual training in SP CBT and safety planning. Also on the training plan for the facilitator is Safety and Crisis Planning, and Child and Family Team Meetings: Facilitation Training for Wraparound Practitioners offered by UC Davis. As reflected in Training plan, coaching and supervision methodologies are utilized to maximize learning that can be applied to explore new strategies that can lead to needed updates in the care of plan of a family. Evidence: KCNC intro to Motivational Interviewing: page 1 (submitted 1.3c); Leap training fliers (submitted 1.1f); Training Plan: Matrix; Page 4 :Safety and Crisis Planning; Child and Family Team Meetings Facilitation Training for Wraparound Practitioners (final submitted 1.2c); Training Plan: Page 4: Safety Planning and Structured Follow-up; Zero suicide C-SSRS; Overview of Evidenced Based Suicide Specific Interventions (submitted 1.2c)
1.11 Transitions as a part of the Fourth Phase of HFW
(a) Kern believes that when families can anticipate and plan for transitions, it reduces anxiety and promotes the family’s sense of ownership. This allows families to set their path based on their choices and celebrate their important steps and successes. The Team Mission is included in the plan of care and on the CFT agenda, reminding the team of their commitment to overcome setbacks and prevent premature discharge from High Fidelity Wraparound (HFW). Transition planning starts early in the engagement phase by discussing what a successful transition looks like for the family. This conversation is revisited and transition plan is further developed throughout all wraparound phases. This plan provides the team with a clear vision of the service structure and defined goals to work towards. The details of the transition plan are measurable, ensuring that the family and team have a shared understanding of when a goal is nearing completion, can be celebrated, or if there are still steps that need to occur for completion. The commitment from the team and the clear goals help to ensure the team’s persistence in the face of challenges. The tracking transitions are also addressed in HFW provider meeting. This standard is also in the provider’s contract. Evidence: HFW CFT Agenda Plan of care development Phase: Plan of Care (submitted 1.8d); Mock Plan of Care: page 2: Team Mission (submitted 1.3a ); Mock Plan of Care: page 8: Transition plan (first submitted 1.3a); HFW Provider Meeting Agenda: page 1: VI g (submitted 1.1a); HFW Exhibit A: Page 3: D phase 4: Transition (first submitted 1.1a)
(b) Transitions from the wraparound process are documented in the plan of care. The transition plan includes the family preferences that consider their values and culture. This is standing agenda item in the HFW provider meeting and also allows for planning to access flex funds if needed for family celebrations. The time and place of the celebration is established in the CFT meeting with the scheduling of the next meeting that is on the standing CFT agenda. Evidence: HFW Provider Meeting Agenda: Page 1: VI g (submitted 1.1a); Mock HFW CFT Agenda: Transition Phase: Page 4: Transition Target Date and Celebration (first submitted 1.11b); Mock HFW CFT Agenda Transition Phase: Page: 4: Schedule time of next meeting (first submitted 1.11b); Mock Plan of Care: page 8: Transition plan (first submitted 1.3a)
Expected Outcomes
2.1 Youth and Family Satisfaction
See HFW Policy Attachment C KC High Fidelity Wraparound Outcomes: Page 1 Youth and Family Satisfaction (first submitted 2.1)
2.2 Improved School Functioning
See HFW Policy Attachment C KC High Fidelity Wraparound Outcomes: Page 2 School Functioning (first submitted 2.1)
2.3 Improved Functioning in the Community
See HFW Policy Attachment C KC High Fidelity Wraparound Outcomes: Page 3 Improved Functioning in the Community (first submitted 2.1)
2.4 Improved Interpersonal Functioning
See HFW Policy: Attachment C KC High Fidelity Wraparound Outcomes: Page 3 Improved Interpersonal Functioning (first submitted 2.1)
2.5 Increased Caregiver Confidence
See HFW Policy: Attachment C KC High Fidelity Wraparound Outcomes: Page 4 Increased Caregiver Confidence (first submitted 2.1)
2.6 Stable and Least Restrictive Living Environment
See HFW Policy: Attachment C KC High Fidelity Wraparound Outcomes: Page 5 Stable and Least Restrictive Living Environment (first submitted 2.1)
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
See HFW Policy: Attachment C KC High Fidelity Wraparound Outcomes: Page 6 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits (first submitted 2.1)
2.8 Reduction in Crisis Visits
See HFW Policy: Attachment C KC High Fidelity Wraparound Outcomes: Page 7 Reduction in Crisis Visits (first submitted 2.1)
2.9 Positive Exit from HFW
See HFW Policy: Attachment C KC High Fidelity Wraparound Outcomes: Page 7 Positive Exit from HFW (first submitted 2.1)
Engagement
3.1 Orientation
(a) The earning of trust and engagement begins with our ability to suspend our judgements and join with our youth and families as we actively take uninterrupted centered time to listen and value the words and personal stories that might be shared. For youth and families that may be in crisis or have feelings of stigma, the sharing of their story requires bravery. Kern teams, with the utmost respect, value the privilege of earning and holding the family’s trust and have formalized orientation processes for all individuals receiving services. For teams that provide HFW additional information that is specific to the model is shared. Transparency about the process further garners trust. The HFW staff orient and engages families to services taking the time to fully and clearly inform the family about the wraparound process including the principles and phases as outlined in our wraparound policy. During initial contact outside the CFT, the HFW family brochure is used as a tool to engage family in a discussion about services, sharing the HFW model, including the 10 principles and 4 phases, and answering any questions the family may have. During the first CFT meeting, this information is reviewed again with all CFT members and the family to ensure a shared understanding of the importance of the 10 principles and the phases of the wraparound process. These items are integrated into the contract Exhibit A and the HFW policy. Evidence: HFW Family Brochure: entire document ( first submitted 3.1a); Mock Kern County progress notes ICC-Assessment plan: page 1: overview of HFW model and Page 2:Natural and community support(submitted 1.2a); HFW Exhibit A:Page 2: 5 Service Delivery Phases: HFW Exhibit A: Page 2: 5:A: Phase 1:Engagement (submitted 1.1a); HFW Policy: Page 5:V Coordination of Wrap Services: A Engagement: 1b (submitted 1.1a)
(b) During the initial contact, the family is informed of their rights to consent to or decline treatment, maintain confidentiality, and authorize information sharing. Exceptions, like safety concerns and suspected child abuse, are discussed with the family so they understand that confidentiality may be required to be breached without consent in these types of situations. The Authorization to Release Information, and Consent to Treat/privacy practices forms are reviewed by mental health staff with family to ensure understanding. Families are informed that they can revoke their consent or authorization at any time. In addition, during the first CFT meeting this information is again reviewed with the CFT. These items are included in the contract Exhibit A and the HFW policy. Evidence: Consent to treat form: entire document (Submitted first 3.1b); Release of information: entire document (fist submitted 3.1b); Mock Kern County Progress Note ICC-Assessment plan: page 1: overview of HFW model (submitted in 1.2a); HFW Exhibit A: Page 2: 5 Service Delivery Phases (first submitted 1.1a); HFW Exhibit A: Page 2: 5:A: Phase 1: Engagement (submitted in 1.1a); HFW Policy: Page 3 & 4: III Referral to HFW: C2 & C3 (first submitted 1.1a)
(c) In the initial meeting where the family is invited into services, the family brochure is provided and the HFW model is explained, including each role and their purpose. The concept of the Child and Family Team is introduced, highlighting that their team will include both formal and natural support, such as tribes, family, or individuals that they feel are important. It is also shared that as the team is formed, they will be able to choose who they want on their team. During the CFT meeting in the engagement phase introductions to the team and discussion about the purpose of natural and community supports are a part of the standing agenda. Introductions are made, outlining each member’s role on the team. Evidence: Family Brochure: What is HFW (first submission 3.1a); Mock Kern County Progress Note ICC-Assessment plan: page 1 Welcome Introduction and Roles; page 1 Overview of HFW Model and page 2:Natural and Community Supports (submitted 1.2a); HFW Policy: Page 5: V Coordination of Wraparound Services: A Engagement: 1b (submitted 1.1a); Exhibit A: page 2: 5 Service Delivery Phases: 5:A: Phase 1:Engagement (first submitted 1.1a)
3.2 Safety and Crisis stabilization
a. When a youth or family is experiencing a crisis or feels unsafe, immediate triaging is conducted to address the urgent need for safety. This discussion occurs during first CFT meeting in the Engagement Phase. Addressing this need takes precedence over all other matters. Kern County has adopted the Zero Suicide framework, which is incorporated into our practices. Safety and crisis concerns are on the standing CFT agendas and also per Zero Suicide framework is a priority when behavioral health staff are interacting with our youth and families during any services. During meetings with youth and families, safety assessment and planning are integrated into the conversation. If necessary, and if the conversation is too sensitive for youth or family to have during a team meeting, we may need to break away from the larger group to process and evaluate the immediate crisis of the youth or family member. As youth and family are ready and able we return to the group to address the immediate crisis and plan for longer term Crisis and Safety risk management. The team is provided with a copy of the crisis plan, and it is documented in the EHR. Enclosed is a mock crisis plan and the standard is outlined in HFW policy. Evidence: Mock Kern County progress notes ICC-Assessment plan: Safety/Crisis plan :page 1 (submitted 1.2a); Zero suicide PowerPoint: page 7 (first submitted 3.2a); Mock Crisis plan: entire document (first submitted 3.2a); HFW Policy: Page 6: V Coordination Wraparound Services: A Engagement : 7 a-e (first submitted 1.1a); Exhibit A:Page 2:5 Service Delivery Phases: A Phase 1: Engagement (first submitted 1.1a)
b. Following resolution of any immediate crisis through the crisis plan, the safety plan is developed identifying anticipated risks and trigger events with a plan to address as needed. As the process continues the information gained may be used to amend and build a more comprehensive safety plan that is proactive. Both crisis and safety plans are documented in the EHR. Safety issues are assessed and supported in every interaction. This standard is also addressed in the contract providers exhibit A. Evidence: Mock Safety plan: entire document (First submitted 3.2b) HFW Exhibit A: Page 2: 5 Service Delivery: B: Phase 2: Plan of Care Development (first submitted 1.1a)
c. At initial contact, families are also given Wraparound teams on call contact information and the Kern County Hotline 988 phone number for 24/7 response. At the time of crisis planning the plan is given to the family which includes contacts and 24/7 on call numbers. Per contract standards providers are required to ensure that staff are available 24/7. Crisis and Safety planning is a standing item on the CFT agenda for all phases of the wraparound process, and should a crisis arise the 24/7 numbers would again be provided. Evidence: 988 Flier fact sheet: Page 1 (submitted 3.2c); Wraparound after-hours card (first submitted 3.2c); HFW Exhibit A: Page 4:9 Staffing and Training Requirements: D. Staffing Availability (submitted in 1.1a)
3.3 Strengths, Needs, Culture and Vision Discovery
(a) Guided by our facilitator, the CFT members support the family in developing their family vision statement. The facilitator structures this as an active process ensuring a safe environment where the family feels comfortable sharing openly and can begin forming their family vision. The facilitator uses tools like the family vision worksheet to prompt discussion. The family vision is documented in all HFW CFT agendas. beginning with the Engagement Phase. The development of family vision is also referenced in the HFW Policy. Evidence: Family Vision Discovery worksheet: entire document (submitted 1.2a); HFW CFT Agenda: Engagement Phase: Family Vision (submitted 1.2a); HFW Policy: Page 7: V Coordination of Wraparound Services: A Engagement: 8a and 8b; (first submitted 1.1a)
(b) During the engagement phase our facilitator guides the team in completing the strengths discovery for the family and the team members. In addition, the family is invited to share their culture and traditions, that have been important to their family. The facilitator utilizes tools like the cultural discovery worksheet to facilitate. The facilitator also supports the family, and the team explores and completes natural and community supports inventory that could help to meet their goals. A discussion around family needs is also initiated with a need’s discovery being completed. The IP-CANS is integrated into the discussion to be used as a tool to enhance the conversations, set a baseline, and update IP-CANS ratings as new domains are identified. The plan of care is reviewed and updated every 90 days including the strengths, needs, and culture. These processes are referenced in the HFW Policy and the IP-CANS Policy. Evidence: Strengths discovery worksheet: Page 1 (first submitted 1.3a); Cultural Discovery worksheet: Page 1 (first submitted 1.7a); Natural and community support discovery worksheet: Page 1 (first submitted 1.6a); HFW Needs discovery worksheet: Page 1 (first submitted 1.4a); Mock Kern County progress notes ICC-Assessment plan: Page 2: Strengths/IP CANS, Needs/IP CANS, and Cultural Discovery (first submitted 1.2a); HFW Policy: Page 8: V Coordination of Wraparound Services: A Engagement: 10a-e and 11a and b (first submitted 1.1a); HFW Policy: Page 9: V Coordination of Wraparound Services: B Plan of Care Development: 4g (submitted 1.1a); 5.1.30 IP-CANS Policy: Page 4 and page 5: III IP-CANS and Cross-System Coordination: A KernBHRS Staff will: 4a and b (first submitted 1.3b)
3.4 Engage All Team Members
(a) During the engagement phase, the Facilitator initiates discussion about the phases of wraparound and the identification of natural supports that can continue to support the family now and after formal wraparound concludes. Utilizing tools like the natural support discovery, the facilitator leads the CFT in completing a natural and community support discovery. The information is captured on the CFT agenda and documented in the youth’s chart. Evidence: Natural and Community Support Discovery worksheet: page 1 (first submitted 3.3a); HFW Policy: Page 8: V Coordination of Wraparound Services: A Engagement: 10b (first submitted 1.1a); HFW CFT Engagement phase agenda: page 1, Natural and Community Supports (first submitted 1.2a)
(b) As referenced in the HFW Wraparound policy, the development of the Child and Family Team starts prior to the first CFT meeting explaining to the family the role of the CFT and exploring who it would be important to have on their team. Family is also told that members will be determined by their preference but for families that are system involved including formal support such as the child welfare social worker, probation officer or educational staff is important. The facilitator confirms the list of CFT members with the family prior to the CFT so that the family knows who to expect and shares with the family that as the process continues that additional members may be added and can be discussed within the CFT meeting. The Facilitator works to coordinate and invite family and partners to a meeting at the agreed-on time and location. It is also important to note that the HFW team includes probation and child welfare staff who are integrated into one team and stationed at the behavioral health site as referenced in the Multi-agency integrated services team and high fidelity wraparound team MOU (MIST/ HFW MOU) For over 20 years this has been a existing commitment memorialized in a MOU between DHS, Probation and Behavioral health to provide coordinated care to foster youth. The submitted document has been agreed on by all agencies and will be submitted again for finalization as the county goes through our regular “contract season” later in 2026. Evidence: HFW Policy: Page 5: V coordination of wraparound services: A engagement: 1c (first Submitted 1.1a); HFW Policy: Page 6: V Coordination of Wraparound Services: A Engagement: 5 (first submitted 1.1a); MIST HFW MOU: Page 1: Whereas: A-D (first submitted 3.4b)
(c) Anchored in the family vision, and having completed the strength inventory, the facilitator helps to explore with the family in the CFT meeting any additional formal and natural supports they wish to include. This occurs in the engagement phase as well as throughout wraparound process as demonstrated in HFW CFT implementation phase standing agenda. The CFT members suggest other professionals, extended family, friends, and tribes (when applicable) that the family trusts and outlines their roles in the overall plan. Our placement agencies are trained in family findings and have a specialized unit devoted to this task. Some of the trainings that have been attended are DHS Family Finding Training: KinnectU CA Strengthening Kinship Kin First and Foremost. The family finding results are shared with the family and team as an additional resource. With the family’s consent, a plan is developed to invite the identified individuals from this conversation to join the CFT. These supports are integrated into the youth’s plan to meet the family’s needs and documented accordingly. In the case of American Indian children, Kern has several agreements that bridges inclusion for Tribes, including attached agreement with Bakersfield American Indian Health Project (BAIHP) that supports consultation and partnering between DHS and Bakersfield American Indian Health Project (BAIHP) KernBHRS also has an agreement with BAIHP that facilitates engagement and collaboration in order to benefit our shared work to serve the American Indian population. Evidence: HFW CFT implementation phase agenda: page 1: Welcome new members and Strength culture, natural and community support (first submitted 1.9b); Mock Kern County progress note ICC-Assessment plan: Page 2: Natural and community supports (first submitted 1.2a); HFW Policy: Page 8: V Coordination of Wraparound Services: A Engagement: 10b (first submitted 1.1a); DHS Family Finding Training: KinnectU CA: Page 1 and 2 (training document) (submitted 1.6b); Kin First and foremost Page 1 and 2 (training document) (first submitted 1.6b); Strengthening Kinship Care in Kern County: page 1-6 (first submitted 1.6b); KernBHRS BAIHP MOU amendment: Page 1 and page 3: scope of work (first submitted 3.4c); DHS BAIHP agreement: page 3: Full descriptions of the Services (first submitted 3.4c)
(d) During the CFT our facilitator provides opportunities that may include ice breakers, discussion around team agreements, or opportunities for each member to share their role and what way that they think they can support the family. Summary of activity is documented in the youth’s file. Evidence: Team engagement activities: page 1 (first submitted 3.4d); (Final 3.4d); Mock Kern County progress notes ICC-Assessment plan: page 1: Ice Breaker (first submitted 1.2a)
3.5 Arrange Meeting Logistics
(a) It is a contract requirement for providers that they are able to meet with families at times that are convenient for families. To accommodate this need the workforce is able to work alternative schedules that include after hours and weekends. Evidence: HFW Exhibit A: Page 4: 9 Staffing and Training Requirements: D. Staffing Availability (first submitted 1.1a); HFW Exhibit A: Page 3: 6. CFT Meetings: C (first submitted 1.1a); Work Schedule Agreement: Page 1 and Page 2 (first submitted 3.5a)
(b) At the end of all CFT Meetings the team agrees on the Date, Time and Location of the next CFT meeting. This is a standing agenda item on the CFT Agenda. The family is given preference. The scheduling in “real” time also helps to ensure that team members are able to coordinate their calendars. This occurs throughout all stages of the HFW process. Meeting invitations are sent to CFT members’ calendars. Evidence: HFW CFT Agenda: Implementation phase agenda: Page 1: scheduled time and location (first submitted 1.9b); CFT calendar item (first submitted 3.5b)
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
a. Our wraparound facilitator works to collaborate with the CFT team to provide overarching supportive structure that will guide the CFT Team and the family in creating a plan of care by first developing family visions, cultural discovery, team mission, strengths and other community and natural supports using worksheets for each item. The information is brought forward to the team by documenting in the HFW CFT agenda note in the youth’s record and shared with the team Evidence: Family vision discovery worksheet: Page 1 (first submitted 1.2a); Team mission Worksheet: Page 1 ( first submitted 1.2a); Strengths discovery worksheet: page 1 (first submitted 1.3a); HFW CFT agenda -engagement phase: page 1: Team mission, Strengths/IP-CANS, family vision (submitted in 1.2a); HFW Policy: Page 8: V Coordination of Wraparound Services: A Engagement:11a and b (first submitted 1.1a)
b. In the CFT meeting our facilitator continues to review the Family’s strengths that had been previously identified. As the group reflects on the strengths, they also use this time to update and add other strengths not previously mentioned that may help the family in their wraparound plan. These Updates are made in the CFT meeting agenda documentation throughout all phases, in the plan of care and updated in the IP-CANS as indicated. This is referenced in the HFW Policy. Evidence: HFW CFT Plan of Care development phase: Page 1 (first submitted 1.8d); HFW CFT Agenda Implementation phase agenda: page 1: Strengths, culture, natural and community support (submitted in 1.9d); HFW Policy: Page 9: V Coordination of Wraparound Services: B Plan of Care Development: 2 and 3 (first submitted 1.1a)
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
(a) The HFW team, guided by a facilitator, collaborates to identify the family’s and youth’s needs. This initially begins in the engagement phase and is solidified in the POC development phase. The family’s voice is primary, with CFT members contributing observations of possible needs, as well as reviewing items from the IP-CANS. Before developing the plan of care, the facilitator ensures all needs are gathered and prioritized using the structure of the HFW CFT agendas which is then documented into the youth’s file. Members listen to the family to help prioritize these needs, using insights from prior interactions and assessments (with family permission). The family and CFT perspective in combination with the IP-CANS ratings aids in deciding which needs to prioritize. Evidence: HFW CFT engagement phase agenda: page 1: Needs/IP-CANS (first submitted 1.2a); HFW CFT POC Development Phase Agenda: Page 1: Plan of care: review each prioritized need (Submitted 1.8d); HFW Policy: Page 8: V Coordination of Wraparound Services: A Engagement: 10c (submitted 1.1a)
(b) Upon clearly prioritizing needs the facilitator will help the team to consider the strengths and resources that can help to alleviate the need. The team will be assisted in developing measurable and actionable strategies/goals with timelines that will be important to the family’s plan. Tools like the IP-CANS are used to help inform the team’s decisions. It is important that each need is discussed and documented and all team members are given a voice at the meeting to share their ideas about possible strategies that could help to alleviate the need. As these discussions evolve, they will be documented in the plan of care. Evidence: HFW CFT Agenda: Plan of Care Development Phase: Plan of care (submitted 1.8d); Mock Plan of care: Page 4: Prioritized Needs, Measurable Goals, Optional Strategies & Page 5: Selected Strategies and action steps (first submitted 1.3a); HFW Policy: Page 9:V Coordination of Wraparound Services: B Plan of Care Development: 4b (submitted 1.1a)
(c) Once the family and team agree on goals, strategies, timelines, and responsibilities, the facilitator helps solidify the information and reviews the initial plan of care with the team and awaits the family’s agreement to ensure all have a shared understanding of the plan. This is on the standing agenda and is documented as a CFT/ICC meeting in the youth file. It is referenced in the HFW policy. Evidence: HFW CFT POC Development phase Agenda: Page 1: Plan of Care (submitted 1.8d); HFW Policy: Page 8: V Coordination of Wraparound Services: B Plan of Care Development; Plan of Care (first submitted 1.1a)
(d) Throughout wraparound our Facilitator norms the process by setting an environment with the goal to explore multiple options the family might be able to use and consider which is the best fit for their family. All voices will be heard as the facilitator continues to gather the team ideas of options and strategies to meet the goals. The CFT agenda documentation captures various options that can be used if the first options are not effective. This is reflected in the HFW policy. Evidence: HFW CFT Agenda: Plan of Care Development Phase: Page 1: Plan of care (submitted 1.8d); HFW Policy: Page 9: V Coordination of Wraparound Services: B Plan of Care Development: 4b (submitted 1.1a); HFW Policy: Page 10: V Coordination of Wraparound Services: C Implementation: 2b (first submitted 1.1a)
(e) Our facilitators will have training which will include but not limited to IP-CANS through Praed foundation, IP–CANS Collaborative Assessment and Planning through Teaming, (UC Davis, as available), and Child and Family Team Meetings: Facilitation Training, (UC Davis) and KernBHRS training SCRIPTS POC training. In addition, basic attending skills will be supported through regular supervision, and coaching. Through use of the TOM 2.0 outcomes will be used to identify facilitator’s specific skill development to improve successful interventions and effective outcomes for families. Evidence: 5.1.30 IP-Cans Policy: Page 2: Background: Praed Foundation (first submitted 1.3b); Training Plan: Page 4: Training Matrix: IP-CANS training: Child and Family Team Meetings: Facilitation Training (first submitted 1.2c); SCRP Care Planning Training flier: Page 1 ( first submitted 4.2e); HFW Coaching log: page 1 (first submitted 1.3d)
(f) As we prioritize needs, the plan of care begins to be formed with clear goals, strategies, timelines and team assignments and documented in the youth’s file. The family and CFT members are guided to ensure that there is consensus within the group on what the priorities will be and the plan of care that has been developed is reflective of an effective path to meet the family’s individualized needs. Evidence: HFW Policy: Page 9: V Coordination of Wraparound Services: B Plan of Care Development: 4 a-e (first submitted 1.1a); Mock Plan of Care: Page 1-9 (first submitted 1.3a)
4.3 Develop an Individualized Child or Youth and Family Plan
(a) KernBHRS offers staff training on creating collaborative care plans, as detailed in the attached “Care Planning – Strategies for Engaging Patients and Providers”. In addition, as reflected in the HFW training plan through supervision and coaching sessions collaborative planning practices that incorporate the HFW principles to ensure fidelity is reinforced. Evidence: SCRP Care Planning Training flier: Page 1 (first submitted 4.2e); Training plan: Page 2: supervision: (Submitted in 1.2c)
(b) Under the Integrated Core Practice Model, cross-system coordination ensures that all partners, including but not limited to Kern Probation, Kern Department of Human Service, educational partners and KernBHRS, work together toward a unified family plan. The HFW Team is a multi-disciplinary team composed of behavioral health staff, CWS social worker, and probation officers that are co-located on the behavioral health site. This partnership is long standing and memorialized in the Multi-agency integrated services team and High-fidelity wraparound team service team MOU (MIST HFW MOU) Strong relationships among partners facilitate focused family meetings, problem-solving, and alignment of larger systems to better serve families and ensure a well-coordinated Plan of Care. The HFW CFT agenda’s documents all team members who are present for each CFT. Evidence: MIST HFW MOU: page 1: D Whereas (first submitted in 3.4b); HFW CFT Agenda: Implementation phase: page 1: members present (first submitted 1.9b)
(c) As consensus is reached, with deference to the family voice, all information in 1 – 6 have been gathered and documented in previous CFT Meetings and this information is brought forward to establish a plan of care for family. Once Plan of care is created in the EHR, it is provided to CFT Members. Evidence: Mock Plan of Care: throughout document (first submitted 1.3a); HFW Exhibit A: Page 3: 6.CFT meetings 😀 (first submitted 1.1a)
(d) Procedures ensure that plans of care are regularly reviewed for continuous quality improvement. The DART will be utilized to review the plan of care. The Performance Management Team will regularly provide CQI reports that will be given to the provider teams with feedback being used by the supervisor and fidelity coach to work with staff to amend plan of care as needed. Evidence: CQI Plan: Page 3: last paragraph, and Page 4 Goals & Objectives (Submitted 1.1a)
4.4 Develop a Crisis and Safety Plan
(a) Understanding that discussing crisis and safety planning can be sensitive for families, within the CFT meeting, the facilitator works to underscore the need to treat the information shared with sensitivity. In addition, it is shared with the family that it is brought forward in the spirit of care and wanting safety and wellbeing for the youth and family. The Facilitator will review the previous crisis and safety plan that was developed in the engagement phase, and with the family and team, assess its effectiveness, identify new risk factors and triggers that need to be added, and determine proactive interventions to prevent escalation. Included in the plan are any new formal and natural supports that can help to enrich the strength and effectiveness of the plan. Updates to the crisis and safety plan are recorded in the youth’s file. This plan is available after hours to all behavioral health providers, including on-call wraparound staff, 988, crisis stabilization unit, or any other provider in the KernBHRS system of care. Other involved CFT members are provided with a copy. Evidence: Mock Crisis plan: entire document (first submitted 3.2a); Mock Safety plan: entire document (First submitted 3.2b); HFW Policy: Page 8 and 9: V Coordination of Wraparound Services: B Plan of Care Development: 1 and 1a (submitted 1.1a)
(b) The development of the crisis and safety plan occurs within the CFT meeting. In terms of training, KernBHRS implemented the Zero Suicide framework in 2019, and all staff are trained in this model which includes detailed safety and crisis assessment/preventative planning. In addition, KernBHRS provides the SCRPT Care Planning – Strategies for engaging patients and different human service and clinical service providers in cohesive treatment planning which teaches strategies and skills to facilitators to support the creation of team-based plans. In addition, an ongoing consultation series for CBT-Suicide Prevention is available for staff to receive consultations on risk management and safety planning from an expert in this area. The facilitator uses this training in addition to coaching received from supervisor to collaborate with the CFT to develop a comprehensive crisis and safety plan. Evidence: Zero Suicide PowerPoint: entire training document (first submitted 3.2a); SCRP care planning training flier: page 1 (first submitted 4.2e); CBT-SP consultation: page 1 (first submitted 1.5b); Mock Kern County Progress Note ICC-assessment plan: Page 1: Safey/crisis plan (submitted 1.2a)
(c) The facilitator develops and reviews crisis plans with the family and CFT members to ensure they reflect family preferences, values, culture, and use natural support. These plans are actionable and specific. Crisis plans are reviewed by supervisors but also in provider team meetings to ensure the entire provider team is aware. The review includes identified strategies, roles, plan for both immediate crisis and possible future risks, utilization of cultural preferences, formal, natural and community supports and any identified amendments. Evidence: Crisis plan: entire document (first submitted 3.2a) and safety plan: entire document (first submitted 3.2a); HFW provider meeting: Page 1: VI c: crisis safety plan review (first submitted 1.1a)
Implementation
5.1 Implement The Plan of Care
(a) Kern wraparound teams will utilize the principles of HFW to systematically implement the plan of care, ensuring careful tracking of action steps and monitoring progress. The facilitator will begin the meetings by reviewing needs, strategies, approaches, and action steps from the last CFT meeting, and any new information that has arisen between meetings. On the CFT agenda, strategies and action steps from the last CFT meeting is a standing agenda item. The action steps from the last meeting, in combination with the plan of care documents, are used to focus the team on reviewing progress that has been made, and any needed updates to the plan of care or strategies. Each team member attends to both individual and joint responsibilities according to their roles. The DART will be used to ensure services are documented and fidelity is being adhered to. Evidence: HFW Policy: Page 10: V Coordination of Wraparound Services: C Implementation: 2 a, b and c: (submitted 1.1a); HFW CFT Agenda Implementation Phase: page 1: Plan of Care Review (submitted 1.9b); Mock Plan of Care: Page 4:Prioritized Need #1 & Optional Strategies: Page 5 Selected Strategy and Action Steps: Page 6: additional notes for this need (first submitted 1.3a)
(b) We find joy in celebrating both small and large successes with our families. These achievements inspire the family and the team and encourage the continued embracing of recovery. The celebrations of these milestones are provided in deference to the family’s preferences and consideration of any cultural traditions that the family values. In addition, should flex funds be needed staff are trained in the process of accessing these funds. In supervision and provider staff meetings staff are coached regarding implementation of the plan of care to fidelity and recognizing successes as families meet their goals. Evidence: Training Plan: Page 3: Coaching (first submitted 1.2c); HFW Provider Meeting Agenda: Page 1: II coaching and consultation needs and Section VI: g (first submitted 1.1a)
5.2 Review and Update The Plan of Care
(a) The facilitator is trained in the 10 principles of wraparound that guide the activation of the Plan of Care. Progress will be monitored through various methods, including the WFAS outcome system specifically the TOM 2.0 to provide observations of how the team is functioning in relation to reviewing actions, progress and strategies for the family’s plan of care. Before the CFT meeting, the facilitator and provider team will review feedback from TOM 2.0 outcomes, supervision, and coaching sessions to prepare for the meeting. It is crucial for the facilitator and the provider team to understand the feedback from outcome measures to evaluate the Plan of Care’s effectiveness, assess progress, and update strategies as necessary. Using the HFW CFT Agenda, the facilitator will lead the CFT in reviewing the plan of care including each action step and strategy, determining whether service delivery has been effective or if other strategies need to be considered. Any changes or updates to action steps or the overall Plan of Care and the CFT meeting documentation in the youth’s record. Evidence: HFW Policy: Page 10: V Coordination of Wraparound Services: C Implementation:1, 2, and 3 (first submitted 1.1a); HFW CFT Agenda Implementation phase: Plan of care section (Submitted 1.9b); Mock Plan of Care: Page 4: optional strategies: Page 5 Selected Strategies: and Page 5: Action steps (first submitted 1.3a)
(b) As the team provides feedback, the facilitator will help the CFT members identify new needs, celebrate successes, and seek group consensus to update the plan of care with new or completed goals and strategies. Successes are also reviewed and recognized. The documented plan of care will be a structured tool reviewed by the team to inspire conversation, implement necessary changes, and assess service effectiveness. Evidence: HFW Policy: Page 10: V Coordination of Wraparound Services: C Implementation: 2 a, b and c (first submitted 1.1a) ; HFW CFT Agenda: Implementation Phase: page 1: Plan of Care Review and Transition plan/celebrations (Submitted 1.9b)
(c) The CFT meeting and review of the plan of care is documented in the youth’s records by the facilitator, noting all changes to the plan of care as well as completion of the HFW CFT meeting agenda documentation, including new needs, new action steps, and strategies, team attendance, use of formal and natural supports, and use of flex funds. Evidence: HFW CFT Agenda: Implementation phase: page 1: Members present, Plan of care, and Strengths, culture, natural and community supports, flex fund (submitted 1.9b); Mock Plan of Care: Page 1: Family/Team Members: Page 6: Prioritized need #2: Page 6-7: Optional Strategies, Page 7: Selected Strategy and Action Steps: Page 10: recent successes and celebration (first submitted 1.3a)
(d) Services are able to be amended in the EHR per attached training instructions as teams identify changes that are needed and upon doing so the new plan of care shall be provided to CFT members. Evidence: How to amend a signed document Page 2 (first submitted 1.5a)
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
(a) Team cohesion and trust form the foundation of the wraparound process. Without this foundation, teams can easily become disjointed or work at cross-purposes. Regularly checking communications and the overall health of the team helps to ensure that negative feelings do not fester, as these can undermine the family’s progress. The Team agreement is integrated at the top of the CFT agenda as well as the family vision statement to have these readily available for the group, and as needed can be reviewed in the CFT meetings. Evidence: HFW CFT Agenda: Implementation Phase: page 1: Family Vision and Team Mission Template (submitted 1.9b)
(b) Kern will aim to utilize our most experienced staff for the role of facilitators; these individuals will primarily be clinically trained, licensed, and waivered clinicians or have multiple years of experience in Behavioral Health. the majority of the facilitators have received basic group skills training in their clinical programs. They are trained in essential group processes, including building cohesion and managing conflicts through their clinical programs. Facilitators will also as available be enrolled in the UC Davis, Child and Family Team Meetings: Facilitation Training for Wraparound Practitioners. In addition, various methods including role playing, shadowing of staff, co-facilitating meetings in order to mentor new skills, and observation of the facilitator to provide specific feedback and suggestions of skills to improve performance as a focus of coaching sessions would support continuous quality improvement. Evidence: Kern County Behavioral Health Therapist I Classification: Page 2: employment standards (first submitted 5.3b); Training Plan: Page 4: Child and Family Team Meetings: Facilitation Training for Wraparound Practitioners (first submitted 1.2c); HFW Coaching Log: Page 1 (first submitted 1.3d)
(c) A major goal in the wraparound process is to bridge and integrate long-term natural supports for the family. To ensure that this intervention is useful for the family, it will be monitored through the utilization of the DART. Supervisors and fidelity coaches will use the DART to determine where increased coaching is needed to integrate use of natural supports. Ongoing agenda items in provider team meeting agendas are also used to monitor information and the effectiveness of staff’s use of natural supports. Evidence: HFW Coaching Log: Page 1 (first submitted 1.3d); HFW Provider Meeting Agenda: Page 1:VI: e (submitted 1.1a)
(d) While maintaining cohesion and consistency of team members is important, there may be times when new members need to be added to address the family’s needs. It’s crucial to do this with the family’s permission and to thoroughly orient the new member on confidentiality, the plan of care, progress made, and the specific role and needs the new member can address. This will be discussed at the onset of services with the family and CFT members in order to normalize the process. As this need arises the new member will be invited and oriented prior to coming into the meeting and then through introductions with the entire CFT the team agreement can be reviewed, the role of the new member and the responsibilities assigned and documented. To help build cohesion the facilitator may use icebreakers to help build connections. Evidence: HFW Policy: Page 6: V Coordination of Wraparound Services: A Engagement: 6b; HFW Policy: Page 10: V Coordination of Wraparound Services: C Implementation: 2c: i (first Submitted 1.1a); HFW CFT Agenda: Implementation Phase: page 1: welcome new members (submitted 1.9b); Team engagement activities: page 2 (first submitted 3.4d); Team agreements are utilized, reviewed regularly, and present at HFW team Meetings.
Transition
6.1 Develop a Transition Plan
(a) The transition plan for families begins at the onset of wraparound. As the team is beginning the engagement phase they are looking forward and encouraging the family to continue to hold hope for their family’s vision statement. Our team has these conversations early in the process so that there are clear markers for when the needs of the family have been successfully completed, defining success with the family and CFT members and actively reviewing progress and remaining needs throughout the wraparound services. As the plan of care is being developed a transition plan is developed with clear indicators of success. This transition plan is updated, reviewing action steps, strategies, progress, and timelines and determining if service provision will yield effective outcomes or if adjustments are needed. As family’s needs are resolving the facilitator assists the family and team to review if family is ready to transition and what supports will be needed. Discussion about transition plans is a part of the standing agenda in the regular review of the plan of care goals as reflected in CFT HFW agenda, this transitional planning is documented in the CFT documentation as well as plan of care. Evidence: HFW Policy: Page 9: V Coordination of Wraparound Services: B Plan of Care Development: 4d; HFW Policy: Page 10: V Coordination of Wraparound Services: D Transition: 1 (first submitted 1.1a); HFW CFT Agenda: Page 1: Implementation phase: Transition plan section (submitted 1.9b); Mock HFW CFT Agenda: Transition phase: page 2: Review of remaining needs and Readiness for Transition: (first Submitted 1.11b); Mock Plan of Care: Page 7: action steps and target completion/completed dates and Page 8 and 9: Transition plan (first submitted 1.3a)
(b) As our family is nearing the transition from wraparound services, the facilitator reinforces and helps the team to celebrate the good work of the family in a way that is meaningful to the family. The facilitator guides the team, ensuring to frame the graduation from HFW as a success for the family. The family and team begin to identify how the transition will occur. The team reviews the natural and community supports that have been integrated and the effectiveness of the fostering connection to these non-formal supports, assessing if natural relationships and community supports are prepared for this transitional bridge. The facilitator will lead the family and CFT members in reviewing, amending and eventually concurring with the transitional plan ensuring if there are any ongoing needs that a strategy is in place to meet this need. The HFW CFT agenda for the transitional phase is used to guide and document the plan. The plan of care is also updated as needed. Evidence HFW Policy: Page 9: V Coordination of Wraparound Services: B Plan of Care Development: 4d (first submitted 1.1a); HFW Policy: Page 10: V Coordination of Wraparound Services: D Transition: 1a and b (first submitted 1.1a); Mock HFW CFTM Agenda: Transition Phase: entire document: (Submitted 1.11b); Mock Plan of Care Page 8 and 9: Transition plan (first submitted 1.3a)
(c) In developing an individualized transition plan, the facilitator brings forward a review of the plan of care, evaluating the progress that family has made in completing goals. If the predetermined benchmarks have been met, the team discusses what needs are left and if the needs can be met by natural or community supports and ensures that the family is actively involved with these resources. If the family and the CFT members agree that transition is appropriate, then the facilitator leads the team in developing a specific transition plan that seeks to anticipate possible needs and ensures that the family has been bridged to those resources. The HFW CFT Agenda -Transition Phase is used to guide and document the transition plan in addition to the plan of care being updated in the youth records. The facilitator receives training through attendance of the UC Davis Transition Skill Lab as available. In addition, using feedback from the DART, coaching and supervision will provide support and feedback to the staff on developing and activating an effective transition plan. Evidence: HFW CFT Agenda: Transition Phase: entire document (submitted 1.11b); Mock Plan of Care: Page 8 and 9: Transition plan (first submitted 1.3a); Training plan: Page 4: training matrix: Transition skill lab (first submitted 1.2c)
(d) During completion of the transition plan the parent partner will help to verify that support will continue to be available once the family ends the HFW process with discussion of findings in the CFT. Typically, at this stage the family has already been introduced and incorporated into community and natural supports for their family, and as possible these supports are engaged in the CFT meetings. However, upon verifying the transition plan if there is an organization/support that the family feels less familiar with the parent partner can help to re-introduce the family and gather a specific name and phone number so that the family has a relationship they can call on if needed and a warm hand off can be arranged. The verification of these services is documented in the CFT Transitional phase agenda, with details of organizations, names and phone numbers being provided to the family. If family was post adoption, coordination would include the DHS adoption unit. Evidence: HFW Policy: Page 9: V Coordination of Wraparound Services: B Plan of Care Development: 4d (submitted 1.1a); Mock HFW CFT Agenda: Transition Phase: Page 3: Natural and Community Supports (submitted 1.11b); Mock Plan of Care: Page 8: Transition plan (first submitted 1.3a)
6.2 Develop a Post-Transition Safety Plan
(a) As a part of the transition plan the facilitator will help the family and the team to identify possible crisis situations that could arise after the completion of wraparound services. Based on this feedback, a specific crisis and safety plan will be developed. The team will review the previous safety and crisis plan and determine if the plan would still be effective and accurate or what updates need to be added, ensuring to review the natural and community supports that had been on the original plan or adding in new resources as needed. Ensure that the plan also includes what to look for, that may be a sign of a pending crisis or safety issue and what proactive action steps can be taken to prevent a crisis. The team also assists to identify natural, and community supports that can fill this need as wraparound services end. These updates are documented into the HFW CFT agenda and in the plan of care. Evidence: Mock HFW CFT Agenda: Transition Phase: page 3: Natural and community supports and page 4 Crisis/safety plan (submitted 1.11b); Mock post safety/crisis plan: Page 1: My warning signs of potential crisis (first submitted 6.2a); HFW Policy: Page 10: V Coordination of Wraparound Services: D Transition: 1c (submitted 1.1a); Mock Plan of care: page 9: Transition Plan: safety and crisis planning (first submitted 1.3a)
(b) The creation of the crisis and safety transition plan will occur in the supporting environment of the CFT meeting and as transition begins a review of the safety plan is updated in the Plan of care that is documented in the EHR. Teams will review previously established safety, and crisis plans and work together to update with any anticipated events and a plan to address future needs. Facilitator and provider staff are trained in SP-CBT and Zero Suicide protocols and will use this knowledge to build a comprehensive crisis and safety transition plan, including managing closure and any anxiety that family may have has the leave wraparound. In addition, the facilitator will attend the UC Davis Safety and Crisis Planning Skills Lab as this training is available. Furthermore, SB-CBT consults are available from a contracted expert. Evidence: Mock Plan of care: page 9: Transition plan: safety and crisis planning (first submitted 1.3a); Mock HFW CFT Agenda Transition Phase: Page 4 safety and crisis planning (first submitted 1.11b); Mock Post safety/crisis plan: Page 1: My warning signs of potential crisis (first submitted 6.2a); CBT SP Consultation (first submitted 1.5b); Zero Suicide Power point: entire document Training slides (first submitted 3.2a ); Training plan: page 4: Matrix Safety and crisis plan lab. (first submitted 1.2c)
(c) Crisis and safety plans are part of the regular CFT agenda items and are documented in the youth’s record. The supervisor will use DART for regular reviews to ensure strategies, cultural, natural, and community support are appropriate. Crisis and safety plans are reviewed in HFW provider meetings with a focus to ensure they are individualized, respect family preferences and culture, use natural supports, and have effective actionable steps. Staff will attend UC Davis natural and community support training as available. Staff attend Kern’s Network for Children Collaborative that provides ongoing updates on new community resources that are used to meet the needs of our youth and families and these are integrated into the plans. Evidence: CFT HFW Agenda Implementation stage: page 1: Safety/crisis plan (first submitted 1.9b); Mock CFT HFW Agenda: Transition phase: page 4: Crisis/Safety Plan (first submitted 1.11b); HFW Provider meeting agenda: page 1: VI:c Crisis. Safety plan reviews (first submitted 1.1a); KCSOS: Collaborative meeting: (first submitted 6.2c); Training plan: page 4: Matrix Safety and crisis planning & KCSOC Network for Children (submitted 1.2c)
6.3 Create a Commencement and Celebrate Success
(a) Who does not like a good celebration? As families are meeting their goals and are ready to transition from formal support to the care they have found in their family, friends, community, culture and traditions, the family is supported in planning a celebration of their success. This ritual of celebration not only provides closure but more importantly helps to build confidence and pride in their accomplishments honoring the efforts they have made and setting the stage for the family’s continued success. As reflected in the HFW CFT agenda the team invites the family to share how they would like to celebrate including the family’s preferences, values, and culture and a plan is developed. Evidence: Mock HFW CFT Agenda: Transition Phase: page 1: Strengths, successes, and celebration and page 4: Transition target date and celebration (first submitted 1.11b); HFW Policy: Page 11: V Coordination of Wraparound Services: D Transition: 2a (submitted 1.1a)
(b) As the family decides on their celebration and guest list, the team uses the family’s preferences with planning the location, confirming community resources, accessing necessary flex funds, and other details to ensure a meaningful celebration. The date of the celebration is decided within the CFT meeting so that all members can coordinate their calendars. The flex fund process is outlined in the in the Request process and a trainings will be provided to staff via coaching, sessions, team provider meeting/booster training and supervision to ensure they are aware of processes. Evidence: Flex fund availability and request: Page 2 (first submitted 1.10b); Flex Fund: Page 1 (first submitted 6.3b); Training plan: Page 3: Coaching(first submitted 1.2c); HFW Provider Meeting Agenda: Page 1:VI:g Upcoming transitions and celebrations (first submitted 1.1a); Mock HFW CFT agenda: Transition Phase: page 4: Transition target date and celebrations. (submitted 1.11b)
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
(a) As HFW is implemented, DHS, Probation, and KernBHRS will collaborate to ensure that the opinions of youth and families are solicited to obtain crucial feedback on service delivery and the overall implementation of wraparound. Kern DHS, Kern Probation, and KernBHRS are strongly committed to engaging with our community and have a robust history of outreach through stakeholder groups and participation in events such as school and community health fairs. Our organizational structure features a fluid relationship among these three lead agencies, as demonstrated in the attached documents. Initial planning of how the Community Leadership Team (CLT) will be imbedded into Kern’s HFW structure is noted in System of Care Interagency Team (SOCIT) meeting minutes. Additionally, examples of MHSA stakeholder processes that routinely engage input from our community include both children-focused and broader system initiatives. One such example involving children is the introduction of the Futures Team, which is implementing Kern’s youth justice initiative. In addition to the CLT we will continue to utilize our outreach to stakeholder’s using our BHRS infrastructure for targeted engagement regarding wraparound services. Evidence: KC HFW Leadership Team Structure: page 1 (first submitted 7.1a); SOCIT Meeting Mins: Page 2 (first submitted 7.1a); MHSA community forum minutes: Page 1: V: Juvenile Justice Future Focused Team (submitted 7.1a); MHSA community forum PowerPoint: page 4: Youth Juvenile Justice Future Focused Team (submitted 7.1a); MHSA community forum Youth Juvenile Justice Initiative Future Program: page 1 (first submitted 7.1a)
(b) Kern has frequent stakeholder meetings as evidenced in MHSA community and youth engagement in community stakeholder forums in 7.1a. Another specific example is that KernBHRS is constructing a facility to enhance crisis services including a family resources center. During the facility’s development, KernBHRS collaborated with the Kern County Superintendent of Schools to hold a stakeholder meeting at the Dream Center, which serves as a one-stop resource hub for TAY population. The purpose of this forum was to gather feedback from the youth on what features would make the facility feel safe, nurturing, and welcoming for both youth and families seeking services. This was a robust conversation that has impacted how we have moved forward with the design and service goals for our children’s crisis and Family resource center. As HFW implements we will continue to utilize this infrastructure and model to hold stakeholder meetings to ensure that our programming of HFW is youth and family driven. Evidence: BHCIP Stakeholder Presentation: page 3 and 10 (first submitted 7.1b); Community Youth Engagement and Planning Forum: page 4, and 5 (first submitted 7.1b)
7.2 Community Leadership Team
a) Discussions and planning in our System of Care Interagency Team have occurred to determine the development and implementation of the Community Leadership Team (CLT). The CLT will be established, and stakeholders will be invited to actively participate in shared decision making in regard to the implementation and ongoing provision of HFW. The Community Leadership Team that will be invited will include but not limited to family members, HFW Providers, Tejon Indian Tribes, Bakersfield American Indian Health Project (BAIHP), HFW providers, as well as Kern Probation, Department of Human Services, KCSOS, Regional Center, Department of Rehab and KernBHRS. A standing agenda will provide structure to maintain Wraparound standards and support ongoing quality improvement. Evidence: SOCIT Meeting Mins: Page 2 (first submitted in 7.1a)
b) Kern regularly includes providers in collaborative meetings to ensure coordinated services. One example is our CSOC foster care meeting that includes all children’s providers as well as probation and child welfare. This meeting, like many of our meetings, works to provide cross-system updates and streamline cross-system coordination. As Wraparound implements, we will continue this best practice using the same structure and existing cross system relationships to ensure that providers are invited to join the Community Leadership Team. Child Welfare also established tribal consultation policy that was developed as part of the implementation of the Interagency leadership team, AB 2083. Additionally, The Tejon Indian Tribe has participated in Kern’s System of Care Interagency Team (SOCIT), a subcommittee of the Interagency Leadership Team, and will also be invited to the Community Leadership. Team. Evidence: Foster youth agenda: page 1 (filled in 1.9d); Community Leadership Team Standing Agenda: page 1 (first submitted 7.2b); Kern DHS Tribal Consultation Policy: page 1 (first submitted 7.2b)
(c) Kern regularly includes providers and engages in stakeholder meetings for coordinated services. This structure and our strong cross-system relationships will ensure members of our Community Leadership Team including providers, tribes, families and other community members will be integrated into both the SOCIT quarterly meeting and the Bi-annual Interagency Leadership Team meeting. A structured agenda will be used in the CLT meetings to ensure all areas 1-6 above are addressed. Evidence: Community Leadership Team Standing Agenda: Page 1: entire document (first submitted 7.2b); AB 2083 Structure: page 1 (submitted 7.2c); KC HFW Leadership structure: page 1 (first submitted 7.1a)
(d) The Community Leadership Team will meet with the Interagency Leadership Team bi-annually or as needed. Additionally, they will meet quarterly with SOCIT, a subcommittee of the ILT, and may refer items to the ILT or SOCIT for discussion. A structured agenda will be used in the CLT to ensure all areas 1-6 above are addressed. Evidence: Community Leadership Team Standing Agenda: Page 1:(First submission 7.2b); CQI Plan: Page 6: Data Collection & Monitoring (First Submitted 1.1a)
(a) For KernBHRS internal wraparound providers, the clinical supervisor will attend the Community Leadership Team.
7.3 Eligibility and Equal Access
(a) The criteria for referrals are outlined in the HFW Policy and in the provider contact Exhibit A. Brochures with program details have been created to ensure the information is readily available to families and the community. Evidence: HFW Exhibit A: Page 1: 2. Eligibility Criteria (first submitted 1.1a); HFW Policy: Page 2 and 3 : I Eligibility Criteria: A, B and C (first submitted 1.1a); HFW family brochure: page 1 (first submitted 3.1a)
(b) To ensure wraparound services meet youth and family needs, the wraparound supervisor will evaluate all referrals through consultation and by reviewing records including the IP-CANS and assessment to ensure that the family receives services that best meet the family’s needs. Criteria that are used is outlined in the HFW policy and the exhibit A of the provider’s contract. In addition, for youth that are dependent or wards, referrals for HFW (previously AB163) are a standing agenda item for Special Multi-Agency and Referral Team (SMART) so that referrals can be streamlined with system partners. Evidence: HFW Policy: Page 4: III Referral to HFW: 4. (submitted 1.1a); HFW Exhibit A: Page 2:5 Service Delivery Phase (submitted 1.1a); SMART Agenda: Page 1: II Wraparound SB163 (submitted in 7.3b)
(c) Through the CQI Plan, Kern BHRS will utilize the KPIC reports similar to how we currently monitor timeliness of initial request to first offered service to monitor timeliness and waitlist. In addition, when referrals are brought to SMART they are placed in the minutes and followed up in the following week’s meetings until the referral is completed. This ensures that no referrals are overlooked and that families receive timely access to the necessary services. Evidence: Timeliness of initial request report: page 2 (submitted 1.1a); SMART Agenda: Page 1: II Wraparound SB163 referrals (submitted 7.3b); CQI Plan: Page 8: Improvement Activities (Submitted 1.1a)
(d) Wraparound services are available 24/7, with staff assigned on a rotating basis and carrying an on-call phone as shown in template for after-hours on call calendar. Kern County utilizes availability pay to support this service. This is a long-standing practice that has ensured continuous, uninterrupted support for families, addressing any crises promptly and efficiently. It is also reflected in the contract provider exhibit A standards. Evidence: Wraparound After hours on call Schedule: page 1 (First Submitted 7.3d); SEIU 521 MOU: page 3 and 4: Availability pay (Submitted 7.3d); HFW Exhibit A: page 4: D Staffing Availability (Submitted 1.1a)
(e) Details about the program will be available in brochures on county agency websites as it is implemented. In addition, Kern County will also share information through collaborative meetings. For instance, in KernBHRS Children’s Treatment and Recovery Committee, which is an open meeting to partners and the public, regular information will be provided to this committee as it implements. Evidence: HFW Family Brochure: entire document (Submitted 3.1a); Children’s Treatment and Recovery Committee: page 2: Department Reports (Submitted 7.3e)
Provider Procedures Ensure:
a. KernBHRS wraparound team will adhere to the criteria that are established in the wraparound policy and the provider contract and will not exclude based on severity or nature of need. Evidence: HFW Policy: Page 4: 4 (submitted 1.1a); HFW Exhibit A: page 2: 5 Service delivery phases (Submitted 1.1a)
b. KernBHRS will adhere to the contract standards outlined in the provider’s contract. 24/7 crisis support is available for families through the wraparound on call phones. As outlined in the exhibit A case load sizes are planned to be between ten (10) and twelve (12) youth. Evidence: HFW Exhibit A: page 4: 10. Caseloads (submitted 1.1a); Wrap around after hour on call schedule: page 1 (submitted 7.3d)
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
(a) To meet the services and support needs of our youth and families, we will use funding from Medi-Cal and BHSA FSP. Matching funds may include Child Welfare Realignment, BH Realignment, FFPSA Aftercare Funding, and County General Funds. Kern DHS, Probation, and KernBHRS have had an integrated service team for over 20 years, and this partnership will continue under the MIST HFW MOU with some updated new language. We have been meeting jointly to determine shared funding strategies that all partners have agreed to and will be included in the MIST HFW MOU. The attached MOU will be renewed in Spring 2026 due to Kern’s contracting schedule. Evidence: HFW Policy: Page 2: Background (submitted 1.1a); MIST HFW MOU: Page 2: 4. Compensation C.1 (first submitted 3.4b)
(b) Funding has been allocated for workforce development and staffing. Kern DHS, Probation, and KernBHRS have had an integrated service team for over 20 years, and this partnership will continue under the MIST HFW MOU with updated new language including for shared funding that all partners have agreed to. The attached MOU will be renewed in Spring 2026 due to Kern’s contracting schedule. In addition, attached are descriptions for each staff role that will be utilized in HFW service delivery. Evidence: MIST HFW MOU: Page 2: 4 Compensation C.2 (first submitted 3.4b) HFW Role descriptions: entire Document: (first submitted 8.1b)
(c) Through KernBHRS IT and QID teams the Wraparound Fidelity Assessment System (WFAS) and IP-CANS will be utilized to track fidelity and outcomes. This data will support shared decision-making, improve service quality, ensure compliance with state regulations, and hold agencies accountable for enhancing care. Funding streams include BHSA funds, KernBHRS realignment funds, Title IV-E, Title IV-B, Family First Prevention Services Funds, and Child Welfare Realignment. Kern DHS, Probation, and KernBHRS have had an integrated service team for over 20 years, and this partnership will continue under the MIST/HFW MOU with some updated new language and fiscal shared funding that all partners have agreed to. The attached MOU will be renewed in Spring 2026 due to Kern’s contracting schedule. Evidence: MIST HFW MOU: Page 3:3 DATA COLLECTION (first submitted 3.4b)
8.2 Equitable Funding Across System Partners
(a) The MIST HFW MOU outlines collaborative work and funding across system partners. As HFW implements, Kern County will continue to meet consistently to develop processes to identify any new available resource that can support the expansion of the HFW model. Evidence: MIST HFW MOU: Page 2: 4. Compensation and shared fiscal responsibility: A-G (first submitted 3.4b)
(b) Kern County is engaged in reviewing past processes and cost of services to assist projecting future financial needs. Kern DHS, Probation and Behavioral Health will continue to meet for system design, implementation, and budgeting. Strategic planning is occurring through this ongoing partnership with the goal of leveraging resources and reviewing specific funding sources that may be utilized. The updates to the HFW MIST MOU are a result of these partnership meetings. Evidence: MIST HFW MOU: Page 2: 4. Compensation and shared fiscal responsibility: A-G (first submitted 3.4b)
(c) Kern County partners have coordinated and shared staff for many years and will continue to build on these strong relationships. The MIST HFW MOU between DHS, Probation and KernBHRS was established more than 20 years ago and continues to be supported by all agencies. This MOU creates multi-disciplinary service teams that embed a DHS social worker, probation officer and behavioral health staff together in one team. Similarly, KernBHRS provides staff to DHS to be a liaison to the Behavioral Health System of Care. Through the MIST HFW MOU integrated teams have been established for both Treatment Foster Care and Wraparound Service Teams. These integrated teams help to ensure that strong cross-system coordination of services occurs. The MIST HFW MOU reflects system operations and outline cost-sharing among agencies that will support High Fidelity Wraparound. Evidence: MIST HFW MOU: Page 2: 4. Compensation and shared fiscal responsibility: A-G (first submitted 3.4b)
(d) Kern County partners have engaged in exploring funding sources with a commitment to leverage resources across our systems. Strategies to continue this expansion include leveraging private insurance when applicable, continuation of MIST HFW MOU with cost sharing agreements, and further exploration of Federal IV-E and IV-B funding. Evidence: MIST HFW MOU: Page 2: 4. Compensation and shared fiscal responsibility: A-G (first submitted 3.4b)
8.3 Cost Savings are Reinvested
(a) In order to utilize cost saving strategies and reinvestment, as HFW implements Kern will track reduction of cost over time. The most significant impact is the realized cost savings that may arise from a lower-level placement, which can help avoid STRTP, hospitalization, or other higher levels of care. In addition, through the leveraging and braiding of funding streams, resources will be enhanced and enable us to build capacity with this cost savings. Kern will also rely on our generous community to leverage community resources. Central to the HFW model, the family wraparound plans will be created to meet the needs of family utilizing community support which will replace the need for the cost of formal supports. Evidence: Wraparound cost saving plan (first submitted 8.3a)
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 are recognized as a critical component to success of our families. The Flex Fund Availability and Request Processes have been established to ensure that funds are available to meet the specific unmet needs of youth and their families. The process of accessing funds and oversight of funds to meet needs in a family’s wraparound plan of care that would not otherwise be met have been agreed on by Probation, DHS and KernBHRS. Furthermore, partners will ensure that flex funds will be included in the upcoming budget and that resources will be braided and leveraged to meet the needs of our families. In addition, to promote clear processes and transparency a training will be provided by the county to wraparound providers of the criteria and process to access flex funds. Evidence: DHS Flex Fund Availability and Request Process: entire document (first submitted 1.10b); Flex Fund: Page 1 (first submitted 6.3b) MIST HFW MOU: page 3: G. Flex funds (first submitted 3.4b)
(b) The Flex Fund Availability and Request Processes have been established to ensure that funds are available to meet the specific unmet needs of youth and their families Evidence: Flex Fund Availability and Request Process:: Page 2: Procedure: 2b (first submitted 1.10b); Flex Fund Availability and Request Process:: Page 2: 10 (first submitted 10.1b); Flex Fund: Page 1(first submitted 6.3b)
8.5 Collaborative Oversight of Flex Funds
(a) To promote transparency regarding the request for flex funds, the amount, purpose and outcome will be reviewed and reported back to the CFT and to SMART. The results of the request will be documented in the family’s wraparound plan and in the SMART Agenda. Evidence: Flex fund availability and request: Page 1 (First submitted 1.10b); Flex fund: Page 1 (submitted 6.3b); SMART Agenda: page 1 III Flex Fund Review (first submitted 7.3b)
(b) Partners will ensure that flex funds will be included in the upcoming budget and that resources will be braided and leveraged to meet the needs of our families as reflected in MIST HFW MOU. Evidence: MIST HFW MOU: page 2: B. Purpose of Cost sharing (first submitted 3.4b); MIST HFW MOU: page 3: G Flex funds (first Submitted 3.4b); Flex fund: Page 1 (submitted 6.3b)
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
(a) Kern County is committed to ensuring the needs of HFW families are met and through collaboration of braided funding will ensure effective flexible funding streams are in place to meet these needs as reflected in MIST HFW MOU Evidence: MIST HFW MOU: Page 2: B. Purpose of Cost Sharing (first submitted 3.4b); Flex fund: Page 1 (first submitted 6.3b)
(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 the gaps. Evidence: MIST HFW MOU: page 2: purpose of cost sharing (first submitted 3.4b); Flex fund: Page 1 (first submitted 6.3b)
(c)To ensure that flex funding is available despite requirements on a funding source Kern DHS, Kern Probation and KernBHRS will coordinate resources and identify other funding sources to meet the needs of families within 24 hours. Evidence: MIST HFW MOU: page 2: A. Statutory and Policy Authority (first submitted 3.4b); MIST HFW MOU: Page 2: Purpose of cost sharing ; Flex fund: Page 1 (first submitted 6.3b)
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
(a) Kern has engaged the Bakersfield American Indian Health Project (BAIHP) to serve and coordinate services for the American Indian Population. KernBHRS has an MOU that has supported increasing referrals between BAIHP and KernBHRS as well as, reducing stigma and increasing KernBHRS’ s knowledge and competency in serving the American Indian population. KernBHRS also has been invited to share in community cultural practices through attendance at some of BAIHP community events. BAIHP has provided presentations regarding their services and cultural considerations when providing services for the Native American Community. In addition, Kern DHS and Probation has a regular meeting with BAIHP to receive consultation about how best to care for youth in care and has a PPSA agreement with BAIHP to support consultation and coordination. Furthermore, all DHS social workers receive training on the American Indian culture and have a liaison within their agency that attend Indian Child Welfare Act (ICWA) trainings and ensure that new information is conveyed to all social workers. These types of opportunities help with an ongoing education and learning that ensures cultural values, that traditions are respected and aid us when serving this population. Evidence by: KernBHRS BAIHP MOU Amendment: Page 3: Scope of work 1B and Page 4: Deliverables: 2C (first submitted 3.4c); Cultural practices and education: Page 1-2: BAIHP Presentation flier and DHS- 32nd Annual California ICWA Conference (Submitted 9.2a) DHS BAIHP Agreement: Page 3: Full Description of the services (Submitted 3.4c)
(b) KernBHRS cultural competence team works to build partnerships that can be leveraged to meet the needs of our families as well as seeks to understand the needs of the community through eliciting feedback from specific community members. In our Cultural Competence plan Criterion 4; clients, family members, and community committee to further integrate into the County Behavioral Health System works to increase collaborative relationships with our community. As a result, multiple subcommittees actively assist to provide a voice for specific groups which includes Hispanic, Asian American Pacific Islander, African American/Black, LGBT+, and American Indian/Alaskan Native subcommittees. The Cultural Competence Resource Committee (CCRC) meets monthly to help cultural advocates, including community partners, contract partners, and staff, work collaboratively on strategies to increase equitable quality of care for our diverse clients on the road to recovery from mental health and substance use challenges. Rooted in our community these relationships are leveraged to help bridge our families, including our wraparound families, to needed community supports. Evidence: Cultural Competence Plan: page 10: Criterion 4 (first submitted 1.7b); Cultural competence Resource Committee minutes: Page 1-5 (first submitted 9.1b)
(c) To support cultural competence, KernBHRS hires bilingual staff for threshold languages and has a certification process to ensure fluency for threshold languages, these staff names are maintained on a roster of spoken languages on a SharePoint link for easy access. Lastly, policy 1.5.1 Accessing Interpreter Services outlines how interpreter services can be accessed, specifically through the Independent Living Center of Kern County or as last resort the use of the Language line. Evidence: Policy 1.5.1 Accessing Interpreter services: Page 4-7: IV Utilizing Interpreter Contractors: A, B and C. (first submitted 9.1c); Cultural Competency Interpreter Services: page 1 (first submitted 9.1c)
9.2 Tribally Responsive Workforce
(a) Kern has engaged the Bakersfield American Indian Health Project (BAIHP) to serve and coordinate services for the American Indian Population. KernBHRS has an MOU that has supported increasing referrals between BAIHP and KernBHRS as well as, reducing stigma and increasing KernBHRS’ s knowledge and competency in serving the American Indian population. KernBHRS also has been invited to share in community cultural practices through attendance at some of BAIHP community events. BAIHP has provided presentations regarding their services and cultural considerations when providing services for the Native American Community. In addition, Kern DHS and Probation has a regular meeting with BAIHP to receive consultation about how best to care for youth in care and has a PPSA agreement with BAIHP to support consultation and coordination. Furthermore, all DHS social workers receive training on the American Indian culture and have a liaison within their agency that attend Indian Child Welfare Act (ICWA) trainings and ensure that new information is conveyed to all social workers. These types of opportunities help with an ongoing education and learning that ensures cultural values, that traditions are respected and aid us when serving this population. Evidence by: KernBHRS BAIHP MOU Amendment: Page 3: Scope of work 1B and Page 4: Deliverables: 2C (first submitted 3.4c); BAIHP Presentation flier: Page 1 (Submitted 9.2a) ; DHS BAIHP Agreement: Page 3: Full Description of the services (Submitted 3.4c); DHS- 32nd Annual California ICWA: page 1 Conference (Submitted 9.2a)
(b) Kern DHS and Probation currently maintain a quarterly tribal partner meeting which is held at the BAIHP building. At this meeting the ongoing needs of Native American youth in care are discussed. This meeting is attended by child welfare, probation, BAIHP, the Owens Valley Career Development center (a local Native American resource) and all local tribes, including Tejon, Kern’s federally recognized tribe. Generally, the format of these meetings is left open to discuss needs as they occur and how to best address the needs of native youth. KCDHS also has a contract with BAIHP to create a Family Advocate position specifically to work with Native American families impacted by the Child Welfare System in Kern. They also maintain a program for our Native American youth, Protecting Our Young Feathers. Kern’s Tribal Consultation Policy helps to guide practices and build communication between the Tejon Tribe and Kern’s ILT to help when serving the American Indian population. KernBHRS staff have attended community cultural practices hosted by BAIHP to provide a better understanding of traditions. KernBHRS has also partnered with the BAIHP to serve the American Indian Population, supported by previously mentioned MOU for mutual referrals and coordination. Evidence: DHS BAIHP Agreement: Page 3: Full Description of the services (Submitted 3.4c); Kern DHS Tribal Consultation Policy; Page 1; Purpose (Submitted 7.2b) ; BAIHP community participation: Pages 1-3: Protectors of our Young Feathers flier; BAIHP Event calendar 2025 and 4th annual Native American Heritage Month Luncheon; “A Celebration of Indigenous Culture. (Submitted 9.2b)
9.3 Flexible and Creative Work Environment
(a) Our Program and Quality improvement processes are firmly rooted in the KernBHRS Mental Health Plan structure with a feedback loop that moves from service level teams to management and back to service teams. Initiated by leadership to balance clear county-wide directives to support quality services while allowing for flexibility to meet community and population specific service needs. The CQI plan is reviewed in a quarterly executive meeting that provides leadership with data and feedback from service provider teams in order to make recommendations for system improvements. As HFW implements the data from Kern’s Continuous Quality Improvement process will be integrated into the KernBHRS Management QID Committee. Results of the QID executive system improvement discussions are shared in the quarterly QID Provider meetings, which are then distributed to provider agencies and implemented by service teams throughout the county. For our wraparound teams, the information from these meetings to promote program quality improvement occurs in our daily morning check-ins and weekly team meetings. The team agenda is designed to focus on our department strategies and directives, while allowing staff to voice their ideas of how best to implement both system-wide and team specific initiatives. Although “Team Corner” is a consistent item on the agenda, these conversations often feel organic, with spontaneous sharing fostering continuous improvement. The team agrees on how necessary changes and improvements will occur, recording them in the meeting minutes. Evidence: CQI Plan: Page 2 Program Overview (Submitted 1.1a); HFW Provider Meeting Agenda: Page 1: IV: b: Team Corner (submitted 1.1a)
(b) We each bring unique values and motivations to this work, yet when we discuss with our teams, we often find shared reasons for choosing a helping profession. Finding these shared reasons is key to our cohesion as a team and connects us to our KernBHRS mission statement, “Working together to support hope, healing and recovery.” Our daily staff team meetings foster trust and transparency, allowing us to connect each morning, creating collective responsibility for the work that will occur on any given day. During weekly staff meetings there is space for team members to participate in “Self-care Check-in Activity” to ensure support is provided as needed. We also provide enrichment activities at both the team and agency levels to promote job satisfaction, connection, staff wellness, and cohesion. Evidence: HFW Provider Meeting Agenda: Page 1: I. Self-care check in (first submitted 1.1a); HFW Provider Meeting Agenda: Page 1: XI: Self Care Check out Activities (first submitted 1.1a); HFW Provider Meeting Agenda: Page 1: IV: b Team corner (submitted 1.1); Staff Enrichment – Bring Your Kid to Work Day and Winterfest page 1 (submitted 9.3b)
(c) Integrating transparency and valuing each staff member’s work, perspectives, and voices fosters open communication within our team and overall system. This supports our shared mission and provides opportunity to integrate discussions that help us adhere to the 10 principles of wraparound and other best practices. Team meetings and individual/group supervision facilitate conversations that promote openness and growth for both our individual staff and our team. Also, it is important that supervisors are readily available for more private consultation to staff to help to foster learning and navigate challenges and create more effective and quality service delivery that will meet family’s needs. On a larger organizational level our KernBHRS director hosts a weekly TEAMS “Director connects” with varying themes for all staff to join and hear updates, ask questions, share about their work on teams and allow for other team building conversations. Evidence: HFW Provider Meeting Agenda: Page 1: IV:b Team corner (first submitted 1.1a); Director Connects Invitation: Page 1: (first submitted 9.3c)
(d) Having a clear mission and compliance with the HFW model requires both head and heart. As a System of Care, we provide policies that will guide practice such as previously mentioned HFW and IP-CANS Policies. Additionally, staff will follow their training plan to ensure ongoing learning of the HFW model and effective service delivery. Equally important is staff embracing the model and understanding on a human level the life changing recovery that the care provided through the wraparound services will help us intimately join with the family as they walk their path of recovery. The shared time in morning meetings helps to foster this environment and binds in this shared mission of service to our community and families. Furthermore, feedback mechanisms such as staff satisfaction surveys or TOM 2.0 (feedback about team dynamics) can provide other information to help support a clear mission and direction of treatment. Evidence: KernBHRS Mission, Vision, and Values Statement: page 1 (submitted 9.3d); HFW Wraparound policy: page 4: IV: Ten Guiding principles, and page 5: V: coordination of Four Phases (Submitted 1.1a)
9.4 Hiring, Performance Evaluation, and Job Descriptions
(a) In forming the HFW teams, Kern will utilize unique positions for all roles, with the exception of clinical supervisor and HFW supervisor. Working within the county staffing structures there is consideration of combining these two roles. Evidence: Role description: entire document (first submitted 8.1b)
(b) Within the Treatment Foster Care, Oregon model that Kern is certified in, a similar approach has been used to ensure that each specific role in the TFCO model is provided to fidelity with each role having clear boundaries and responsibilities. As wraparound implements a similar approach will be utilized in meeting fidelity requirements. Each team member will actively be supported to pursue provision of services in alignment with their designated role and function within the team. As allowable, there is consideration due to civil service structure of combining the HFW clinical supervisor with the HFW supervisor. All other positions will have a dedicated staff for each role. Supervision, coaching and training will occur that will support the broad learning of the wraparound team as well as individualized functions of each role. Evidence: MIST-TFCO BHSS plan; Page 2 (first submitted 9.4b); HFW Role descriptions: entire document (first submitted 8.1b) Training plan: Page 1: introduction and KernBHRS Training Overview (first submitted 1.2c) Training Plan: Page 2: Wraparound Implementation Training and Page 4: Matrix: Role (first submitted 1.2c)
(c) In implementing HFW, Kern will ensure that staff are supported and trained to understand and successfully meet the competencies of their positions. Role descriptions will be provided and discussed in supervision with each staff member to ensure they understand their assigned roles. As indicated in the Training Plan, initially, as the teams are forming, all staff will receive orientation training through UC Davis Wraparound 101: Foundations of Fidelity training to understand the model. Once these are completed, staff will begin role-specific training and supervision to ensure opportunity to improve role specific skills and knowledge that will aid in adherence to role boundaries and fidelity to the HFW model. Evidence: HFW Role Descriptions: entire document (first submission 8.1b); Training Plan: Page 2: wraparound implementation training (first submitted 1.2c); Training Plan: Page 4: wrap around implementation training Matrix (first submitted 1.2c)
(d) KernBHRS allows candidates to highlight their abilities through an interview process, usually conducted by a panel. There are procedures for both new job seekers, and for current staff from other teams to apply. Given that HFW serves some of our most complex youth, hiring existing experienced staff will help to ensure the matching of skills for each role that is being filled. During the interview process interviewees are typically asked about their interest and expertise to include best fit. For instance, candidates are asked if they have a preference of working on a team that services adults versus children. During the interview process staff are prompted to share this information. Evidence: Interview question and supplement: Page 1- 6 (first submitted 9.4d)
(e) It is a KernBHRS standard that at onset of employment on any given team, the employee performance review (EPR) process is initiated through a Day 1 evaluation that provides the staff with information about their duties and expectations about what is expected. This conversation with the team supervisor is tailored to the mission and purpose of both the agency and the specific team. For HFW this will include discussion about the wraparound model, and fidelity which will include training and supervision around the specific role of each staff. Per policy weekly supervision occurs for opportunities to coach and provide feedback. Additionally following the Day One EPR, formalized EPRs are completed initially at three (3), six (6) months and annually thereafter. Evidence: Day One EPR template: Entire document (first submitted 9.4e); Rater’s Guide to EPR: Page 3 & 4: II The process and value of Performance Appraisal: B 1 & 2 (first submitted 9.4e) Rater’s Guide to EPR: Page 5: III The Employee Performance Report Form: A (first submitted 9.4e); Training plan: Page 1 and 2: II Wraparound specific training: A. Role based training and Training Plan: Page 2: Supervision (First Submitted 1.2c)
9.5 Workforce Stability
(a) Kern County Human Resources has implemented strategies and processes that result in the maintenance of a stable workforce thereby minimizing turnover. A crucial component of this strategy is the implementation of the Cost-of-Living Adjustment (COLA) salary schedule as outlined in Section 6 of the SEIU MOU. As part of this agreement, effective January 1, 2022, a 10-step Base COLA Salary Schedule was adopted for all employees covered by this MOU, excluding those paid a flat rate biweekly or hourly. Each step within this schedule includes a 2% incremental growth, ensuring that all employees move to the next higher base COLA step annually until they reach Step 10. Additionally, starting July 1, 2024, employees will receive an extra 2% COLA, with negotiations for further COLAs planned for 2025, 2026, and 2027. The agreement also provides a 6% salary adjustment for all SEIU bargaining unit employees following the adoption of this agreement. Furthermore, the County and the Union have committed to regular meetings within the first six months of the agreement to review and propose potential changes to salary ranges, job specifications, and flexible classification series eligibility for positions that are challenging to recruit or retain. Community providers in Kern County have their own wage processes. However, Kern supports them through an annual contract process that includes setting fair compensation based on DHCS rates. These rates are negotiable depending on community needs. During discussions, the NACT is reviewed to assess demographics, Medi-Cal eligibility, and specific area needs. Evidence: SEIU 521 MOU: Page 5: section 6 A-D (submitted 7.3d)
(b) KernBHRS works to support staff effectiveness by managing workloads in several ways. First, DATA in the EHR is monitored. Using an error report incomplete documentation is tracked which may signal to supervisors when staff need extra support. These reports are provided to staff in supervision and allows for supervisor and staff to plan strategies like helping staff to carve out protected time, reviewing caseloads sizes, or pausing new assignments. The expected caseload for HFW is 10-12 families per team. Additionally, HFW families will receive adjunctive EPSDT services from other community providers as needed which will help to support families with intensive needs. Evidence: Service Error Report: page 1(first submitted 9.5b)
(c) KernBHRS Peer Specialists are utilized as a way to hire those with lived experience. This offers not only a way for our services to be enriched with individuals with lived experience but also provides opportunities for individuals to gain needed experience to meet requirements for promotion to other Job classifications. Evidence: Kern County Peer Specialist job description: Entire document (First Submitted 9.5c)
(d) As mentioned in 9.5a, the County of Kern provides annual wage increment raises at the beginning of each fiscal year with the SEIU MOU agreement. Moreover, KernBHRS, in accordance with the SEIU MOU, has flexible classifications for our difficult to recruit/retain classifications that allow permanent employees to be promoted when they meet the qualifications and there is merit. While lived experience is not required, individuals with such experience often qualify for roles such as Substance Use Disorder Specialist, BH Recovery Specialist, Vocational Nurse, BH Nurse, BH Therapist Trainee, BH Unit Supervisor, and Clinical Psychologist. Kern has also developed a mentoring program to pair individuals with mentors, promoting professional growth and the acquisition of job and leadership skills. Evidence: SEIU 521 MOU: Page 5: section 6 A-D (submitted 7.3d); SEIU 521 MOU: page 6: Section 7 A-C (first submitted 7.3d); Professional Growth and Mentoring: Page 1:(first submitted 9.5d)
9.6 High Fidelity Training Plan
(b) Upon receiving initial Wrap around 101: Foundations in Fidelity, as referenced in the training plan, staff will continue to have individualized ongoing training that will expand their role specific knowledge. Various learning methodologies will be used to match individual learning styles and will include both web based and live training, which will be integrated into supervision and coaching sessions as well as booster training within the team meetings. Evidence: Training Plan: page 2: C integration of learning and ongoing training (first submitted 1.2c); Training Plan: page 4 Matrix (first submitted 1.2c)
(c) Staff will renew their training annually by attending the Wraparound 101: Foundations in Fidelity as reflected in the training plan. This will be included in their annual training plan that is tracked through Relias. Evidence: Training Plan: page 4: Matrix (first submitted 1.2c)
(d)Clinical supervisors/supervisors will also annually attend Wraparound 101: Foundations in Fidelity. In addition, as available other UC Davis web-based training will be added onto their annual training plan. Examples of training from UC Davis site may include coaching in Wraparound: Coaching Teams, Coaching institute for wraparound or coaching wraparound: coaching to fidelity. Training Plan: page 4 Matrix (first submitted 1.2c)
(e) All staff are required to take no less than 6 hours of cultural competence training. The ICWA trainings will be incorporated into staff’s training plan. All staff will receive ICWA and Tribal Sovereignty training initially to ensure an understanding of culturally responsive practices as well as increase knowledge of legal standards when serving Native youth and families. The initial training will be provided by attendance at the ECHO: ICWA and Tribal engagement training for the May 13th and June 3rd training through UC Davis and Professional Ed. (see website link below) Subsequently training on ICWA and tribal sovereignty will be included in staff’s annual cultural competency trainings plan.
Evidence: Training plan: page 4: Matrix: cultural competence ECHO: ICWA and Tribal Engagement: https://iecho.org/public/program/PRGM17558197216925CNESAZ54U
9.7 Community-based Training Program
(a) As a routine practice, KernBHRS invites community members and partners to engage in collaborative training. In order to give community members and partners the most flexibility in providing feedback to us, we provide various venues and types of opportunities for collaboration. Examples of these opportunities include Mental Health Services Act (MHSA) Team’s Stakeholder/Community Forums and Cultural Competence Team’s Community Listening Sessions. We also have had staff participate in community events such as the Bakersfield Khair Townhall, which was hosted by Bakersfield Khair, a Sikh high school student group focused on substance use prevention. KernBHRS also partners with The Center for Sexuality and Gender Diversity for an annual training (Understanding LGBTQ Community) which is facilitated by individuals with lived experience as part of the LGBTQ+ community and who provide support to the LGBTQ+ community, As we implement HFW this existing structure in our agency will be utilized and youth family and peers will be invited into assisting with feedback, planning and providing wraparound trainings. Evidence: Community outreach: Page 1: MHSA Team’s stakeholder community forum; Bakersfield Khair Sikh high school focus group: page 1 and Understanding LGBTQ Community (first submitted 9.7a)
(b) Our training program works to engage community members, clients, and partners by offering presentations and training that are tailored to different age ranges, languages, and populations. As previously mentioned KernBHRS TAY offers ongoing TIP training that is open to the community. It is typical that our broader children’s system of care attends this training, which includes educational staff, probation, and child welfare. As HFW implements this approach will continue to be used and training will be open to partners. In addition, KernBHRS CSOC specialty teams have Child Welfare and Probation embedded in our children’s teams and these staff will be integrated into our training for HFW teams as well as service providers and other community partners. Evidence: TIP Training agenda: entire document (first submitted 1.4b)
9.8 Coaching and Supervision
(a) As reflected in the training plan staff also will be trained for the Wraparound 101: Foundations of Fidelity training through UC Davis, and other role-specific training (Passport Trainings). On a global level the onboarding process for staff to KernBHRS is comprehensive. Initially, staff are introduced to our system of care, and once assigned to a specific team, they receive more targeted team and role-specific training. As Wraparound implements this will include additional trainings from the UC Davis platform and other Wraparound-specific trainings which will be incorporated into staff’s individualized training plan in our Relias system. Also typically, we assign each new staff member to an experienced team mentor who provides hands-on training and shadowing. During this mentorship, new staff members will learn about the core values, principles, phases, and activities of High-Fidelity Wraparound (HFW). They will also gain practical guidance on the use of flex funds, which are essential for meeting the unique and immediate needs of families through supervision and training. Evidence: Training plan: Page 2: B Wraparound Implementation training (first submitted 1.2c); Training plan: Page 3: Coaching (first submitted 1.2c); Training plan: Page 4: Matrix (First submitted 1.2c)
(b) There is always a licensed staff member that is available within the children’s care system that is able to provide supervision, direction and coaching for staff. In addition, support is also available through our 24/7 youth crisis facility, as well as through 988. Evidence: Wraparound after hours on call Schedule (first submitted 7.3d); HFW Coaching log: page 2 (submitted 1.3d); HFW Exhibit A: Page 4: D. Staff availability (first submitted 1.1b)
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
(a) Kern County will be using the WFAS outcome tools in evaluating outcomes and supporting continuous quality improvement to ensure fidelity to the model as demonstrated in both the CQI plan and the Kern County HFW Outcomes plan. Details regarding the collaborative implementation of the Continuous Quality Improvement (CQI) plan which includes partnership with providers and System of Care (SOC) partners and collection of required data elements (Items 1–3) are outlined in the CQI Plan. Evidence: CQI Plan: Page 1 Program Overview (first submitted 1.1a); CQI Plan: Page 2: 2. CQI Philosophy and approach (first submitted 1.1a); CQI Plan: Page 4 : 3 Goals and Objectives (First submitted 1.1a); CQI Plan: Page 5 Goals & Objectives (first submitted 1.1a); CQI Plan: Page 6: Data Collection & Monitoring (Submitted 1.1a); HFW Policy Attachment C KC High Fidelity Wraparound Outcomes: Introduction and throughout document (first submitted 2.1)
(b) Information regarding how Kern County partners, including child welfare, probation, behavioral health, contracted provider and KernBHRS collaborate and share data to implement the CQI plan is reflected in the Continuous Quality Improvement (CQI) Plan. Evidence: CQI Plan: Page 1: Program Overview (first submitted 1.1a); CQI Plan: Page 2: Program Overview (first submitted 1.1a); CQI Plan: Page 3 CQI Philosophy & Approach (first submitted 1.1a); CQI plan: page 7 Analysis & Reporting (first Submitted 1.1a)
(c)A description of how collected data is maintained as current and accurate, and how it is utilized to inform practice improvements and ensure accountability for achievement of desired outcomes, is provided in the Continuous Quality Improvement (CQI) Plan. In addition, the Kern County HFW Outcome document outlines processes to monitor and achieve positive outcomes Evidence: CQI Plan: Page 2 CQI Philosophy & Approach (first submitted 1.1a); CQI Plan: Page 3 CQI Philosophy & Approach (Submitted 1.1a); HFW Policy Attachment C KC High Fidelity Wraparound Outcomes: Entire Document (first submitted 2.1)
(d) An explanation of how data is collected at the level closest to the individual and then analyzed is outlined in the Continuous Quality Improvement (CQI) Plan. Evidence: CQI Plan: Page 4: CQI Philosophy & Approach (first submitted 1.1a); CQI Plan: Page 5: Data Collection & Monitoring (first submitted 1.1a); CQI Plan: Page 7 Data Collection & Monitoring (Submitted 1.1a)
10.2 Evaluation Metrics & Outcomes
(a) A description of how data is used to improve practice with youth and families including providing timely feedback to staff and identifying training need is reflected in the Continuous Quality Improvement (CQI) Plan Evidence: CQI Plan: Page 3: CQI Philosophy & Approach, (First submitted 1.1a); CQI Plan: Page 6: Data Collection & Monitoring (First submitted 1.1a); CQI Plan: Page 8 Analysis & Reporting (Submitted 1.1a).
(b) The Continuous Quality Improvement (CQI) Plan outlines how data is analyzed to identify and address program needs in order to enhance service delivery and improve overall program effectiveness. Evidence: CQI Plan: Page 3: CQI Philosophy & Approach (First submitted 1.1a); CQI Plan: Page 5: Goals & Objectives (First submitted 1.1a) ; CQI Plan: Page 6: Data Collection & Monitoring (First submitted 1.1a); CQI Plan: Page 8: Improvement Activities (Submitted 1.1a)
(c) Processes for using data to identify system barriers and communicate findings to the Community Leadership Team and other stakeholders to inform and strengthen High Fidelity Wraparound (HFW) implementation are described in the Continuous Quality Improvement (CQI) Plan. Evidence: CQI Plan: Page 2: Program Overview (First submitted 1.1a); CQI Plan: Page 4: CQI Philosophy & Approach (First submitted 1.1a); CQI Plan: Page 8 Improvement Activities (Submitted 1.1a)
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
RCS Wraparound Program Manual Pgs: 5, 7, 8, 15-16, 23-24
Wraparound ICWA Collaboration P&P
Wraparound Screening and Assessment Procedures P&P
Wraparound Roles & Expectations P&P
1.2 Led by Youth and Families
RCS Wraparound Program Manual Pgs: 3, 6, 7, 21-22, 23
Wraparound ICWA Collaboration P&P
Family Story Form
CFT Observation Tool
1.3 Strength-Based
RCS Wraparound Program Manual Pgs: 3, 6, 7, 8, 13, 15, 16, 21-22
Wraparound Screening and Assessment Procedures P&P
Plan of Care Form
Family Story Form
1.4 Needs Driven
RCS Wraparound Program Manual Pgs: 3, 4, 5, 9, 13, 15, 23
Wraparound Screening and Assessment Procedures P&P
Wraparound Services & Aftercare P&P
CFT Observation Tool
Plan of Care Form
Family Story Form
1.5 Individualized
RCS Wraparound Program Manual Pgs: 3, 6, 7, 8, 9, 11, 13, 15, 16, 17, 21-22
Wraparound Screening and Assessment Procedures P&P
Wraparound ICWA Collaboration P&P
Wraparound Services & Aftercare P&P
CFT Observation Tool
CFT Form
Plan of Care Form
Family Story Form
Safety Plan Form
Transition Plan Form
1.6 Use of Natural and Community Based Supports
RCS Wraparound Program Manual Pgs: 3, 6, 7-8, 9, 10, 11, 13, 14, 15, 17, 20, 21-22, 23
Wraparound Screening and Assessment Procedures P&P
Wraparound ICWA Collaboration P&P
Wraparound Services & Aftercare P&P
CFT Observation Tool
CFT Form
Plan of Care Form
Family Story Form
Safety Plan Form
Transition Plan Form
1.7 Culturally Respectful and Relevant
RCS Wraparound Program Manual Pgs: 3, 4, 6, 7-8, 10, 12, 14, 15-16, 21-22
Wraparound Screening and Assessment Procedures P&P
Wraparound ICWA Collaboration P&P
Wraparound Services & Aftercare P&P
CFT Observation Tool
CFT Form
Plan of Care Form
Family Story Form
Safety Plan Form
Transition Plan Form
1.8 High-Quality Team Planning and Problem Solving
RCS Wraparound Program Manual Pgs: 3, 7, 9, 21-22, 23-24
Wraparound Continuous Quality Improvement P&P
CFT Observation Tool
Plan of Care Form
Transition Plan Form
1.9 Outcomes Based Process
RCS Wraparound Program Manual Pgs: 3, 4, 6,-9, 13, 16, 17, 22, 23-24
Wraparound Continuous Quality Improvement P&P
Wraparound Screening and Assessment Procedures P&P
CFT Scaling Form
CFT Observation Tool
Plan of Care Form
Transition Plan Form
1.10 Persistence
RCS Wraparound Program Manual Pgs: 3, 4, 6, 8, 10, 11, 13, 16
Wraparound Screening and Assessment Procedures P&P
Wraparound Services & Aftercare P&P
Wraparound Flex Funds & Client Expenses P&P
CFT Observation Tool
Plan of Care Form
1.11 Transitions as a part of the Fourth Phase of HFW
RCS Wraparound Program Manual Pgs: 3, 9, 10, 16, 21
Wraparound Screening and Assessment Procedures P&P
Wraparound Services & Aftercare P&P
Wraparound Flex Funds & Client Expenses P&P
CFT Observation Tool
Plan of Care Form
Transition Plan Form
Expected Outcomes
2.1 Youth and Family Satisfaction
RCS Wraparound Program Manual Pgs: 4, 18, 21-22, 23
Wraparound Continuous Quality Improvement P&P
Wraparound ICWA Collaboration P&P
2.2 Improved School Functioning
RCS Wraparound Program Manual Pgs: 4, 16, 17, 21-22, 23
Wraparound Continuous Quality Improvement P&P
IP-CANS
CFT Form
Plan of Care Form
Family Story Form
Transition Plan Form
2.3 Improved Functioning in the Community
RCS Wraparound Program Manual Pgs: 4, 19, 21-22, 23
Wraparound Continuous Quality Improvement P&P
IP-CANS
CFT Form
Plan of Care Form
Family Story Form
Transition Plan Form
2.4 Improved Interpersonal Functioning
RCS Wraparound Program Manual Pgs: 4, 19, 21-22, 23
Wraparound Continuous Quality Improvement P&P
IP-CANS
CFT Form
Plan of Care Form
Family Story Form
Transition Plan Form
2.5 Increased Caregiver Confidence
RCS Wraparound Program Manual Pgs: 4, 13-14, 21-22, 23
Wraparound Continuous Quality Improvement P&P
IP-CANS
CFT Form
Plan of Care Form
Family Story Form
Transition Plan Form
2.6 Stable and Least Restrictive Living Environment
RCS Wraparound Program Manual Pgs: 4, 21-22, 23
Wraparound Continuous Quality Improvement P&P
IP-CANS
CFT Form
Plan of Care Form
Family Story Form
Transition Plan Form
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
RCS Wraparound Program Manual Pgs: 4, 21-22, 23
Wraparound Continuous Quality Improvement P&P
IP-CANS
CFT Form
Plan of Care Form
Family Story Form
Transition Plan Form
2.8 Reduction in Crisis Visits
RCS Wraparound Program Manual Pgs: 4, 21-22, 23
Wraparound Continuous Quality Improvement P&P
IP-CANS
CFT Form
Plan of Care Form
Family Story Form
Safety Plan Form
Transition Plan Form
2.9 Positive Exit from HFW
RCS Wraparound Program Manual Pgs: 4, 10, 21-22, 23
Wraparound Continuous Quality Improvement P&P
Wraparound Services & Aftercare P&P
Wraparound Screening and Assessment Procedures P&P
Wraparound Flex Funds & Client Expenses P&P
IP-CANS
CFT Form
CFT Observation Tool
Plan of Care Form
Family Story Form
Safety Plan Form
Transition Plan Form
Engagement
3.1 Orientation
RCS Wraparound Program Manual Pgs: 4-6, 7
Wraparound Screening and Assessment Procedures P&P
Wraparound ICWA Collaboration P&P
CFT Observation Tool
CFT Form
Plan of Care Form
Family Story Form
Safety Plan Form
Wraparound Process Users Guide
3.2 Safety and Crisis stabilization
RCS Wraparound Program Manual Pgs: 4-6, 7, 9
Wraparound Screening and Assessment Procedures P&P
CFT Observation Tool
CFT Form
Plan of Care Form
Family Story Form
Safety Plan Form
Crisis Resources Form
Wraparound Process Users Guide
3.3 Strengths, Needs, Culture and Vision Discovery
RCS Wraparound Program Manual Pgs: 3, 4-6, 7, 8, 10, 13, 15, 16, 21-22
Wraparound Screening and Assessment Procedures P&P
Wraparound ICWA Collaboration P&P
CFT Observation Tool
CFT Form
Plan of Care Form
Family Story Form
Safety Plan Form
Wraparound Process Users Guide
3.4 Engage All Team Members
RCS Wraparound Program Manual Pgs: 4-6, 7, 8, 9,
Wraparound Screening and Assessment Procedures P&P
Wraparound ICWA Collaboration P&P
CFT Observation Tool
CFT Form
Plan of Care Form
Family Story Form
Wraparound Process Users Guide
3.5 Arrange Meeting Logistics
RCS Wraparound Program Manual Pgs: 4-6, 13, 14, 15
Wraparound Screening and Assessment Procedures P&P
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
RCS Wraparound Program Manual Pgs: 6-9
Wraparound Screening and Assessment Procedures P&P
Wraparound ICWA Collaboration P&P
CFT Observation Tool
CFT Form
Plan of Care Form
Family Story Form
Safety Plan Form
Wraparound Process Users Guide
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
RCS Wraparound Program Manual Pgs: 6-9, 13-19
Wraparound Screening and Assessment Procedures P&P
Wraparound ICWA Collaboration P&P
CFT Observation Tool
CFT Form
Plan of Care Form
Family Story Form
Safety Plan Form
Wraparound Process Users Guide
4.3 Develop an Individualized Child or Youth and Family Plan
RCS Wraparound Program Manual Pgs: 6-9, 12, 13-19
Wraparound Screening and Assessment Procedures P&P
Wraparound ICWA Collaboration P&P
Wraparound Services & Aftercare P&P
Wraparound Continuous Quality Improvement P&P
CFT Observation Tool
CFT Form
Plan of Care Form
Family Story Form
Safety Plan Form
Transition Plan Form
Wraparound Process Users Guide
4.4 Develop a Crisis and Safety Plan
RCS Wraparound Program Manual Pgs: 6-9, 16, 17, 20
Wraparound Screening and Assessment Procedures P&P
Wraparound Services & Aftercare P&P
CFT Observation Tool
CFT Form
Plan of Care Form
Family Story Form
Safety Plan Form
Crisis Resources
Transition Plan Form
Implementation
5.1 Implement The Plan of Care
RCS Wraparound Program Manual Pgs: 9-10, 13-19, 23-24
CFT Observation Tool
CFT Form
Plan of Care Form
Family Story Form
Safety Plan Form
Transition Plan Form
5.2 Review and Update The Plan of Care
RCS Wraparound Program Manual Pgs: 6-10, 13-19, 23-24
CFT Observation Tool
CFT Form
Plan of Care Form
Family Story Form
Safety Plan Form
Transition Plan Form
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
RCS Wraparound Program Manual Pgs: 4-10, 13-19, 23-24
CFT Observation Tool
CFT Form
Plan of Care Form
Family Story Form
Safety Plan Form
Transition Plan Form
Transition
6.1 Develop a Transition Plan
RCS Wraparound Program Manual Pgs: 9-10, 16, 17, 23
Wraparound Services & Aftercare P&P
Wraparound Continuous Quality Improvement P&P
CFT Observation Tool
CFT Form
Plan of Care Form
Transition Plan Form
6.2 Develop a Post-Transition Safety Plan
RCS Wraparound Program Manual Pgs: 9-10, 16, 17, 23
Wraparound ICWA Collaboration P&P
Wraparound Services & Aftercare P&P
CFT Observation Tool
CFT Form
Plan of Care Form
Family Story Form
Safety Plan Form
Crisis Resources
Transition Plan Form
6.3 Create a Commencement and Celebrate Success
RCS Wraparound Program Manual Pgs: 9-10
Wraparound ICWA Collaboration P&P
Wraparound Services & Aftercare P&P
Wraparound Continuous Quality Improvement P&P
CFT Form
Plan of Care Form
Transition Plan Form
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
RCS Wraparound Program Manual Pgs: 10-11, 21-22
7.2 Community Leadership Team
RCS Wraparound Program Manual Pgs: 10-11, 21-22
7.3 Eligibility and Equal Access
RCS Wraparound Program Manual Pgs: 10-11, 21-22
Wraparound Screening and Assessment Procedures P&P
Wraparound Roles & Expectations P&P
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
RCS Wraparound Program Manual Pgs: 21
Wraparound Roles & Expectations P&P
Wraparound Continuous Quality Improvement P&P
8.2 Equitable Funding Across System Partners
RCS Wraparound Program Manual Pgs: 11-12, 21
Wraparound Flex Funds & Client Expenses
Wraparound Roles & Expectations P&P
Family Budget Form
8.3 Cost Savings are Reinvested
RCS Wraparound Program Manual Pgs: 11-12, 21
Wraparound Flex Funds & Client Expenses
Wraparound Roles & Expectations P&P
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.
RCS Wraparound Program Manual Pgs: 9-13, 21
Wraparound Flex Funds & Client Expenses
Wraparound Roles & Expectations P&P
Flex Fund Request Form
8.5 Collaborative Oversight of Flex Funds
RCS Wraparound Program Manual Pgs: 9-13, 21
Wraparound Flex Funds & Client Expenses
Wraparound Roles & Expectations P&P
Flex Fund Request Form
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
RCS Wraparound Program Manual Pgs: 9-13, 21
Wraparound Flex Funds & Client Expenses
Wraparound Roles & Expectations P&P
Flex Fund Request Form
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
RCS Wraparound Program Manual Pgs: 13-19
Wraparound Roles & Expectations P&P
9.2 Tribally Responsive Workforce
RCS Wraparound Program Manual Pgs: 13-19
Wraparound Roles & Expectations P&P
Wraparound ICWA Collaboration P&P
9.3 Flexible and Creative Work Environment
RCS Wraparound Program Manual Pgs: 13-19
Wraparound Roles & Expectations P&P
Wraparound ICWA Collaboration P&P
Wraparound Continuous Quality Improvement P&P
9.4 Hiring, Performance Evaluation, and Job Descriptions
RCS Wraparound Program Manual Pgs: 13-19
Wraparound Roles & Expectations P&P
Care Coordinator Job Description
Parent Partner Job Description
License (Waiver) Mental Health Clinician Job Description
Mental Health Rehabilitation Specialist Job Description
Mental Health Rehabilitation Specialist IV-V Job Description
Program Specialist Job Description
9.5 Workforce Stability
RCS Wraparound Program Manual Pgs: 13-19
Wraparound Roles & Expectations P&P
9.6 High Fidelity Training Plan
RCS Wraparound Program Manual Pgs: 13-19
Wraparound Roles & Expectations P&P
Wraparound ICWA Collaboration P&P
9.7 Community-based Training Program
RCS Wraparound Program Manual Pgs: 13-19
9.8 Coaching and Supervision
RCS Wraparound Program Manual Pgs: 13-19
Wraparound Roles & Expectations P&P
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
RCS Wraparound Program Manual Pgs: 21-24
Wraparound Continuous Quality Improvement
Fidelity Indicators
1.1 Timely Engagement and Planning
a.) When the Wraparound Team receives a referral (either through Sacramento County Behavioral Health or a self-referral (AAP) for services, the first contact to the family is made within 10 calendar days or less and the first face-to-face assessment would take place within 10 calendar days or less by the assigned Facilitator. (System for Wraparound Client Assessment and Monitoring of Level of Treatment Intensity. Exhibit A, Scope for Service for Wraparound, Agreement between SCH and Sacramento County.)
b.) Within the first 30 calendar days, the assessment is completed by the Facilitator (typically through weekly meetings with the youth/family, and completion to assessment tools – CANS, PSC-35, etc.). This process can include other evaluative tool in relation to presentation (UCLA PTSD Index, Youth Outcome Questionnaire, CSE-IT, etc. – to assess for evidenced-based treatment modalities as appropriate). Also, within 30 calendar days, Wraparound Plan of Care is also completed based on information obtained from the assessment process. The Plan of Care is developed more fully through the planning phase and revisited during CFT’s. (System for Wraparound Client Assessment and Monitoring of Level of Treatment Intensity.)
c.) Teams review the plan in a CFT monthly and more frequently when appropriate.
d.) The plan of care is redistributed to the family and their team as well as uploaded into the youths’ chart quarterly by the facilitator.
e.) Supervisors work closely with the SCH QI department regarding CQI and any feedback received is provided to team members. If areas are highlighted for training opportunities the supervisors utilize weekly team meetings for such training.
f.) Staff are trained to meet these expectations within their first 120 days of employment. All staff are trained in the following subjects: Motivational Interviewing, engagement activities (per High Fidelity Wraparound) and other activities to engage the youth and family to help effect the Wraparound process, as well as cultural needs including tribal youth and families. (Wraparound Training Table of Contents)
1.2 Led by Youth and Families
a.) It is the mission of the Sacramento Children’s Home Wraparound program to celebrate the youth’s and family’s culture and tribe. SCH Wraparound employs a high fidelity Wraparound model, and in this way, the Wraparound Program utilizes staff’s skills to join with the family, elicit youth and family values, culture, expertise, capabilities, interests, and skills. The Wraparound process is designed to be family-driven and youth-guided, ensuring that the voices of the youth and family are central to all decision-making. The youth and family play a primary role in identifying priorities, establishing goals, and determining the strategies included in the Plan of Care. During Child and Family Team meetings, the Wraparound Facilitator ensures that the youth and family are provided meaningful opportunities to express their perspectives, preferences, and desired outcomes. Team members, including professionals and natural supports, work collaboratively to develop solutions that align with the youth and family’s vision, cultural values, and identified strengths. Further, High Fidelity Wraparound providers prioritize the perspectives and voices of the youth, family and Tribe – emphasizing equal voice to the Tribe in Child and Family Team meetings. (Wraparound Training Table of Contents, ACL 25 47 BHIN 25 027)
b.) In keeping with the principles of High Fidelity Wraparound, the youth and family are encouraged to actively guide the direction of services, participate in problem-solving discussions, and make informed decisions regarding supports and interventions. The Child and Family Team operate using a shared decision-making approach in which the perspectives of the youth, family, and Tribe are respected and incorporated into the development and ongoing revision of the Plan of Care. This process is aided by the use of the Strengths, Needs, Culture and Vision Discovery (SNCVD) – a tool which helps guide discussions with the youth and family to explore cultural needs and values. The activity operates alongside other interventions (Initial Meeting with the Family, Preparing Family for the First Child and Family Team meeting, and the Initial and Implementation Child and Family Team meetings) in which the family’s values are explored and, with the assistance of the youth and family, help to develop the Family Vision and Team Mission (and statements). (System for Wraparound Quality Assurance)
c.) In additional to these processes, Supervisors routinely observe Child and Family Team meetings, review information gathered and provide feedback to staff to improve staff skills and improve the efficacy of services provided. (Blank Observation Form One: Initial Meeting with Child and Family. Blank Observation Form Two: Preparing the Family for the Initial Team Meeting. Blank Observation Form Three: Initial Wraparound Plan. Observation Form Four: Implementation Wraparound Meeting)
d.) Furthermore, our Quality Improvement department routinely administers the TOM 2.0 (for observation of Child and Family Team meetings) and well as WFI-EZ (follow-up of services survey) to evaluate the services provide. This feedback is provided to the supervisors and staff. (System for Wraparound Quality Assurance. Blank TOM. Blank WFI-EZ.)
1.3 Strength-Based
a. & b.) Sacramento Children’s Home Wraparound Program utilizes a strength-based approach, and this is reinforced in the numerous evaluative tool and interventions in which the staff are trained. Some examples of the tools that are administered are: IP-CANS, Strengths Needs and Culture and Vision Discovery, Initial Meeting with the Family and the Team Observation Measure (TOM) all of which emphasize a strength-based approach. Strengths identified through these things are inventoried into the youths chart. Additionally strengths are identified at the start of each CFT and logged into the youths chart via the CFT meeting minutes. (System for Wraparound Client Assessment and Monitoring of Level of Treatment Intensity. System for Wraparound Quality Assurance. Blank TOM Tool. CFT Meeting Minutes Template)
c.) As mentioned above, all of these tools inform the Team’s Mission and Vision, the service plan for the family, and all interventions provided in the service of the youth and the family. In addition, staff are provided ongoing coaching/training on providing strength-based, solution-focused service delivery. (System for Wraparound Quality Assurance. Wraparound Training Table of Contents. Blank Observation Form Four: Implementation Wraparound Meeting. )
d.) Furthermore, feedback from the youth and family is essential and important training information in our continuous quality improvement. To get feedback, we utilize a satisfaction survey, the Team Observation Measure, the Wraparound Fidelity Index (WFI-EZ), as well as supervisors/managers attending Child and Family Team meeting (and providing contact information to the family in case they have concerns or feedback about their services). (System for Wraparound Quality Assurance. Blank WFI Tools. Blank TOM)
1.4 Needs Driven
a.) Sacramento Children’s Home follows a high fidelity model that emphasizes the youth and family developing and expressing their needs and priorities. This is often a struggle since youth and families are often referred to Wraparound support from system entities that have their own priorities. As mentioned above, many efforts are made to identify strengths in which the youth and the family possess (utilizing the IP-CANS, SNCVD, Initial Meeting with the Family, etc.). These strengths are emphasized as a means to addressing the needs that are presented (also, informed by evaluation tools such as the IP-CANS). (Wraparound System of Implementation and Plan of Care)
b.) Staff receive initial training (within their first 120 days with Sacramento Children’s Home) and annual training on interventions (including the IP-CANS), and the development of needs statements (within the service plan) which are reflective of an underlying reason why situations or behaviors occur. Providing needs-focused planning is evaluated by the supervisors and manager of our program through observation of Child and Family Team meetings as well as documentation reviews. (Wraparound Training Table of Contents. Blank Observation Form One: Initial Meeting with Child and Family. Blank Observation Form Two: Preparing the Family for the Initial Team Meeting. Blank Observation Form Three: Initial Wraparound Plan. Observation Form Four: Implementation Wraparound Meeting)
c.) In the development of the service plan and problem list, the youth and family identify prioritized needs to which the goals and strategies are developed. Service plans must include the needs identified by the IP-CANS. (System for Wraparound Client Assessment and Monitoring of Level of Treatment Intensity. Wraparound System of Implementation and Plan of Care)
d.) Lastly, along with the development of the family vision, transitions are planned based on family agreement of meeting the needs prioritized by the youth/family. (System for Wraparound Client Assessment and Monitoring of Level of Treatment Intensity.)
1.5 Individualized
a.) Sacramento Children’s Home Wraparound Program service and treatment delivery is inherently individualized, as consumers referred to our program have vastly different backgrounds and experiences. Individuality in service delivery is emphasized in relation to the youth and family’s needs, strengths, values, culture, and preferences. Our team utilizes creativity and flexibility in developing strategies and interventions, recognizing that there is no one-size-fits-all approach to care. Interventions are thoughtfully customized to address each youth and family’s unique challenges while building upon existing strengths. Service plans incorporate and celebrate family strengths, natural supports, community resources, other supportive networks, and tribal affiliation when applicable. Through this individualized and creative approach, services are tailored to empower youth and families while promoting meaningful, sustainable outcomes. (System for Wraparound Client Assessment and Monitoring of Level of Treatment Intensity.)
b.) All staff, including Wraparound Facilitators, receive ongoing training, support and coaching (SCH Wraparound utilizes a “scaffolding” approaching in it’s training approach) in the high fidelity wraparound service delivery, the development of an individualized plan and service interventions which emphasizes the individualized needs, strengths, values, culture and preferences of the youth and family. (System for Quality Assurance. Wraparound Training Table of Contents.)
c. & d.) Furthermore, supervisors and manager routinely reviewed to assure that staff are emphasizing the youth and family’s individualized strengths, needs, expressed outcomes, and utilizing strategies that utilize identified strengths, natural supports, community and family networks. (System for Wraparound Quality Assurance. Blank Wraparound Facilitator Evaluation by Supervisors)
e.) Family feedback (through satisfaction surveys and feedback provided to supervisors/manager) and other information obtained from the family (utilizing evaluative tools such as the WFI-EZ and TOMs) to address training needs and additional support for the staff to meet service goals prioritized by the youth and family. (System for Wraparound Quality Assurance. Blank WFI Tool. Blank TOM Tool.)
1.6 Use of Natural and Community Based Supports
a.) The identification and engagement of natural and community supports is an intentional component of the Sacramento Children’s Home Wraparound process. During the Strengths, Needs and Cultural Discovery creation and the Initial Family Interview, the Wraparound Facilitator and Family Partner work collaboratively with the youth and family to identify individuals who are meaningful sources of support in their lives. Once potential natural supports are identified, the youth and family are supported in determining which individuals they would like to invite to participate in the Child and Family Team (CFT). This inventory list of supports is a living document that is routinely updated throughout the course of services. Natural supports that agree to participate in the CFT are documented in the Plan of Care and their roles are clearly identified. (Wraparound Training Table of Contents. Blank Plan of Care Page 1 & 2. ACL 25 47 BHIN 25 027)
b.) All Wraparound staff receive ongoing training, coaching, and supervision in the identification, engagement, and integration or natural supports. Training emphasizes not only the identification of natural supports but also strategies to actively engage and integrate them into service planning in a meaningful way. Staff are coached in promoting family-driven, solution-focused practices that elevate the family’s own networks and strengths, with the goal of decreasing reliance on formal supports over time and increasing long-term sustainability. Natural Supports also get retrained and workshopped with the Sacramento Children’s Home Wraparound team twice a year in relation to their current caseload. (System for Wraparound Quality Assurance. Wraparound Training Table of Contents. Blank Demonstration Form Two: Strengthening the Natural Support System for a Family.)
c.) Plans of Care are routinely reviewed and updated to ensure the active inclusion of natural and community supports. During ongoing CFT’s, the team assesses the effectiveness of current strategies, the level of participation of supports, and opportunities to further leverage community and informal supports. Action steps within the Plan of Care explicitly identify the roles and responsibilities of natural supports whenever appropriate and possible. Furthermore, supervisors and managers routinely reviewed to assure that staff are emphasizing the youth and family’s individualized strengths, needs, expressed outcomes, and utilizing strategies that utilize identified strengths, natural supports, community and family networks. (System for Wraparound Quality Assurance. Blank Documentation Form Two: Wrap Plan.)
d.) Family feedback (through satisfaction surveys and feedback provided to supervisors/manager) and other information obtained from the family (utilizing evaluative tools such as the WFI-EZ and TOMs) to address training needs and additional support for the staff to meet service goals prioritized by the youth and family. (System for Quality Assurance.)
1.7 Culturally Respectful and Relevant
a.) Through the Engagement and Planning phase, the Facilitator and Advocacy staff begin to gather information not only for assessment completion, but also for the Strengths, Needs, and Culture and Vision Discovery (SNCVD). The SNCVD is a living document that evolves and continues to grow and be added to as the team and family further their understanding and grow within the program. The SNCVD formation and development begins after the first contact with the client and family.
b.) The SNCDV gets retrained and workshopped with the Sacramento Children’s Home Wraparound team twice a year in relation to their current caseload. (Wraparound Training Table of Contents. Documentation Form One: Strengths, Needs, and Cultural Discovery)
c.) Family feedback (through satisfaction surveys and feedback provided to supervisors/manager) and other information obtained from the family (utilizing evaluative tools such as the WFI-EZ and TOMs) to address training needs and additional support for the staff to meet service goals prioritized by the youth and family. (System for Wraparound Quality Assurance.)
1.8 High-Quality Team Planning and Problem Solving
a.) Team agreements are developed for every family and team during the initial CFT. These agreements are documented in the youth’s file and serve as a foundation for how the team will work together, communicate, make decisions, and support the youth and family.
b. ) Family feedback (through satisfaction surveys and feedback provided to supervisors/manager) and other information obtained from the family (utilizing evaluative tools such as the WFI-EZ and TOMs) to address training needs and additional support for the staff to meet service goals prioritized by the youth and family. Additionally the team is provided the Sacramento County CFT survey. (System for Wraparound Quality Assurance.)
c.) Feedback collected from families, team members, and partnering providers is actively used to support continuous quality improvement. Supervisors and managers review this information to identify strengths and areas for growth and training opportunities. (System for Wraparound Quality Assurance)
d.) CFT evaluation is completed by reviewing CFT minutes that include strength, barriers, actions plans, and identified follow. The Facilitator supervisor reviews plans of care and meeting minutes routinely to ensure shared ownership and completion of the family progress across providers, natural support, client, and caregivers alike.
1.9 Outcomes Based Process
a.) The HFW Plan of Care includes clearly identified, specific, and measurable strategies and action items that are directly tied to the prioritized needs identified by the youth, family, and assessments. All actions items have a projected expected completion date.
b.) Facilitators utilize the RAAAR approach for action step follow through Reviewing, Assessing, Adjusting, Assigning, and Revisiting to ensure proper and timely completion of tasks that move the child and family towards progress. Any action steps completed and progress being made is updated and reflected. (Wraparound Training Table of Contents)
c.) The Plan of Care containing the actions steps are updated or changed as needed and redistributed to the team and family.
d.) The IP-CANs is completed within the first 30 days of assessment and every 6 months thereafter. The Family Facilitator will identify if themselves or the assigned therapist will continue the 6 month IP-CANS assessment as identified in our internal system. (Wraparound Client Assessment and Monitoring of Level of Treatment.)
e. Wraparound uses IP-CANS to identify needs and strengths through structured assessment. It helps develop strategies by linking scores to goals and interventions in the Wraparound Plan of Care. And it contributes to monitoring outcomes by tracking change in scores over time. The relationship between the IP-CANS and the Wraparound Plan of Care informs us of the strengths and needs presenting. It provides insight on where the team may want to focus on developing strategies through the prioritized needs as well as identify strategies to address the need and who is responsible for the action steps. As the Plan of Care is put into action the IP-CANS scores reflect the areas of improvement as the assessment is re-administered to track change over time. This allows the team to adjust strategies if needed or identify new goals as previous goals are accomplished. The IP-CANS additionally gives everyone a shared language and framework to keep discussion consistent.
1.10 Persistence
a.) Internal systems are in place to support teams to keep working with families even when faced with setbacks or barriers until agreeance that services should end is determined. (Wraparound Family Systems Approach.)
b.) Internal systems also provide the clear process for teams to access help when faced with challenges. This prompts a review of the Common Breakdowns trained to in our yearly 2-day Wrap Camp internal training as well as during our 3rd quarter where we review and workshop the Implementation Phase. Questions commonly asked include: Are plans developed to address the needs prioritized by the family? Are the plans do not use options based on their strengths or culture? Do the families understand the plans or need help implementing them? Are we taking steps to make sure the families are sufficiently engaged or motivated? Wraparound staff must continually examine how their actions influence engagement, follow through and success. (Wraparound Family Systems Approach. Wraparound Training Table of Contents.)
c.) Safety Planning is also trained to during our yearly 2-day Wrap Camp internal training as well as during our 2nd quarter where we review and workshop the Planning Phase of Wraparound internally. Additionally, our internal system highlights the importance of ensuring the child/caregiver are included in the process and development of the Three Tiered Safety Plan utilized within our program. The Facilitator is encouraged to develop or review the safety plan within CFT’s, as the client and caregiver feel comfortable, to ensure full support and understanding needed for the family’s supports. When conflict resolution arises or brainstorming and plan revision is needed, the facilitator is expected to utilize the RAAAR technique previously mentioned to assist with solutions. (Wraparound Training Table of Contents. System for Wraparound Safety and Crisis Planning.)
1.11 Transitions as a part of the Fourth Phase of HFW
a.) The Transition Readiness Tool is utilized at the beginning of the Wraparound progress to provide the team with beginning marks to assist with tracking progress in the families assets of Visions Goals, Advocates, Navigates Systems, Culture of Support, Accesses Resources, Manages Crisis, Communicates and Manages Support, and Develops and Maintains Support System. The Transition Readiness scale is then completed periodically to review the client and families progress developing skills in these areas and better inform the team where to provide support and guidance. This is used to also assist with proactive planning of the Transition Phase and to rationalize when transition is presented as the next step for the client. It provides us with measurements of the progress overtime that we can point to and celebrate with them. This also allows us to review the families readiness for transition with the family on a regular basis so transition is always part of the process and plan. (Wraparound Transition Readiness Scale)
b.) Transitions out of Wraparound are celebrated through a closing CFT also referred to as a graduating CFT. These graduations are planned with the family to ensure the celebration is according the 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.
Expected Outcomes
2.1 Youth and Family Satisfaction
Wraparound services will be delivered with fidelity to the model. To ensure quality, the Team Observation Measure (TOM) will be used, and the Document Assessment and Review Tool (DART) will be completed in collaboration with the Quality Improvement Staff. Quality Improvement personnel and the Clinical Program Manager will also consult with families and client to confirm that needs are being met and service billed are accurate. (System for Wraparound Quality Assurance)
Additionally, the Wraparound Fidelity Index (WFI) will be administered at mid- and end-of-service to capture feedback from youth and caregivers. The county’s biannual Consumer Perception Survey will provide further input. Data from WFI and Consumer Perception Survey will be reviewed by the Quality Improvement personal and leadership members to guide program improvements, including policy development, training enhancements, and strategies to better support youth and families.
In the case of an Indian Child, the Tribe is able to provide feedback regarding their satisfaction via the Consumer Perception Evaluation, the county CFT Survey, and are offered directly the option to meet with the supervisor or Clinical Program Manager to discuss.
2.2 Improved School Functioning
Wraparound services will be delivered with fidelity to the model. To ensure quality, the Team Observation Measure (TOM) will be used, and the Document Assessment and Review Tool (DART) will be completed in collaboration with the Quality Improvement Staff. Quality Improvement personnel and the Clinical Program Manager will also consult with families and client to confirm that needs are being met and service billed are accurate. (System for Wraparound Quality Assurance)
Additionally, the Wraparound Fidelity Index (WFI) will be administered at mid- and end-of-service to capture feedback from youth and caregivers. The county’s biannual Consumer Perception Survey will provide further input. Data from WFI and Consumer Perception Survey will be reviewed by the Quality Improvement personal and leadership members to guide program improvements, including policy development, training enhancements, and strategies to better support youth and families.
Improved school functioning will also reflect in the IP-CANS under Educational Setting, School Behavior, School Achievement, and School Attendance.5 Improvements on IP-CANS are reflected in the clients Plan of Care and uploaded to the youths chart.
Furthermore, coordination with applicable school is provided to monitor and address school attendance and performance when applicable. SCH Wraparound provides valuable support to the youth and caregiver with regard to educational and vocational attainment that can include addressing problematic behavior as well as advocacy within such educational/vocational systems.
2.3 Improved Functioning in the Community
Wraparound services will be delivered with fidelity to the model. To ensure quality, the Team Observation Measure (TOM) will be used, and the Document Assessment and Review Tool (DART) will be completed in collaboration with the Quality Improvement Staff. Quality Improvement personnel and the Clinical Program Manager will also consult with families and client to confirm that needs are being met and service billed are accurate. (System for Wraparound Quality Assurance)
Additionally, the Wraparound Fidelity Index (WFI) will be administered at mid- and end-of-service to capture feedback from youth and caregivers. The county’s biannual Consumer Perception Survey will provide further input. Data from WFI and Consumer Perception Survey will be reviewed by the Quality Improvement personal and leadership members to guide program improvements, including policy development, training enhancements, and strategies to better support youth and families.
Improved community functioning will also reflect in the IP-CANS under Community Life. Improvements on IP-CANS are reflected in the clients Plan of Care and uploaded to the youths chart.
Helping youth and families to accessing community resources as well as improving their engagement is such resources is a valuable element of SCH Wraparound. So, in addition to the tools administered above, we help to educate on the resources available, improvement and advocacy of needs within these resources as well as address social skills needed to engage in such resources.
2.4 Improved Interpersonal Functioning
Wraparound services will be delivered with fidelity to the model. To ensure quality, the Team Observation Measure (TOM) will be used, and the Document Assessment and Review Tool (DART) will be completed in collaboration with the Quality Improvement Staff. Quality Improvement personnel and the Clinical Program Manager will also consult with families and client to confirm that needs are being met and service billed are accurate. (System for Wraparound Quality Assurance)
Additionally, the Wraparound Fidelity Index (WFI) will be administered at mid- and end-of-service to capture feedback from youth and caregivers. The county’s biannual Consumer Perception Survey will provide further input. Data from WFI and Consumer Perception Survey will be reviewed by the Quality Improvement personal and leadership members to guide program improvements, including policy development, training enhancements, and strategies to better support youth and families.
Improved interpersonal functioning will also reflect in the IP-CANS under Interpersonal, Family Functioning, Living Situation, and Social Functioning. Improvements on IP-CANS are reflected in the clients Plan of Care and uploaded to the youths chart.
As mentioned in other sections, and in addition to the tools mentioned, we address the interpersonal skills needed to function and engage in the resources in the youth’s community (education/vocational, etc.) in an effort to improve overall functioning and personal efficacy.
2.5 Increased Caregiver Confidence
Wraparound services will be delivered with fidelity to the model. To ensure quality, the Team Observation Measure (TOM) will be used, and the Document Assessment and Review Tool (DART) will be completed in collaboration with the Quality Improvement Staff. Quality Improvement personnel and the Clinical Program Manager will also consult with families and client to confirm that needs are being met and service billed are accurate. (System for Wraparound Quality Assurance)
Additionally, the Wraparound Fidelity Index (WFI) will be administered at mid- and end-of-service to capture feedback from youth and caregivers. The county’s biannual Consumer Perception Survey will provide further input. Data from WFI and Consumer Perception Survey will be reviewed by the Quality Improvement personal and leadership members to guide program improvements, including policy development, training enhancements, and strategies to better support youth and families.
Improved caregiver confidence will also reflect in the IP-CANS under the Caregiver resources and needs section.8 Improvements on IP-CANS are reflected in the clients Plan of Care and uploaded to the youths chart.
2.6 Stable and Least Restrictive Living Environment
Wraparound services will be delivered with fidelity to the model. To ensure quality, the Team Observation Measure (TOM) will be used, and the Document Assessment and Review Tool (DART) will be completed in collaboration with the Quality Improvement Staff. Quality Improvement personnel and the Clinical Program Manager will also consult with families and client to confirm that needs are being met and service billed are accurate. (System for Wraparound Quality Assurance)
Additionally, the Wraparound Fidelity Index (WFI) will be administered at mid- and end-of-service to capture feedback from youth and caregivers. The county’s biannual Consumer Perception Survey will provide further input. Data from WFI and Consumer Perception Survey will be reviewed by the Quality Improvement personal and leadership members to guide program improvements, including policy development, training enhancements, and strategies to better support youth and families.
Helping the youth to maintain least restrictive living environment is achieved through providing support (in whatever form is necessary) in relation to the presenting problems of the youth, providing appropriate advocacy to the youth and family,
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Wraparound services will be delivered with fidelity to the model. To ensure quality, the Team Observation Measure (TOM) will be used, and the Document Assessment and Review Tool (DART) will be completed in collaboration with the Quality Improvement Staff. Quality Improvement personnel and the Clinical Program Manager will also consult with families and client to confirm that needs are being met and service billed are accurate. (System for Wraparound Quality Assurance)
Additionally, the Wraparound Fidelity Index (WFI) will be administered at mid- and end-of-service to capture feedback from youth and caregivers. The county’s biannual Consumer Perception Survey will provide further input. Data from WFI and Consumer Perception Survey will be reviewed by the Quality Improvement personal and leadership members to guide program improvements, including policy development, training enhancements, and strategies to better support youth and families.
2.8 Reduction in Crisis Visits
Wraparound services will be delivered with fidelity to the model. To ensure quality, the Team Observation Measure (TOM) will be used, and the Document Assessment and Review Tool (DART) will be completed in collaboration with the Quality Improvement Staff. Quality Improvement personnel and the Clinical Program Manager will also consult with families and client to confirm that needs are being met and service billed are accurate. (System for Wraparound Quality Assurance)
Additionally, the Wraparound Fidelity Index (WFI) will be administered at mid- and end-of-service to capture feedback from youth and caregivers. The county’s biannual Consumer Perception Survey will provide further input. Data from WFI and Consumer Perception Survey will be reviewed by the Quality Improvement personal and leadership members to guide program improvements, including policy development, training enhancements, and strategies to better support youth and families.
2.9 Positive Exit from HFW
Wraparound services will be delivered with fidelity to the model. To ensure quality, the Team Observation Measure (TOM) will be used, and the Document Assessment and Review Tool (DART) will be completed in collaboration with the Quality Improvement Staff. Quality Improvement personnel and the Clinical Program Manager will also consult with families and client to confirm that needs are being met and service billed are accurate. (System for Wraparound Quality Assurance)
Additionally, the Wraparound Fidelity Index (WFI) will be administered at mid- and end-of-service to capture feedback from youth and caregivers. The county’s biannual Consumer Perception Survey will provide further input. Data from WFI and Consumer Perception Survey will be reviewed by the Quality Improvement personal and leadership members to guide program improvements, including policy development, training enhancements, and strategies to better support youth and families.
Furthermore, our Quality Improvement personnel works with Wraparound Leadership to review the Performance Measures compiled by the county research staff regarding positive exits from HFW.
Engagement
3.1 Orientation
a.) Efforts to build alliance with the youth and family is essential for family to get the most benefit from Wraparound services. Orientation to a High Fidelity Wraparound services starts with engagement which includes the important initial meeting with the caregiver and/or youth. The initial meeting is conducted by, typically, the Family Partner and Family Facilitator. The staff conducting the initial meeting introduce themselves, explain their roles and actively listen to the concerns of the family and youth (and tribe, if applicable). It is through this meeting that important alliance building occurs with the family, exploring the specific family needs in relation to the referral (since referrals are often made by system partners and not directly by the family), the function of the Child and Family (CFT) meetings, discuss confidentiality and the youth and family rights, the roles of each team member that may be added to the team (including natural supports, family and tribe – if applicable), and addressing any immediate of the family. Alliance building can also include the advocacy staff sharing their lived experience if applicable. This intervention is aided by documents that are made available to the youth and family. For example: our intake packet is an extensive collection of paperwork that includes an “Intake Packet Checklist” to ensure all parts of wraparound are discussed including the program makeup, legal and ethical considerations, and the roles of team members. Our intake packet includes a brochure that helps the conversation of adding team members. (Wraparound Intake Packet Checklist. Advocacy Trifold 2x. Wraparound Brochure)
a.) This also provides us with an opportunity to explain the phases and principals of Wraparound. We start with the Engagement Phase, their current phase, then go into the Planning, Implementation, and Transition Phase and the steps it takes to progress from one phase to another highlighting the providers, clients, tribe, informal supports and caregivers role within each phase. We explain to the family that Wraparound is a team-based process that helps families create a plan to support their child. Instead of services being decided for them, they are built with them centered on the family’s strengths, culture, and goals. They can expect the Wraparound process to follow the phases of engagement and team building, planning and creating their plan based on their goals and strengths, implementation and supporting, and lastly intentional transition. We ensure that the principles of Wraparound are not only told to them but modeled throughout their time with the program. (Wraparound Brochure.)
b.) Legal and ethical considerations are essential in the delivery of High Fidelity Wraparound services. Of course, confidentiality is respected and when sharing information becomes essential, the Wraparound staff would obtain the necessary release of information. Furthermore, SCH Wraparound provides informed consent – which means that we explain the limited of confidentiality to our youth and clients and would apply to information to which we becomes aware of that requires mandated report (e.g., suspected child or adult abuse, imminent risk of suicide, or duty to protect) responsibilities become evident. (Wraparound Intake Packet Checklist)
c.) The Plan of Care helps clarify the roles of each team member and the responsibilities they hold in relation to the success of the plan and family. This is in addition to reviewing and discussing the roles listed in the Wraparound Brochure. This includes assigned task and proposed completion dates. In subsequent Child and Family Team meetings, these plan of care are review for explore if/when these assignments were completed and the impacts on the youth/family and team. Plan of Care typically involves all team members, and this includes the team members, family, natural supports, and Tribes if applicable. (Wraparound Brochure. Blank Plan of Care.)
3.2 Safety and Crisis stabilization
a.) When a client is referred to the SCH Wraparound program, the staff completes an assessment which includes an evaluation of safety and crisis issues. This sometimes includes suicidal, homicidal, exposure to domestic violence and community violence, homelessness, etc. amongst other issues. SCH Wraparound develops a written safety and crisis plan that responds to the concerns. Safety and crisis plans are developed immediately if needed that provides immediate intervention and stabilization and a copy is given to the family, and a copy is uploaded to the youth’s chart. (System for Wraparound Safety and Crisis Planning)
b.) As part of this procedures, safety and crisis concerns are discussed at initial intake as well as throughout the engagement process following the High Fidelity Wraparound process. As stated, urgent concerns are addressed immediately with a written plan which is provided to the family as well as documented in the electronic health record. This plan works in conjunction with the High Fidelity Wraparound Safety Plan that is developed during the Plan Development phase. (System for Wraparound Safety and Crisis Planning)
c.) The family is also provided emergency numbers for 24/7 crisis response. (System for Wraparound Safety and Crisis Planning)
3.3 Strengths, Needs, Culture and Vision Discovery
a.) The SCH Wraparound program follows a High Fidelity Wraparound model – which includes an examination of the youth and family’s strength, needs and culture, as well as help the youth and family to develop a vision. As part of this process, the facilitator and other staff ask questions in an effort to understand the cultural needs of the youth and family. From this, the facilitator prepares a written summary of the strengths, needs, culture and vision that is a culmination of all that has been discovered about the youth and family at that point in time. This document also serves the purpose of orienting new Child and Family Team members as team members are added. (Documentation Form One: Strengths, Needs, and Culture Discovery. SCH System for Wraparound Strength Needs Culture and Vision Discovery.)
During the Engagement phase, the vision (for success – which is based on the youth and family’s vision of success) is discussed. This can take several meeting with the youth and family to help develop the vision. Once the Family Vision is identified it is documented in the youths chart. (Documentation Form One: Strengths, Needs, and Culture Discovery. SCH System for Wraparound Strength Needs Culture and Vision Discovery.)
b.) Once developed, the Strengths, Needs and Cultural Discovery is updated every 90 days. This process often complements the identification of natural supports which can be very helpful for families to utilized their own personal supports in preparation for discharge from the program. Again, the SNCD is provided to new team members to help them understand the family’s perspective. (Documentation Form One: Strengths, Needs, and Culture Discovery. SCH System for Wraparound Strength Needs Culture and Vision Discovery.)
3.4 Engage All Team Members
a.) Through the Engagement and Planning phase the Facilitator and Advocacy staff begin to gather information not only for assessment completion, but also for the Strengths, Needs, Culture, and Vision Discovery (SNCVD). The SNCVD is a living document that evolves and continues to grow and be added to as the team and family further their understanding and growth within the program. The SNCVD formation and development begins after the first contact with the client and family (and tribe, if applicable). In addition to identifying strengths and needs, this tool assists and starts the process of identifying cultural value and potential natural supports for the youth and family. Examination of natural support and the family’s own way of creating solutions for themselves is also addressed in the first interventions of this high fidelity Wraparound model. This intervention is called the Initial Interview of the Family. This is conducted as a collaborative meeting by the family partner or youth peer mentor and the family facilitator. (SCH System for Wraparound Strength Needs Culture and Vision Discovery. Demonstration Form Two: Strengthening the Natural Support System for a Family Blank Plan of Care Page 1 &2)
b.) The children’s system of care members are also explored and engaged throughout the initial phase of Wraparound to ensure the program has a complete and full understanding of the family and their support team. They are included from the beginning to gather information and develop the SNCVD as well as included in the initial CFT to allow for collaboration during the development of the Wraparound Plan of Care. (Demonstration Form Three: Integration Engaging and Maintaining Team Members.)
c.) Additionally, the Facilitator inquires with the family which of those individuals they would like us to ensure is included in their CFT’s moving forward. The Wraparound Plan of Care identifies everyone’s role on the team including both formal and informal supports. (Blank Plan of Care Page 1 & 2.)
d. Attempts to engage and team build is documented in client charts including Meeting Minutes to reflect attendance, case notes highlighting additional supports to be pursued, and case notes reflecting attempted contacts of said supports.
3.5 Arrange Meeting Logistics
a.) In accordance to High Fidelity Wraparound principles, meetings take place at a time and in a location that is convenient and accessible to all team members with priority given to the family and youth’s needs and voice and choice. Aspects of logistics that should be taken into consideration include family schedule, culture and history of trauma – in an effort to afford equitable access for the youth and family. (System for Wraparound Intake Procedures, CFT, and Treatment Frequency)
b.) In order to affect such flexibility, staff are trained to schedule meeting times and locations to accommodate family and the CFT Team needs. Of course, staff are trained to work collaboratively with families and other members of the CFT to schedule meetings that meet the family’s needs and reference to maximize participation. Wraparound leads the scheduling responsibilities to ensure all things are considered including securing transportation, arranging interpreter needs, verifying telehealth capabilities, providing meals if needed, and brining any necessary materials for a successful CFT. (System for Wraparound Intake, CFT, and Treatment Frequency.)
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
a.) It is the mission of the Sacramento Children’s Home Wraparound program to celebrate the youth’s and family’s culture and tribe. SCH Wraparound employs a High Fidelity Wraparound model, and in this way, the Wraparound Program utilizes staff’s skills to join with the family, elicit youth and family values, culture, expertise, capabilities, interests, skills, and strengths. This process is aided by the use of the Strengths, Needs, Culture and Vision Discovery (SNCVD) – a tool which helps guide discussions with the youth and family to explore cultural needs and values. The activity operates alongside other interventions (Initial Meeting with the Family, Preparing Family for the First Child and Family Team meeting, and the Initial and Implementation Child and Family Team meetings) in which the family’s values are explored and, with the assistance of the youth, family and tribe, help to develop the Family Vision and Team Mission (and statements) as well as conceptualizing what the family would like to see in relation to team agreements. The teams’ strengths identified throughout initial engagement are reflected in the youths’ files to refer to when the family and team are ready to formulate the Plan of Care. (System for Wraparound Quality Assurance. Observation Form Two: Preparing the Family for the Initial Team Meeting. Blank Plan of Care Page 1 &2.)
b.) The youth’s and family’s strengths are updated to reflect additional discoveries as they are identified and are documented in the youth file. This typically occurs in relation to when the Plan of Care is being reviewed and updated. (Observation Form Three: Initial Wraparound Plan.)
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
a.) During the Engagement Phase, the assessment period begins. During this phase, underlying needs are identified and prioritized for each family member. These plan development sessions are documented in the youth’s chart.
b.) Measurable goals and outcomes are developed from the identified needs. (Blank Plan of Care. Documentation form Two: Wrap Plan)
c.) The goals and outcomes are developed with the youth, family, and Wraparound team collaboratively. (Documentation Form Two: Wrap Plan)
d.) The multiple plan development sessions are documented in the youth file as well as in meeting minutes and the Plan of Care to refer to as needed. (Blank Plan of Care. Blank Meeting Minutes)
e.) Staff receive initial training (within their first 120 days with Sacramento Children’s Home) and annual training on the development of strategies and developing action items (within the service plan) which are reflective of the identification an prioritization of the family needs. Providing needs-focused planning is evaluated by the supervisors and manager of our program through observation of Child and Family Team meetings as well as documentation reviews. (Wraparound Training Table of Contents) The Planning Phase is also trained to during our yearly 2-day Wrap Camp internal training as well as during our 2nd quarter where we review and workshop the Planning Phase of Wraparound internally. Facilitators utilize the RAAAR approach for action step follow through Reviewing, Assessing, Adjusting, Assigning, and Revisiting to ensure proper and timely completion of tasks that move the child and family towards progress. The Facilitator supervisor observes CFTs to ensure shared ownership and completion of the family progress across providers, natural support, client, and caregivers alike. 3 Outcome measures and action steps are identified and individual CFT plans are frequently evaluated by the Facilitator for the following CFT. (System for Wraparound Client Assessment and Monitoring of Level of Treatment. Wraparound Training Table of Contents.)
f.) The actual Plan of Care is developed by a CFT. The youth and family select the team. The individualized plan is child centered and family focused with maximum family involvement, with variation depending on the needs of the youth and family. The process focuses on strengthening the natural family, extended family and social supports for the youth by involving them in the planning and implementation process. The youth and family are integral parts of the team and must have ownership of the plan. (Observation Form Three: Initial Wraparound Plan.)
The plan is based on the unique strengths, needs, values, norms, preferences, and culture of the youth, family, and community that are observed and identified prior to the initial CFT. No interventions are allowed in the plan unless they match youth, family, and community strengths. By building on these strengths, the plan supports who the youth is and how the youth will positively progress in life. The plan highlights the specific outcomes desired by the family and team and includes measurable and timely actions items to complete by services providers, the client, and the family. The plan is focused on typical needs in life domain areas that all persons (of like age, sex, culture) have. These life domains are independence, family, living situation, financial, educational/vocational, social/recreational, behavioral/emotional, psychological, health, legal, cultural, safety, and others.
4.3 Develop an Individualized Child or Youth and Family Plan
a.) All Wraparound staff (including facilitators) are trained in the SCH Wraparound Implementation and Plan of Care System. The Facilitator will administer an appropriate process based on this system. This would include aligning with the family, exploring vision of the family, help the family to develop a mission statement. This process follows the administration of the strengths, needs, culture and vision discovery (SNCVD), and the facilitator will utilize the awareness brought about through the SNCD in completing the family vision and mission. (System for Wraparound Implementation and Plan of Care. Wraparound Training Table of Contents. Demonstration Form Three: Integration Engaging and Maintaining Team Members.)
b.) System partners are also invited in this process (based on priorized needs of the family and through obtaining appropriate releases from family or privilege holder), through the Child and Family Team (CFT). Furthermore, following the Child and Family Team (CFT) process, the facilitator will help to identify strengths, challenges, needs to address the challenges and a strategic action plan to address these needs. This can include utilizing natural supports, community resources and systems partners. The strategic action plan from each Child and Family Team (CFT) who will be taking responsibility to address each item on the action plan and the due date for accomplishing each item. (Demonstration Form Three: Integration Engaging and Maintaining Team Members.)
c.) All services and support offered will be a balance (as stated earlier) of a balance of formal services, natural supports and community and family resources with emphasis upon natural supports. (System for Wraparound Implementation and Plan of Care.)
In addition, SCH Wraparound Plan of Care emphasizes utilization of an array of services and supports with the Sacramento County Children’s System of Care including services provided under Sacramento County Behavioral Health, Human Assistance and the full array of housing and other community resources. Priority is given to family needs and family voice and choice – family schedule, culture and history of trauma and ensuring access for all youth and families.(System for Wraparound Quality Assurance.)
Furthermore, in the administration of the SCH Wraparound Plan of Care, the facilitator help the family to examine the domains of their life to determine areas in which help is needed, what natural supports exists, and establishing priorities in relation to these needs. (Documentation Form Two Wrap Plan)
As discussed earlier, natural support and sustainable community resources are emphasized and included within the Plan with thought to accessing those services by the youth and family when SCH Wraparound transitions out of the youth and family’s life. In addition, referrals have an emphasis of reduction of restrictive, intrusive and formal services through the Wraparound process and with the proviso of working towards the family’s own pace. (System for Implementation and Plan of Care)
All Plans of Care are reflected in the youths chart as well as distributed to all team members by the facilitator.
d.) Supervisors routinely review Plan of Care documents and provide feedback to staff in an effort to improve staff skills and improve the efficacy of services provided. Furthermore, our Quality Improvement department routinely administers the TOM 2.0 (for observation of Child and Family Team meetings) and well as WFI-EZ (follow-up of services survey) to evaluate the services provide. This feedback is provided to the supervisors and staff. (System for Wraparound Quality Assurance.)
4.4 Develop a Crisis and Safety Plan
a.) Within the first meeting Child and Family Team meeting, the facilitator leads the team in developing a crisis and safety plan that identifies and priorities 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. It also includes the information for 24/7 support. (Blank New Tiered Bxl Criris Safety Plan.)
b.) The development of the plan occurs in a CFT to ensure a team based, collaborative environment. Safety and crisis planning is retrained to twice annually, Once during Wrap Camp and secondly during the Quarter Two Planning Phase workshop. (Wraparound Training Table of Contents. )
c.) Identified strategies should be chosen by the youth and family, should be culturally relevant, and should maximize the use of natural supports wherever possible. (System for Wraparound Safety and Crisis Planning. Observation Form Five: Crisis Plan Meeting. Documentation Form Four: Crisis Plan)
Implementation
5.1 Implement The Plan of Care
a.) As part of the implementation of the Wraparound Plan of Care, the High Fidelity Wraparound Team discusses the strengths and needs of the client. Strengths and needs are illuminated to the team through the completion of the IP-CANS as well as the Strengths, Needs, Culture and Vision Discovery. Action items are identified, strategies for fulfilling those action items (including identification of natural supports and other resources that the family possesses). Usually during the first Child and Family Team (CFT) meeting, the Plan of Care is typically completed by the facilitator. This includes Team members names and information, individualized plan (that includes prioritized needs, strategies and desired outcomes). Relevant IP-CANS scores are noted as well. The Child and Family Teams celebrate the successes of the clients and families as the specific goals are achieved. (System for Wraparound Implementation and Plan of Care. Observation Form Four: Implementation Wraparound Meeting. Documentation Form Two: Wrap Plan.)
Facilitators utilize the RAAAR approach for action step follow through Reviewing, Assessing, Adjusting, Assigning, and Revisiting to ensure proper and timely completion of tasks that move the child and family towards progress. This approach is utilized to strategies and action items from meeting minutes and the Plan of Care to track individual assignments, meeting timelines, meeting deliverables, and adjust the strategies and action items as needed.
b.) The team receives training on the Plan of Care twice annually. Once during our annual Wrap Camp and during the Planning Phase in a workshop in Quarter 2. Additionally coaching is provided as needed. Trainings and processes include celebrating success both throughout and at the end during transition. (Wraparound Training Table of Contents)
5.2 Review and Update The Plan of Care
a.) Prior to the implementation phase of the High Fidelity Wraparound service, the Facilitator and Family Partner will have conducted the initial meeting with the child and family. Within this meeting, a thorough explanation is provided with regard to High Fidelity Wraparound service – goals, types of services provided, exploration of needs and significant support is provided with regard to helping the youth and family to identify needs, empowerment with regards to expressing those needs, and discussion in relation to the necessity of the referral to our program. As discussed earlier, the IP-CANS and Strengths, Needs, Culture and Vision Discovery are implemented as well – which provides opportunities to identify strength, natural supports and other resources to which the youth and family possess. (System for Implementation and Plan of Care. System for Strengths, Needs, Cultural and Vision Discovery. Observation Form Four: Implementation Wraparound Meeting. Documentation Form Two: Wrap Plan.)
Through this process, the facilitator engages the family and Team in the development of the plan of care during a CFT. During subsequent meetings through the Implementation phase, the facilitation is provided in relation to progress the youth and family have made towards the goals, effectiveness of strategies, and if goals have been accomplished. (System for Wraparound Implementation and Plan of Care.)
b.) Further, in Implementation Child and Family Team meetings, minutes are taken and within it is noted when tasks are completed, new assignments, team attendance, use of formal and natural supports, flex funds approvals and updates to the plan. Updates to the plan include any changes, adjustments, and success. A comprehensive update of the Plan of Care is conducted every 90 days at least (as needed) and is added to the youth’s chart. (System for Wraparound Implementation and Plan of Care. Observation Form Four: Implementation Wraparound Meeting)
c.) Meeting minutes and updated Plan of Care are completed and uploaded to the youths chart after each CFT by the facilitator. These meeting minutes and Plan of Care include completion of tasks, new assignments, team attendance, use of formal and natural supports, flex fund usage, and updates to the plan. These meeting minutes are provided to all team members. (Blank Plan of Care. Blank Meeting Minutes.)
d.) Forms are updated to meet the youth, family, and team’s changing individualized needs.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
a.) The initial stages of High Fidelity Wraparound (such as initial meeting with facilitator and family partner) are essential to building trust with the youth and family. Furthermore, the Strengths, Needs, Culture and Vision Discovery and IP-CANS help to identify essential strengths and natural supports that the youth and family possess. These are essential steps to build an effective High Fidelity Wraparound Team. Furthermore, through the process of discussing family vision and mission, the facilitator and Wraparound Team reinforce the cohesiveness of the particular HFW Team. This cohesiveness is maintained by reviewing the team agreements at the start of each CFT and implemented throughout the meetings as needed. The Plan of Care with the team agreements included are present at every meeting. (Blank Plan of Care Pages 1 & 2. Observation Form Four: Implementation Wraparound Meeting.)
b.) Facilitators receive ongoing training and coaching on building, engaging, and maintaining effective teams. Facilitators are also provided the opportunity to assess and address team cohesion during weekly Facilitator meetings. The team collectively complete our internal annual Wrap Camp to ensure consistent cohesion to the model. (Wraparound Training Table of Contents. Demonstration Form Three: Integration Engaging and Maintaining Team Members.)
c.) Also, cohesiveness and commitment are compounded by adding natural supports to the Child and Family Team (CFT). (Demonstration Form Two: Strengthening the Natural Support System for a Family.)
d.) Along this process, the team orient and engages the new team members as they are added which reinforce the goals, strategies and focus of the Child and Family Team (CFT). (System for Wraparound Implementation and Plan of Care.)
Transition
6.1 Develop a Transition Plan
a.) Since High Fidelity Wraparound utilizes a process of purposeful transition, which starts at the very beginning of the high fidelity Wraparound services, the HFW Facilitator leads a process in which goals, mission and vision from the family’s perspective is established at the very beginning. Therefore, benchmarks which indicate sufficient progress towards goals, mission and vision guide when the Child and Family Team (CFT) to know when the transition phase has arrived.
b.) Once these benchmarks are reached, the High Fidelity Wraparound Team discusses and develops the individualized transition plan, and this process is typically led by the facilitator; however, consistent with Wraparound philosophy, families are often leading their own child and family team (CFT) meetings at this point. This process is aided by the administration of the High Fidelity Wraparound Transition Readiness Scale which is used to help the youth and family to identify if there are any areas (of the youth/family systems) that needs continued support. This plan is distributed to all team members as well as reflected in the youths chart. (Transition Readiness Scale.)
c.) As discussed, the Child and Family Team develop a written plan that documents how they are going to use the identified supports, meet their needs, respond to crisis, celebrate accomplishments and contributions, and reflect on the progress made and lessons learned through the Wraparound process. HFW Facilitators receive training and coaching in the process. This throughout the year, and is reinforced twice annually . Once during the our annual Wrap Camp and secondly during quarter 4 focused on the Transition Phase. Trainings are supported by ongoing consultation and coaching by trained coaches. (Wraparound Standard Discharge Protocols. Documentation Form Six: Transition Planning.)
d.) The team verifies that service and supports identified in the transition phase will persist past formal HFW and that the family is able to access them, including post adoption services if applicable. The facilitator completes any referrals needed before transition and will verify a intake date has been identified. This is documented in the youths chart. (Documentation Form Six: Transition Planning.)
6.2 Develop a Post-Transition Safety Plan
a.) A crucial element is the development of post-Wraparound safety planning, in which the Wraparound facilitator and the Child and Family Team discuss potential crisis situations that may occur after transitioning from the High Fidelity Wraparound Services. The safety plan includes proactive and reactive crisis management strategies that maximize use of natural supports that are identified by the family. This is all documented in the youths chart. (Documentation Form Six: Transition Planning)
b.) As mentioned above the crisis and safety transition plan occurs in a team based, collaborative environment. Facilitators receive training in this process during our annual Wrap Camp training. Coaching is provided throughout as needed and opportunities are provided during our weekly Facilitator meeting. (Wraparound Training Table of Contents)
c.) As with all safety and crisis planning, this plan is individualized, proactive and reactive strategies for the youth, family and other supports. It is culturally responsive and utilizes natural and community supports for the family whenever possible. (Wraparound Standard Discharge Protocols.)
6.3 Create a Commencement and Celebrate Success
a.) In recognition of the great efforts of the youth and family during the High Fidelity Wraparound process, a team celebration is held and the youth and family are recognized through Wraparound providing them with a celebratory gift (that is meaningful to the youth and/or family). This celebration is culturally relevant and respectful of the youth and family’s wishes. (Wraparound Standard Discharge Protocols.)
b.) Our internal processes are supportive of engaging in celebration ensuring access to flex funding, time for community resourcing, community partnerships, and ensuring staff are available to attend the graduations. (Wraparound Standard Discharge Protocols. Documentation Form Six: Transition Planning)
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
a. ) Sacramento Children’s Home Wraparound program eagerly seeks child and family involvement in its decision-making processes. Since we are administering a high fidelity model, we utilize high consumer involvement in decisions that the Child and Family Team (CFT) make that affect the youth and family. Additionally, families are offered the opportunity to join the county Community Leadership Team. In addition to the ongoing involvement of the youth and family, we encourage feedback from the family utilizing the Wraparound Fidelity Index (WFI). Also, youth and family are encouraged to participate in biannual survey (Consumer Perception Survey) as well as the CFT Survey administered through Sacramento County.
b.) Involvement of the consumer is emphasized in the frequent trainings provided to the staff as well as monitored through the utilizing of the Team Observation Measure (TOM) in the administration of the Child and Family Team meetings. In addition, the Wraparound Fidelity Index (WFI) is administered at mid-service and end of service points to obtain impressions the consumers (child and caregivers) have of the services provided. Further, the county administers the biannual Consumer Perception Survey (CPS). The results, feedback and data that are obtained from both the WFIs and CPS is utilized by the Performance and Quality Improvement committee of the SCH Wraparound Program for quality improvement of the program including development of new systems and policy, improvement and development of new trainings and exploration of other ways in which the SCH Wraparound Program can support the youth and families to be successful. (System for Wraparound Quality Assurance)
7.2 Community Leadership Team
a.) There is an identified SCH representative who actively participates in the Community Leadership Team.
7.3 Eligibility and Equal Access
a. ) Sacramento Children’s Home Wraparound program provides services to all eligible cases regardless of their level of need being severe. SCH provides appropriate planning to assure that once enrolled, families have access to an adequate level of support. (System for Wraparound Client Assessment and Monitoring of Level of Treatment Intensity. System for Wraparound Intake, CFT, and Treatment Frequency.)
b.) Caseloads are assigned and managed based on severity of cases, so that families get the level of support that they need. Sacramento Children’s Home Wraparound program provides 24/7 support to meet complex needs of the child and family. (System for Wraparound Client Assessment and Monitoring of Level of Treatment Intensity. System for Wraparound Intake, CFT, and Treatment Frequency.)
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
a.) Sacramento Children’s Home will continue to provide high fidelity services and support in alignment with our contract with Sacramento County. The said contract defines and highlights the services and supports expected to meet the immediate individualized needs of youth and families. SCH has implemented hiring, training, and monitoring to ensure compliance with the expectations of HFW.
b.) SCH has a staffing model to meet the required workforce development and staffing. This includes the required roles and functions. (Wraparound Scope)
c.) Also, the contract sets out the required data collection and data management systems expected. In addition, we conduct meetings with our county contract monitor monthly to ensure continued alignment with all contract requirements. Furthermore, Wraparound services provided will be consistent with and provide fidelity to the Wraparound model. Therefore, Team Observation Measure (TOM) will be administered to ensure quality of Child and Family Team meetings. Additionally, the Wraparound Document Assessment and Review Tool (DART) is completed in relationship with our Quality Improvement personnel. Furthermore, Quality Improvement personnel and Clinical Program Manager will discuss services provided with family members and clients to ensure that needs are met as well as verification of services billed. (System for Wraparound Quality Assurance. Wraparound Scope.)
SCH also has a Quality Improvement Department with staff who support HFW fidelity and outcome monitoring.
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 and included as a part of the funding plan for HFW. The county contract provides funding that meets the requirements of flexible funds for youth and families. The Sacramento Children’s Home will continue to provide high fidelity services and support in alignment with our contract with Sacramento County. The said contract defines and highlights the services and supports expected to meet the immediate individualized needs of youth and families including flexible funds.
B.) In the Child and Family Team (CFT) meetings, the assigned Family Facilitator will engage the youth, family, natural supports and other team members in a discussion to identify needs of the youth and family in relation to implementing and achieving the permanency plan. A CFT can be called at any time in case of an emergency or urgent need (within 24 hours). If the team identifies a need that requires spending flex funds, and the majority of the family and team agree with such needs, the Family Facilitator will lead a discussion in relation to maximum cost, possible vendors, and seek approval of the team (agreement by the majority of team signifies approval). The team will also discuss which member of the team will take on the responsibility of purchasing such item(s). Also, ongoing (weekly) expenses are acceptable—for rewards or the like. (Wraparound Flex Funds System)
All uses of flex funds must meet the approved criteria and standards for what the funds can be used for per state and county policies.
The process to appeal denied request is to conduct a process review with a Wraparound Supervisor and/or the Program Manager in attendance to discuss the reason for denial. (Process Review System)
8.5 Collaborative Oversight of Flex Funds
a.) Approval details will be recorded in the CFT minutes and scanned into the client’s chart. The amount, purpose, and team recommendation for the request is documented. Progress notes will also be entered once a month to reflect utilization of flex funds in clients’ charts. (Wraparound Flex Funds system)
b.) The county has a system in place where SCH enters in non-specialty mental health services (with an assigned reimbursement rate) into the electronic health record. Monthly invoicing generates revenue for SCH to use to support flexible fund expenses in the HFW program. SCH is able to maintain a modest pool of funds to cover all needed expenses and the excess revenue is returned to the county.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
a.) The SCH county contract contains braided funding from multiple sources to ensure the HFW services are adequately funded.
b.) The county contract specifies the amount of available funding that exists in the pool of Wraparound funds each year. SCH and the county monitor the use of funds in various funding areas on an ongoing basis. If at any time SCH appears to be at-risk of using all the allocated funding in a given area, there is a process to alert the county to initiate a budget reallocation to ensure that adequate resources are available to fully administer HFW services and supports. c.) The Sacramento Children’s Home Wraparound Program ensures that funding does not limit the availability of flexible funding or the resources developed to meet the needs of the youth, families, Tribes, and communities served.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
a.) SCH strives to align with the National Culturally and Linguistically Appropriate Services standards (CLAS) to provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs. The National Standards for Culturally and Linguistically Appropriate Services (CLAS) are standards that ensure services are respectful and responsive to each person’s culture and communication needs, specifically seeking to improve cultural competence, language services use, and quality of services. SCH has a long-standing Culturally Responsiveness Committee and participate in the Sacramento County Behavioral Health Racial Equity Collaborative as well. Furthermore, the SCH Strategic Plan that includes development of a culturally responsive workforce. Along these lines, SCH will adopt CLAS standards listed below, whenever possible and appropriate:
I. Governance, Leadership, and Workforce
II. Communication and Language Assistance
III. Engagement, Continuous Improvement and Accountability (Administrative – Cultural Responsiveness Policy)
b.) Additionally, Wraparound takes all steps to build Wraparound teams around the families cultural, racial, and linguistic needs including exploring natural or formal supports on the team. We ensure all staff attend the agency training entitled Cultural Responsiveness and all staff attend the Sacramento County Cultural Competency training courses. (WRAP Access to Interpreter Services System)
c.) Lastly a translator or natural support person is utilized when necessary.
9.2 Tribally Responsive Workforce
a.) Staff are trained through the UC Davis ICWA & Tribal Engagement courses. This includes training in tribal sovereignty, traditions, and values, as well as how to ensure respectful communication, collaboration, and advocacy. Additionally, the team is provided with and sites the Tribal Engagement Guide. (Tribal Engagement Guide.)
b.) All Tribal Representatives are invited to CFT’s and MDT’s held in relation to the family. This is to ensure a partnership is build with the tribal representative and value is placed in understanding the services and supports the Tribe have to offer.
9.3 Flexible and Creative Work Environment
a.) The Wraparound team participates in a monthly Performance and Quality Improvement meeting that is separate from weekly staff meetings. These meetings focus on evaluating programming processes, identifying areas for improvement, and developing initiatives to address those needs. Improvements are often identified by staff, who play a primary role in leading initiatives, fostering collective responsibility and shared ownership of program outcomes. In our weekly staff meetings, we have a standing agenda item to review cases that teams would like to bring to whole Wraparound team to allow for fresh perspectives, robust brainstorming, and creative solutions to barriers or challenges.
b.) To promote team cohesion, maintain a clear sense of mission, and ensure compliance with the HFW philosophy, staff participate in an annual two-day training known as Wrap Camp. This training allows leadership to ensure consistent implementation of HFW principles, values, phases, and activities, while also encouraging collaboration across the team. Staff are given ample opportunities to share and explore different approaches and communication styles across various scenarios, with the goal of identifying the most cohesive and effective ways to uphold HFW in all aspects of practice.
c.) Open communication is encouraged and reinforced through leadership’s active participation in these activities. Sacramento Children’s Home also completes an annual Staff Satisfaction Survey which allows all employees to provide anonymous feedback regarding their employment. Leadership is provided with the outcomes and reviews them with management to address any areas of improvement while also highlighting the satisfaction within the last year.
d.) Leadership leads in creating a clear sense of mission and compliance with the HWF philosophy, including the principles, values, phases, and activities.
9.4 Hiring, Performance Evaluation, and Job Descriptions
a.) Our team is comprised of the listed and expected roles. Each position has a detailed job description that outlines job responsibilities and expectations.
b.) The job description and responsibilities of each role include the role purpose, functions and qualities specific to each role or function. (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. (Job Descriptions)
d.) Each position has their own set of interview questions to ensure the questions allow candidates to highlight their attitude and skills essential for the specific position. (Interview Questions)
e.) Additionally, the new hire 120 evaluations are different from one another to ensure employees are provided with the opportunity to demonstrate attitudes and skills essential to that specific position. (120 Evaluations.) Each employee is provided with a job description and 120 evaluations so they can be aware of what is expected of their performance as well as how it is being measured. Afterwards they are also provided with their annual evaluation tool ahead of time. (Annual Reviews) Each employee is provided with weekly supervision for areas of support, feedback, and coaching.
9.5 Workforce Stability
(a) Matching wages to cost of living in the location of the organization/service implementation area
SCH routinely completes salary surveys to maintain competitiveness and, when needed, adjust salaries to recruit and retain qualified applicants. SCH also provides a robust benefit package that includes high quality healthcare, vacation, retirement savings, etc.
(b) Maintaining manageable workloads for staff
Program management routinely review staff caseloads and productivity to support staff to client ratios that represent best practices.
(c) Having clearly communicated and accessible promotion/advancement structures that are not prohibitive for those with lived experience
SCH encourages advancement and promotion in the agency and supports staff in seeking such growth opportunities through transparent HR policies and practices.
(d) Providing wage increases or leadership opportunities that do not require a position change to achieve
SCH encourages growth within current positions and provides training and educational stipends to staff. SCH also provides leadership training opportunities for staff.
Sacramento Children’s Home has implemented efforts to recruit a competent workforce and retain its staff. These efforts include appropriate acknowledgement of staff effectiveness through the annual SCH Impact award, comprehensive evaluation of staff, inclusion of staff in the decision making process (through the Performance and Quality Improvement committee) and recognition of staff through the use of Recruitment and Retention Funds.
9.6 High Fidelity Training Plan
A1.) All SCH Wraparound staff complete an intensive High Fidelity Wraparound training upon hiring at Sacramento Children’s Home (during their initial 120-day training period). Staff complete the High Fidelity Wraparound training provided by University of California, Davis. In addition, the training is augmented through regular (weekly) consultation with our supervisors (who are both HFW Coaches), as well as training on working with youth with Tribal involvement (ICWA and Tribal sovereignty). This consultation is provided in relation to specific roles within the Wraparound process.
b.) In addition, the team goes through annual “Wraparound Camp” in which the team undergoes an intensive two or three day training that reinforces HFW concepts. Furthermore, HFW Coaches regularly monitor updated to training requirements through various resources (including Medi-Cal HFW Center for Excellent, updates by the state (through ACLs) and UC Davis Continuing and Professional Education).
c.) The team receives booster training every quarter in relation to each phase of Wraparound in general and in relation to their specific role. (Wraparound Training Table of Contents)
d.) Clinical Supervisors and HFW supervisors/managers attend general Wraparound training as well as receive initial, ongoing, and refresher trainings specific to their leadership/supervisory roles as well. (Wraparound Training Table of Contents)
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 well. (Wraparound Training Table of Contents)
9.7 Community-based Training Program
a.) The SCH High Fidelity Wraparound program’s focus is on the family and youth as the center of the Child and Family Team meeting. They are actively supported by the SCH advocacy staff (Youth Peer Mentor and Parent Partner), and with their support, the family and youth’s voice and choice shapes the mission and vision that guides the Child and Family Team.
b.) As part of this process, staff are provided training in our community partners, the Children’s System of Care, and the community resources that are available to the families and youth and vice versa. Additionally the Wraparound contract monitor provides presentations and trainings to county providers trainings on Wraparound. As stated above, HFW Coaches regularly monitor updated to training requirements through various resources (including Medi-Cal HFW Center for Excellent, updates by the state (through ACLs) and UC Davis Continuing and Professional Education).
9.8 Coaching and Supervision
a.) As stated earlier, during the initial 120-day training period, and ongoing afterward (including annual Wraparound Camp) staff receives coaching and trainings that emphasizes Wraparound values, principles, phases and activities, and the effective us. This includes systems that underscore effective use of flex funds to meet family needs. As stated earlier, HFW Coaches regularly monitor updated to training requirements through various resources (including Medi-Cal HFW Center for Excellent, updates by the state (through ACLs) and UC Davis Continuing and Professional Education).
b.) Staff have access to coaching and support at all times. Similar to how the families and youth are provided support at the time they needs support (including staff who have flexible scheduling and crisis response needs.
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 to or reports relevant to their service provision and using data to identify staff training needs. This is done through supervision and coaching, consultation, Weekly team meetings, or designated quarterly trainings as well as our teams’ monthly PQI Committee meeting.
b.) Fidelity to the Wraparound model is crucial, and in addition to assessment tools (such as IP-CANS) that are utilizes to comprehensively evaluate youth and family functioning, the SCH Wraparound program utilizes data from the youth and family in it’s program evaluation. SCH Wraparound is actively involved in collecting data for such purposes – utilizing the Wraparound Fidelity Index (Brief version) also known as the WFI-EZ. Other tools that are utilized in program evaluation include the TOM (Team Observation Measure) which is utilized to evaluate adherence to the model in our implementation of Child and Family Team meetings (a central intervention in the HFW model). Another evaluation tool include the Documentation Assessment and Review Tool (DART). The Community Supports for Wraparound Inventory (as evaluation tool that evaluates the county system of care to support the wraparound process) has not been utilized yet within Sacramento County.
In addition to these evaluative process, Sacramento Children’s Home participates (among with 4 other California counties) in the California Quality Improvement Pilot study conducted through the University of Washington, Seattle. This study provides valuable feedback as well as compliance to the expectations as a high fidelity provider.
c.) Data is also utilized and brought to the Community Leadership Team when system barriers are identified that impact HFW implementation.
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 team works together regularly to collaborate and strategize their approach to improve treatment outcomes throughout the week and in formal treatment team meetings (TTM). The Facilitator supports the team’s action plans and goals to ensure progression towards outcomes while incorporating wraparound principles.
FPS 4 Service Planning Procedure, Page 4-5, 1-4
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
Merced County will be contracting with a High Fidelity Wraparound vendor. We have always contracted with Aspiranet Do With who already is implementing some of these key components and are currently going through HW certification at the moment. Currently our wrapteam is to see the referred child the same week of wraparound assignment so we are already meeting the 10 day time frame. Do With actually sets a standard to see the child within 5 days.
1.2 Led by Youth and Families
Merced County will be contracting with a High Fidelity Wraparound vendor. We have always contracted with Aspiranet Do With who already is implementing some of these key components and are currently going through HW certification at the moment. Youth will be apart of CFTMS and weekly team meetings and will get to advocate or use their voice. The youth partner will also attend and assist youth in voicing they needs related to decision making and outcomes. We will make sure the family is assigned to the appropriate worker who speaks the same language.
1.3 Strength-Based
Merced County will be contracting with a High Fidelity Wraparound vendor. We have always contracted with Aspiranet Do With who already is implementing some of these key components and are currently going through HW certification at the moment. Wraparound team along side the assigned SW will use a strength based approach and utilize the CANS tool to drive practice, objectives, goals, and needs. SW will be certified in CANS through Fresno State Training CACWT.
1.4 Needs Driven
Wraparound team along side the assigned SW will use a strength based approach and utilize the CANS tool to drive practice, objectives, goals, and needs. SW will be certified in CANS through Fresno State Training CACWT. Wrapteam or facilitator will also be certified in CANs and attend training. Need will be geared toward family and child needs.
1.5 Individualized
Contracted Wrap team will use individual treatment plan based on the needs of the child and family after an assessment is completed. The strategies will gear towards current needs and address mental and behavioral goals.
1.6 Use of Natural and Community Based Supports
Wrapteam will identify natural support system and include those individuals in their file or safety plans. They will be invited to CFTM. They can be parents, RFA parents, teachers, CASA, coaches, SWs, youth partners, relatives as long as they are supportive and appropriate.
1.7 Culturally Respectful and Relevant
All members will work together in a culturally appropriate approach while respecting others. Team will incorporate youth and family’s culture. If child or family speaks a different language other than English team will find a translator.
1.8 High-Quality Team Planning and Problem Solving
Wrap team will meet regularly and consult with their management team to collaborate on the family and child’s plan. Wrapteam can bring case to Placement Council to brainstorm ideas or discuss a complicated case. Placement Council consist of Merced County Children’s Services, Probation, Behavioral Health, Public Health Nurses, Merced County office of Education, Central Valley Regional Center, and the wrap team. Cases will be presented to placement council quarterly or as needed.
1.9 Outcomes Based Process
Wrap team will meet regularly and consult with their management team to collaborate on the family and child’s plan. Wrap team will collaborate with assigned SW or probation officer.
1.10 Persistence
Wrap team will meet regularly and consult with their management team to collaborate on the family and child’s plan. Wrapteam will coordinate with assigned SW or probation officer. Wrapteam will use HFW principles and makes sure it aligns with integrated core practice model.
1.11 Transitions as a part of the Fourth Phase of HFW
Currently when a youth is ready to be discharged from the program they are to be presented during Placement Council to make sure everything has been met and a transition plan to a lower level of service is provided which may look like less intensive services or outpatient services. A CFTM is also had prior to closure.
Expected Outcomes
2.1 Youth and Family Satisfaction
Do With will provide the satisfaction tool and provide to families and share with the assigned sw or probation officer. Their survey will be for youth and parents. They are using the Wraparound Fidelity Assessment system WFI EZ.
2.2 Improved School Functioning
Foster care liaison will work in conjunction with the wrap team to help ensure school needs are being met. IEP and SST will be assessed if needed.
2.3 Improved Functioning in the Community
Youth in wraparound will work closely with youth partner and ongoing documentation will be completed after every contact to document interaction. Youth will be invited to engagement activities in the community. Field trips will be funded and provided.
2.4 Improved Interpersonal Functioning
Merced County will be contracting with a High Fidelity Wraparound vendor. Vendor will communicate in a professional and trauma informed lenses that is strength based.
2.5 Increased Caregiver Confidence
A parent partner will be assigned to each family to be their voice and work on areas that need improvement and encourages parents to implement treatment plan. Weekly contacts will be made with parent partner. 24-7 crisis help will be available.
2.6 Stable and Least Restrictive Living Environment
Wrap around services will be implemented as a prevented measure to salvage placement, stabilize placement and mental health needs. wraparound will be implemented as a step down process if a child steps down from STRTP.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Wraparound team will have weekly CFTM to measure outcomes and talk about treatment plan to make sure youth is stabilizing and come up with new goals if current goals are not working. CFTM will be facilitated by facilitator who will use a teaming perspective and hear everyone’s voice and opinions. 24/7 crisis will be available from the wrap team. Regularly doctor visits to psychotropics meds will be part of at treatment if needed.
2.8 Reduction in Crisis Visits
A safety plan will be implemented so caregivers and refer to independently but also know that 24/7 crisis is available too.
2.9 Positive Exit from HFW
Youth and family will be staffed with placement council every quarterly to see if they are eligible for discharge or present status as an ongoing need. However, county and vendor will meet bi weekly for updates on children who are in wrap around to make sure vendor is meeting contract agreements and high fidelity standards.
Engagement
3.1 Orientation
The wrap team will complete orientation within the 10 day timeframe when being assigned to the team or approved for wrap. Currently orientation occurs within 5 days which we will keep as the same process to meet the 10 day.
3.2 Safety and Crisis stabilization
All wrap family will be aware of the crisis number and after hours numbers. If a true crisis arise the crisis team will make contact and develop a safety plan and will provide that plan to the SW. Every crisis response will be documented in the case file and will be monitored throughout the up coming appointment to see if crisis is still present. Weekly CFTMs will be had this can be discussed during those meeting to measure outcome. If need a safety crisis plan will be implemented.
3.3 Strengths, Needs, Culture and Vision Discovery
Wrap team will use CANS as part of the strengths and needs which correlates with treatment planning. Wrap facilitator will document strengths and needs which relates to family’s culture and vision of all teams. This will be discussed during CFTMS and will be updated every 90 days.
3.4 Engage All Team Members
Wrap team will present cases to placement council to discuss treatment plan, strengths, and needs. However during the week, contacts will be made with family members and team members, support systems are also welcome. During contacts and sessions engagement and activities will be explored.
3.5 Arrange Meeting Logistics
Meeting can occur in the home, office, or community but somewhere that is private especially during clinical sessions and somewhere the family and youth feels comfortable. Transportation will be provided if that is a barrier to the family.
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
This should be completed during the first cftm. Wrap team meets weekly and conducts CFTMs which this can be discussed and brought up as a group agreement in order to get everyone’s buy in and participation.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
Facilitator will set up weekly cftm with youth, family, and stakeholders to talk about treatment plan and goals. The team will discuss what is working and barrier and come up with new or continue current strategies based on the needs.
4.3 Develop an Individualized Child or Youth and Family Plan
Clinician will come up with treatment plan based on child’s diagnosis, needs, CANS, and the voice of the child and family. The team will Identify and build competence in using key strategies/methodologies to engage families and youth in the Wraparound process and evaluate the importance of strengths-based engagements which is culturally responsive and linguistically relevant. They will also use specific clinical modalities during sessions and treatment plan.
4.4 Develop a Crisis and Safety Plan
Based on the needs of the child especially if suicidal ideation and self harm has been identified, the clinician or a trained HFW staff will create a crisis and safety plan and coach the caregiver what do to if a need arise.
Implementation
5.1 Implement The Plan of Care
All HFW team will be aware of the treatment plan and the implementation of the care plan so the child stabilizes and their needs are being met. This plan will be discussed during CFTMs and reviewed quarterly. Celebrating success is key when family and child are meeting goals.
5.2 Review and Update The Plan of Care
The team will implement a structured 90-day (or more frequent as needed) review cycle in which the facilitator convenes the HFW team to assess progress toward goals, evaluate the effectiveness of strategies and supports, and collaboratively update the Plan of Care to reflect changes in the youth’s and family’s strengths and needs. Following each meeting, the facilitator will document decisions and the revised Plan of Care to all team members to ensure shared accountability and continuity of care. The review of plans will also presented every 90 days by a HFW staff to Placement Council for feedback.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
HFW, SW, and stakeholders will work as a team.
Transition
6.1 Develop a Transition Plan
When a child or family has met all their goals and are ready for discharge from the HFW program, a CFTM will be held to talk about the step down process to a lower level of care which can be one on one counseling services, less intensive services, or all together ending counseling. A transition will be established and sessions can be slowly tampered off until the end date. One last CFTM will be had and the case will be presented to Placement Council for review of closure.
6.2 Develop a Post-Transition Safety Plan
HFW team will develop a post transition safety plan with minor and caregivers to ease the transition and still be able to use 24/7 care until fully discharged from the program.
6.3 Create a Commencement and Celebrate Success
HFW team will celebrate discharge and “graduation” of a program.
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
Families will be engaged in regularly weekly CFTM to talk about whats working and what is not working. The meetings will be child and family centered. Their voices will be heard.
7.2 Community Leadership Team
CWS is the lead however there will be weekly meetings that include Probation, Mental Health, public health, education foster care liaison, and Wrap Team Aspiranet. If a child is identified that has ICWA, this team will be inviting tribes to the meeting. This meeting will be held to present new cases for proposal for wrap services, strtp, or lower level of services if child does not meet wrap services. This meeting is also going to be collaborative and if there are specific cases that are challenging then clinician or facilitator and present the case to the team for feedback. Cases that are graduating from program will be presented for step down or discharge.
7.3 Eligibility and Equal Access
The vendor will ensure that HFW eligibility, referral criteria, and processes are clearly defined and implemented to promote equitable access, without excluding youth and families based on the severity or nature of their needs. The vendor will ensure that HFW services are adequately publicized, accessible, and available so that all eligible families and referral sources understand how to access and participate in services. The vendor will ensure effective program planning, including tracking service access, monitoring waitlists, and maintaining sufficient funding and staffing to provide an appropriate array of services and 24/7 crisis support. The vendor will also ensure staffing structures and caseloads are appropriately managed to meet the intensity and frequency of services required to support families with complex needs.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
HFW program will have their own fiscal team billing or invoicing the county on a monthly basis.
8.2 Equitable Funding Across System Partners
The county will collaborate with the vendor to ensure all available federal, state, local, and private resources across the Children’s System of Care are fully leveraged to adequately fund and support HFW services for youth and families. The county and vendor will work together to promote cross-system collaboration, equitable resource contribution, and appropriate use of funding sources, including Medi-Cal for eligible. Vendor will bill county monthly and county will have their own fiscal team working closing with program.
8.3 Cost Savings are Reinvested
Money saved or generated will be used for youth and families and or enhance program 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.
Flex funds will be available for HFW needs.
8.5 Collaborative Oversight of Flex Funds
Program will work with County fiscal team closely and monitoring monthly billing and flex funds
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
Flex funds will not limited.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
County will make sure vendor is culturally appropriate and aware when working with difference families. will use translator or interpreter.
9.2 Tribally Responsive Workforce
County will notify HFW team if child has ICWA and HFM will invite tribe.
9.3 Flexible and Creative Work Environment
County and HFW vendor will work cohesively on shared vision and goals.
9.4 Hiring, Performance Evaluation, and Job Descriptions
This will be written in the contact.
9.5 Workforce Stability
County is contracting out wrap services and HFW will be fully staffed and will continue to put out job posting if staff resign.
9.6 High Fidelity Training Plan
In the contract will state that HFW vendor will need to be trained and certified through CDSS/UC DAVIS to get HFW certification.
9.7 Community-based Training Program
Vendor will utilize youth, family, steak holders voice when delivering services. MCOE, Probation and BHRS will be team members of weekly team meetings on developing program along side with HFW team to make sure clients are getting best services.
9.8 Coaching and Supervision
County will ensure the contracted vendor are providing staff appropriate training and be available when needed. HFW wrap will be 24/7 and have a crisis team with supervisor on call to help staff.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
County will make sure to be included in their quality improvement routinely check and also provide feedback from SW and families.
10.2 Evaluation Metrics & Outcomes
County is contract with Aspiranet HFW who will be collecting data for HFW.
Fidelity Indicators
1.1 Timely Engagement and Planning
(a) Wraparound expectation is that staff make contact with families within 24 hours of receiving the referral. We utilize Wraparound Enrollment Paperwork Checklist that includes the Referral Date as well as the date of verbal contact with the family that was made. This checklist is completed by staff and submitted to the AD within 5 days of receiving the referral. (b) Plan of Care (CFT-Matrix) expectations is to be conducted within 30 days of enrollment. We utilize the Wraparound Enrollment Paperwork Checklist to track and ensure this with a designated space to input Enrollment Date and Child and Family Team Meeting (CFTM) Due Date. In addition, we use a 4 Step Model Checklist that Facilitators complete indicating when Case Exploration, Staff Engagement, Child and Family Engagement, CFT Matrix, and Debrief took place, with sections with sections for dates and comments. (c) Wraparound expectation is to conduct CFTMs every 4-6 weeks. During this meeting, the Plan of Care (CFT-Matrix) document is updated as needed/necessary. CFTM template includes a section for the team to indicate when they will meet again, where and who will be invited. (d) Facilitator provides copies of the CFT minutes and Plan of Care to the families and formal supports in attendance (CSWs/POs will be emailed regardless of attendance). The document is also uploaded onto our EHR, EXYM, in an External Documents folder so that all team members have access to review. Facilitators first send a copy to AD to review and then it is uploaded onto EXYM. (e and f) Weekly supervisions and Team Meetings occur to discuss timelines and engagement strategies. Assistant Directors are in contact with DMH Liaison on a weekly basis to provide updates regarding cases as well as to determine if Staffing is needed to be scheduled with all formal support including DCFS to strategize engagement practices; these occur as needed.
1.2 Led by Youth and Families
A) Our CFT Plan of Care document roles; during intake each team member role is clearly explained to all family members, the vital role of the youth and family voices are included in this discussion. Team meetings are utilized to ensure team role specific assignments are clear; such as Parent partner leading for resource/flex funds, SI/HI type incidents are lead by the therapist; skill building and behavior management by the Child Family Specialist (CFS); contact and liasoning with social worker or additional supports by the facilitator. We utilize a Welcome to WRAP letter at intake which includes names and contact information of all team members to make contact as easy as possible. All team members emphasize the importance of and encourage youth and family to share their individual needs and to advocate and share as they feel comfortable, as their voice is equal to and leads the direction of services. B) Each team member works to create a safe environment for youth and family to share in CFTM’s. These efforts and perspectives are documented in CFTM notes, individual supervisions, team meetings, case conferences, Plan of Care docs, and clinical progress notes. Plan of Care (CFT Matrix) documents are added to youth’s chart, management reviews and provides feedback during supervision. C) We currently debrief and review meeting document in individual supervision, clinical supervision, team meetings, and case conferences all held weekly, and as needed to address feedback. Assistant Directors follow up with staff and discuss Plan of Care(/CFT Matrix) and provide additional reviews as needed in supervisions. We will begin sending out Supervisors/Coaches to observe HFW meetings. d) We conduct annual agency satisfaction surveys and county Consumer feedback surveys. Our intake documentation also includes information about our QA run phone line that families can utilize to provide feedback at any time. Families are reminded of this annually and as needed with more frequency.
1.3 Strength-Based
(a) Strengths inventory is embedded in the process of enrolling youth. Starting with Staff Engagement, please refer to Staff Engagement Worksheet, that facilitator conducts with CSW and or PO which includes a section entitled Strengths: what has been working for this child/youth and family? CFTM also includes a section for Strengths to be included from child/youth perspective, as well as family/caregivers, and formal supports. This is reviewed and added upon at each CFTM every 4- 6 weeks. (b) Clinician completes CANS at assessment and every 6 months from that date and discharge. Facilitators, CFSs, and Therapists are all trained and certified to complete the CANS. CANS completion and upcoming due dates are maintained and monitored by Wrap Assistant Directors in weekly supervision to ensure we remain up to date and each team works off a tracker for compliance (c) Individual supervision, Weekly Team Meetings, and Group Supervisions are all spaces where staff receive ongoing coaching and training related to strengths-based, solution focused services and strategies. (d) We conduct annual agency satisfaction surveys by program and participate in the county Consumer feedback survey process. Comments and feedback from these surveys are synthesized by our quality department and shared back with program management and staff. As we begin to institute observations of HFW meetings, we will incorporate the feedback into our supervision process to provide feedback and coaching to individual staff.
1.4 Needs Driven
(a) As soon as a new referral is received the wraparound team reviews the documentation for potential underlying needs. Intake and initial engagement sessions begin with a focus on identifying and gathering information on the youth and families underlying needs. These needs are the foundations that eventual goals and strategies are built upon. The Facilitator conducts Staff Engagement with CSW/PO and has a documented discussion regarding initial thoughts about Underlying Needs. The CFTMs further includes Underlying Needs per the Child/Youth Perspective as well as Family/Caregivers. The Underlying Needs developed carry through treatment and guide focus. Underlying Needs are reviewed at CFTMs and modified as needed. (b) Wraparound staff are required to attend multiple DMH Wraparound related training courses prior to the end of their first year of employment working within the Wraparound program that specifically address Underlying needs including: 6-hour Shared Core Practice Model with an emphasis on Underlying Needs and Underlying Needs and A Strengths/Needs Based Service Crafting Approach. As availability opens up in the UC Davis HFW trainings we will ensure staff attend and become certified through this new training series. All St. Anne’s staff are also required to attend our Trauma Informed Care Training “Risking Connections” which focuses on the impact of trauma on behaviors and individual needs and sees symptoms as adaptations rather than “problems.” Individual Supervision, Weekly Team Meetings, and Group Supervision are all settings to further discuss Underlying Needs. (c) Wraparound staff utilize CANS outcomes, reference to Staff Engagement documentation, and CFTM youth and family voice to inform needs. (d) Clinician formulates Problem Areas in the clinical chart based on youth and family voiced symptoms/behaviors, the Underlying Needs identified by the family, consultation with team, CANS, and consultation with clinical supervisor. The team documents progress towards Problem Areas when completing clinical documentation as well as noted on the CFTM Action Items to demonstrate progress met.
1.5 Individualized
(a) The wraparound teams used county mandated forms, Staff Engagement Worksheet, Child and Family Team Meeting Planning Sheet, Genogram, Timeline, Child and Family Team Meeting Agenda, Plan of Care (CFT-Matrix) and Family Safety and Crisis Plans which all allow for space to provide individualized plans for each youth and their family. (b) Wraparound staff are required to take 11 county DMH sponsored Wraparound Trainings throughout their first year of employment (please refer to DMH Wraparound P&P and training plans in supporting documentation). Our agency also provides trauma informed care training and in service trainings with rotating topics to all staff. Staff are given time and are encouraged to utilize our Learning Management System, Relias, as well as DMH offered trainings to further promote ongoing learning. (c) Facilitators are trained included in the training detailed in section b above, and have a training plan tracked in Relias with Facilitator specific offerings (see Facilitator training plan in supporting documents.) (d) Wraparound Assistant Directors review all CFTMs (provided every 4-6 weeks) to provide support, guidance, and suggestions to staff. Staff are also utilizing Child and Family Team Meeting Planning Sheet to help the family identify supports/ build their informal network. CFTM’s allow space to brainstorm other natural supports to include in treatment. (e) Agency implements DMH and agency satisfaction surveys annually related to client satisfaction. Family feedback about their experience will be solicited through observed HFW meetings and quality assurance phone calls.
1.6 Use of Natural and Community Based Supports
(a) Facilitator completes Family Engagement Planning Sheet starting at intake and updates during CFTM’s as needed, which allows the family to identify both natural/informal and formal supports that they would like to include in treatment. Facilitator revisits if any new supports should be included in each CFTM (please refer to section Who else should be invited to the next CFTM)..) When completing the Family Safety and Crisis Plan youth and family are encouraged to identify people they can trust (family and friends) to further provide support as needed. (b) Wraparound staff are required to take 11 county DMH sponsored Wraparound Trainings throughout their first year of employment (please refer to DMH Wraparound P&P and training plans in supporting documentation). Our agency also provides trauma informed care training and Inservice trainings with rotating topics to all staff. Staff are given time and encouraged to utilize our Learning Management System, Relias, as well as DMH offered trainings to further promote ongoing learning. (c) Wraparound Assistant Directors review all CFTM’s (provided every 4-6 weeks) to provide support, guidance, and suggestions to staff. Staff are also utilizing Child and Family Team Meeting Planning Sheet to help the family identify supports/ build their informal network. CFTM’s allow space to brainstorm other natural supports to include in treatment. (d) Agency implements DMH and agency satisfaction surveys annually related to youth satisfaction. Family feedback about their experience will be solicited through observed HFW meetings and quality assurance phone calls.
1.7 Culturally Respectful and Relevant
(a) We invite tribal representatives and culturally relevant supports to participate in Child and Family Team ( meetings (CFTM) to ensure diverse voices are heard and honored, and we emphasize a strength-based approach that highlights each youth’s resiliency, cultural identity, assets, and natural supports; during these meetings we engage social workers, family members, extended kin, tribal liaisons, and community partners to gain a holistic understanding of the youth’s strengths, needs, preferences, and additional supports, and we intentionally create a respectful environment where cultural context guides how behaviors and goals are understood. CFTM’s focus on identifying what is working well for the family and building treatment planning around cultural strengths and traditions — such as community roles, language, spirituality, rituals, and family values — while also identifying and connecting youth to informal and natural supports like elders, mentors, and culturally aligned community groups. We collaboratively explore potential barriers to engagement, including historical mistrust, language access, transportation, or systemic discrimination, and work together to develop strategies to address those barriers. The process emphasizes youth and family empowerment by helping them articulate their priorities and goals so that treatment plans reflect what matters most to them, and these strength-based, culturally informed goals and interventions are documented and revisited regularly to ensure ongoing relevance and responsiveness to progress and changing needs. (b) Our MH assessment process includes ongoing clinical supervision with constant conversations about cultural humility, and culture is regularly discussed in team meetings to better connect youths’ with meaningful cultural supports and resources — for example, linking immigrant families with consulate services, connecting Latinx youth to Para Los Niños, and referring African American youth to Brotherhood Crusade or mentorship programs such as Big Brothers Big Sisters when a safe adult or positive role model is needed. We emphasize skill-building to support functioning beyond wrap team resources, and approach caregivers with sensitivity to their history, trauma, and lived experiences and how these influence family dynamics; this holistic lens considers how intergenerational trauma may impact current treatment, behaviors, and symptoms. To support staff competence and cultural responsiveness, we provide trainings and resources on topics such as intergenerational trauma, trauma-informed de-escalation, and culturally specific frameworks like the TGI Cultural Transformation Series for Transgender, Gender Expansive, and Intersex youth, while regularly discussing cultural and political events that may affect youth. We also prioritize staff well-being by checking in on feelings, countertransference, and the impact of clinical work, and ensure our wrap clinical staff are master’s-level clinicians to maintain safety and quality. Administrative supervision helps reframe language to be strength-based and addresses burnout, and leadership routinely discusses cultural humility, staff concerns, and training needs. When appropriate, we adjust team assignments to best meet client preferences and needs — for example, collaboratively problem-solving when a youth requests a Black or female therapist and exploring why that match may be important to the youth. (c)We utilize satisfaction surveys to gather feedback (e.g., consumer feedback survey). We hold staffing’s with DMH and Probation to address concerns, including culturally relevant issues, as an interdisciplinary team. Administrative leadership works directly with families to address questions or concerns. We also consult with DMH and other professionals (e.g., DMH Roundtable, liaison meetings) to identify resources and interventions that support culturally responsive treatment.
1.8 High-Quality Team Planning and Problem Solving
(a)The wraparound team begins services by building rapport with each client and their family. Developing team agreements is part of this process. Our Plan of Care (CFT-Matrix) documents this. It also documents roles, and during intake each team member role is clearly explained to all family members. The vital role of the youth and family voices are included in this discussion. The Welcome Letter and development of the Family Safety Crisis plan is also part of developing team agreements. (b)Each team member works to create a safe environment for youth and family to share in CFTMs) around engagement and collaboration. These efforts and perspectives are documented in CFTM notes, individual supervisions, team meetings, case conferences, Plan of Care docs, and clinical progress notes. Plan of Care (CFT Matrix) documents are added to youth’s chart. Our intake documentation also includes information about our QA run phone line that families can utilize to provide feedback at any time. Families are reminded of this annually and as needed with more frequency. Agency implements DMH and agency satisfaction surveys annually related to youth satisfaction. Family feedback about their experience will be solicited through observed HFW meetings and quality assurance phone calls. Wraparound management currently join all Staffing’s that occur. (c)Our agency CQI process runs monthly and quarterly; we review feedback weekly, as needed and program outcomes are reviewed quarterly. We currently debrief and review meeting documents and feedback in individual supervision, clinical supervision, team meetings, and case conferences all held weekly, and as needed to address feedback. Assistant Directors follow up with staff and discusses Plan of Care(CFT-Matrix) and any youth feedback. We will begin sending out Supervisors/Coaches to observe HFW meetings. (d) Wraparound Assistant Directors review all CFTM minutes and Plan of Care(CFT-Matrix) documents to provide support, guidance, suggestions, and to ensure action item loop closure with staff in individual supervision, clinical supervision, team meetings, and case conferences all held weekly.
1.9 Outcomes Based Process
(a) Specific and measurable goals, strategies and action items, with timelines, are documented in the POC document. The Four phases of Wraparound are utilized and referenced from weekly wrap team meeting consultation discussions.
( b/c ) Plan of Care (CFT-Matrix), CFTM minutes, goal completion, action items, progress, and new strategies and/or interventions are discussed and documented in the weekly wraparound team meetings run by Wraparound Assistant Directors, attended by all members of the wrap team.
(d) The wraparound Therapist completes the CANS at assessment and every 6 months from that date and at discharge. Our Facilitators and CFS’s are also trained and certified to complete the CANS, in the event of a vacation or unexpected leave. CANs completion and upcoming due dates are maintained and monitored by Wrap Assistant Directors in weekly supervision to ensure we remain up to date and each team works off a tracker for compliance.
(e) Data from the CANS is shared with the team during our weekly team meetings so it can be incorporated with underlying needs, POC, and ongoing action items.
1.10 Persistence
(a) Teams meet with Wraparound Assistant Directors on a weekly basis to discuss cases including obstacles or difficulties with engaging clients. These discussions occur in weekly supervisions, team meetings, case conferences, or as needed to brainstorm strategies for engagement. Wraparound Assistant Directors conducts weekly checks in with DMH Liaison if family engagement is a struggle to provide updates, seek consultation, as well as arrange for Staffing to involve all formal supports to come together and develop a plan if needed. Facilitator works to remain in contact with CSW/PO on a weekly basis to discuss challenges as they arise, share team efforts, and brainstorm strategies. Clinical group supervision is also utilized to elicit additional strategies from peers. (b)Each staff member participates in weekly individual admin and clinical supervision, group supervision, case conference and team meetings to elicit feedback regarding treatment or additional support if needed. Flex Funding is discussed in CFTM and in individual and collateral sessions with youth and family. There is space/time dedicated to flex funding in weekly team meetings to update progress, answer questions, and provide additional item specific training. Wraparound management developed and provided a Flex Fund Training and step by step guide for all wraparound staff and remains accessible to all staff. (c)Wraparound Facilitators are required to attend agency Trauma Informed Training Risking Connections, 2 Day Child and Family Team Facilitator Training, Overview of Child and Family Teaming training, and Family Safety Crisis Planning Training. In house trainings, debriefs, and group supervision further provide support and coaching in addressing crises and conflict resolution. Wraparound management developed and provided Incident Reporting and Crisis Planning Training, which remains accessible to all wrapround staff to access and review.
1.11 Transitions as a part of the Fourth Phase of HFW
(a) Family graduation, termination, and/or transitions begin to be discussed as early as at intake. As underlying needs are identified and goals are developed a clear path to successful termination is part of these goals. When circumstances arise that lead to unplanned termination/transitions, they are not happening in isolation. Team members and wraparound management teams on-going communication with CSW/POs and consistent consultation with DMH Liaison is necessary and happening prior to proceeding with any closures/exits. Per current Wraparound requirements once a DCFS case closes, the team has 30 days to provide and ensure linkage; however, this conversation is actively happening throughout treatment. Parent Partners work diligently to identify resources to provide ongoing support once the case is closed. Therapist and/or CFS provide linkage to ongoing mental health services when appropriate and soft hand offs are timed with discharge to ensure no gap in services occurs. (b) Regardless of successful graduation or unplanned transitions, teams are encouraged and are able to celebrate all of a youth and family’s successes during CFTM Termination sessions, which, when possible includes a shared meal and certificate made to capture progress made. Wraparound Team is actively involved in communication with CSWs/POs so that they are informed of case plan and potential closure. Staff also participate in a Placement Stability Training to review strategies to support consistency in placement to deter unnecessary transitions and placement disruptions.
Expected Outcomes
2.1 Youth and Family Satisfaction
Important data regarding client outcomes, Client satisfaction, employee satisfaction, management and operations outcomes, etc. will be collected, cleansed and analyzed on a regular basis (monthly, quarterly, annually). It is the responsibility of the VP of Organizational Quality and Impact to ensure Quality staff coordinate and manage the collection and analysis of data, and the responsibility of Program Directors and Department Heads to ensure their respective program/department is collecting and submitting the data by the established deadline. This includes Youth and Family Satisfaction.
CQI Metrics
In order to ensure the systematic collection of data, Program Directors and Department Heads will submit data on a monthly or quarterly basis to the Quality Department in the form of CQI metrics, which are identified measures that satisfy contract and licensing requirements, as well as CQI purposes. These measures have been identified and selected by agency stakeholders through a process of engagement in order to ensure participation and reflection of stakeholder insights. These numbers will be entered for tracking by the respective department, and the Quality Department will then perform cleansing, aggregation and analysis to prepare and present quarterly outcome summaries for further analysis.
Stakeholder Participation (From CQI Plan pg. 7)
In order to ensure comprehensive continuous quality improvement, it is imperative that efforts involve all agency stakeholders to gain broad insight and feedback from individuals connected to St. Anne’s in a variety of ways. For the purpose of identifying participants in the CQI process, “stakeholders” shall include the following: Program Participants, Employees, Community Partners, and Board of Directors.
Client Satisfaction Surveys: In order to obtain feedback from clients, each Program will administer client satisfaction surveys. Surveys will include standardized tools as required by various contracts, and questions related to benchmarking and program-specific topics. Surveys will be distributed at least annually, and in some cases more frequently. Results will be cleansed and aggregated by the Quality Department and provided to programs for review in Quarterly Program Outcomes Meetings.
Safety and Helpline: All St. Anne’s program participants are encouraged to provide feedback, including concerns, issues, and questions, to the agency Safety and Helpline, available at extension 520. The QA Director or designee will respond to all Safety and Helpline calls within 24 hours, and any reported concerns or issues will be immediately responded to and resolved within seven days.
Client Councils/Advisory Groups: Each Division will develop and maintain a council or an advisory group consisting of program participants who will meet regularly to provide feedback and identify program quality issues, including gaps in services and complaints, as well as suggestions for improvement. Information collected during these meetings will be documented and reviewed by the respective Program Director and a Quality staff member, and identified concerns addressed through the improvement planning process.
The organization implements a program logic model that describes how resources and program activities will support the achievement of positive outcomes.
We implement and use the CANS and YOQ to get baseline and change overtime metrics for client functioning. QA calls will be implemented on a quarterly basis and weekly HFW Team meetings and supervisions are spaces created for documentation review and feedback review and support. Continuous quality improvement drives our program and system monitoring and evaluation.
2.2 Improved School Functioning
Important data regarding client outcomes, Client satisfaction, employee satisfaction, management and operations outcomes, etc. will be collected, cleansed and analyzed on a regular basis (monthly, quarterly, annually). It is the responsibility of the VP of Organizational Quality and Impact to ensure Quality staff coordinate and manage the collection and analysis of data, and the responsibility of Program Directors and Department Heads to ensure their respective program/department is collecting and submitting the data by the established deadline. This includes School Functioning improvement.
CQI Metrics
In order to ensure the systematic collection of data, Program Directors and Department Heads will submit data on a monthly or quarterly basis to the Quality Department in the form of CQI metrics, which are identified measures that satisfy contract and licensing requirements, as well as CQI purposes. These measures have been identified and selected by agency stakeholders through a process of engagement in order to ensure participation and reflection of stakeholder insights. These numbers will be entered for tracking by the respective department, and the Quality Department will then perform cleansing, aggregation and analysis to prepare and present quarterly outcome summaries for further analysis.
Stakeholder Participation (From CQI Plan pg. 7)
In order to ensure comprehensive continuous quality improvement, it is imperative that efforts involve all agency stakeholders to gain broad insight and feedback from individuals connected to St. Anne’s in a variety of ways. For the purpose of identifying participants in the CQI process, “stakeholders” shall include the following: Program Participants, Employees, Community Partners, and Board of Directors.
Client Satisfaction Surveys: In order to obtain feedback from clients, each Program will administer client satisfaction surveys. Surveys will include standardized tools as required by various contracts, and questions related to benchmarking and program-specific topics. Surveys will be distributed at least annually, and in some cases more frequently. Results will be cleansed and aggregated by the Quality Department and provided to programs for review in Quarterly Program Outcomes Meetings.
Safety and Helpline: All St. Anne’s program participants are encouraged to provide feedback, including concerns, issues, and questions, to the agency Safety and Helpline, available at extension 520. The QA Director or designee will respond to all Safety and Helpline calls within 24 hours, and any reported concerns or issues will be immediately responded to and resolved within seven days.
Client Councils/Advisory Groups: Each Division will develop and maintain a council or an advisory group consisting of program participants who will meet regularly to provide feedback and identify program quality issues, including gaps in services and complaints, as well as suggestions for improvement. Information collected during these meetings will be documented and reviewed by the respective Program Director and a Quality staff member, and identified concerns addressed through the improvement planning process.
The organization implements a program logic model that describes how resources and program activities will support the achievement of positive outcomes.
We implement and use the CANS and YOQ to get baseline and change overtime metrics for client functioning. QA calls will be implemented on a quarterly basis and weekly HFW Team meetings and supervisions are spaces created for documentation review and feedback review and support. Continuous quality improvement drives our program and system monitoring and evaluation.
2.3 Improved Functioning in the Community
Important data regarding client outcomes, Client satisfaction, employee satisfaction, management and operations outcomes, etc. will be collected, cleansed and analyzed on a regular basis (monthly, quarterly, annually). It is the responsibility of the VP of Organizational Quality and Impact to ensure Quality staff coordinate and manage the collection and analysis of data, and the responsibility of Program Directors and Department Heads to ensure their respective program/department is collecting and submitting the data by the established deadline. This includes Community Functioning improvement.
CQI Metrics
In order to ensure the systematic collection of data, Program Directors and Department Heads will submit data on a monthly or quarterly basis to the Quality Department in the form of CQI metrics, which are identified measures that satisfy contract and licensing requirements, as well as CQI purposes. These measures have been identified and selected by agency stakeholders through a process of engagement in order to ensure participation and reflection of stakeholder insights. These numbers will be entered for tracking by the respective department, and the Quality Department will then perform cleansing, aggregation and analysis to prepare and present quarterly outcome summaries for further analysis.
Stakeholder Participation (From CQI Plan pg. 7)
In order to ensure comprehensive continuous quality improvement, it is imperative that efforts involve all agency stakeholders to gain broad insight and feedback from individuals connected to St. Anne’s in a variety of ways. For the purpose of identifying participants in the CQI process, “stakeholders” shall include the following: Program Participants, Employees, Community Partners, and Board of Directors.
Client Satisfaction Surveys: In order to obtain feedback from clients, each Program will administer client satisfaction surveys. Surveys will include standardized tools as required by various contracts, and questions related to benchmarking and program-specific topics. Surveys will be distributed at least annually, and in some cases more frequently. Results will be cleansed and aggregated by the Quality Department and provided to programs for review in Quarterly Program Outcomes Meetings.
Safety and Helpline: All St. Anne’s program participants are encouraged to provide feedback, including concerns, issues, and questions, to the agency Safety and Helpline, available at extension 520. The QA Director or designee will respond to all Safety and Helpline calls within 24 hours, and any reported concerns or issues will be immediately responded to and resolved within seven days.
Client Councils/Advisory Groups: Each Division will develop and maintain a council or an advisory group consisting of program participants who will meet regularly to provide feedback and identify program quality issues, including gaps in services and complaints, as well as suggestions for improvement. Information collected during these meetings will be documented and reviewed by the respective Program Director and a Quality staff member, and identified concerns addressed through the improvement planning process.
The organization implements a program logic model that describes how resources and program activities will support the achievement of positive outcomes.
We implement and use the CANS and YOQ to get baseline and change overtime metrics for client functioning. QA calls will be implemented on a quarterly basis and weekly HFW Team meetings and supervisions are spaces created for documentation review and feedback review and support. Continuous quality improvement drives our program and system monitoring and evaluation.
2.4 Improved Interpersonal Functioning
Important data regarding client outcomes, Client satisfaction, employee satisfaction, management and operations outcomes, etc. will be collected, cleansed and analyzed on a regular basis (monthly, quarterly, annually). It is the responsibility of the VP of Organizational Quality and Impact to ensure Quality staff coordinate and manage the collection and analysis of data, and the responsibility of Program Directors and Department Heads to ensure their respective program/department is collecting and submitting the data by the established deadline. This includes Interpersonal Functioning improvement.
CQI Metrics
In order to ensure the systematic collection of data, Program Directors and Department Heads will submit data on a monthly or quarterly basis to the Quality Department in the form of CQI metrics, which are identified measures that satisfy contract and licensing requirements, as well as CQI purposes. These measures have been identified and selected by agency stakeholders through a process of engagement in order to ensure participation and reflection of stakeholder insights. These numbers will be entered for tracking by the respective department, and the Quality Department will then perform cleansing, aggregation and analysis to prepare and present quarterly outcome summaries for further analysis.
Stakeholder Participation (From CQI Plan pg. 7)
In order to ensure comprehensive continuous quality improvement, it is imperative that efforts involve all agency stakeholders to gain broad insight and feedback from individuals connected to St. Anne’s in a variety of ways. For the purpose of identifying participants in the CQI process, “stakeholders” shall include the following: Program Participants, Employees, Community Partners, and Board of Directors.
Client Satisfaction Surveys: In order to obtain feedback from clients, each Program will administer client satisfaction surveys. Surveys will include standardized tools as required by various contracts, and questions related to benchmarking and program-specific topics. Surveys will be distributed at least annually, and in some cases more frequently. Results will be cleansed and aggregated by the Quality Department and provided to programs for review in Quarterly Program Outcomes Meetings.
Safety and Helpline: All St. Anne’s program participants are encouraged to provide feedback, including concerns, issues, and questions, to the agency Safety and Helpline, available at extension 520. The QA Director or designee will respond to all Safety and Helpline calls within 24 hours, and any reported concerns or issues will be immediately responded to and resolved within seven days.
Client Councils/Advisory Groups: Each Division will develop and maintain a council or an advisory group consisting of program participants who will meet regularly to provide feedback and identify program quality issues, including gaps in services and complaints, as well as suggestions for improvement. Information collected during these meetings will be documented and reviewed by the respective Program Director and a Quality staff member, and identified concerns addressed through the improvement planning process.
The organization implements a program logic model that describes how resources and program activities will support the achievement of positive outcomes.
We implement and use the CANS and YOQ to get baseline and change overtime metrics for client functioning. QA calls will be implemented on a quarterly basis and weekly HFW Team meetings and supervisions are spaces created for documentation review and feedback review and support. Continuous quality improvement drives our program and system monitoring and evaluation.
2.5 Increased Caregiver Confidence
Important data regarding client outcomes, Client satisfaction, employee satisfaction, management and operations outcomes, etc. will be collected, cleansed and analyzed on a regular basis (monthly, quarterly, annually). It is the responsibility of the VP of Organizational Quality and Impact to ensure Quality staff coordinate and manage the collection and analysis of data, and the responsibility of Program Directors and Department Heads to ensure their respective program/department is collecting and submitting the data by the established deadline. This includes Caregiver confidence improvement.
CQI Metrics
In order to ensure the systematic collection of data, Program Directors and Department Heads will submit data on a monthly or quarterly basis to the Quality Department in the form of CQI metrics, which are identified measures that satisfy contract and licensing requirements, as well as CQI purposes. These measures have been identified and selected by agency stakeholders through a process of engagement in order to ensure participation and reflection of stakeholder insights. These numbers will be entered for tracking by the respective department, and the Quality Department will then perform cleansing, aggregation and analysis to prepare and present quarterly outcome summaries for further analysis.
Stakeholder Participation (From CQI Plan pg. 7)
In order to ensure comprehensive continuous quality improvement, it is imperative that efforts involve all agency stakeholders to gain broad insight and feedback from individuals connected to St. Anne’s in a variety of ways. For the purpose of identifying participants in the CQI process, “stakeholders” shall include the following: Program Participants, Employees, Community Partners, and Board of Directors.
Client Satisfaction Surveys: In order to obtain feedback from clients, each Program will administer client satisfaction surveys. Surveys will include standardized tools as required by various contracts, and questions related to benchmarking and program-specific topics. Surveys will be distributed at least annually, and in some cases more frequently. Results will be cleansed and aggregated by the Quality Department and provided to programs for review in Quarterly Program Outcomes Meetings.
Safety and Helpline: All St. Anne’s program participants are encouraged to provide feedback, including concerns, issues, and questions, to the agency Safety and Helpline, available at extension 520. The QA Director or designee will respond to all Safety and Helpline calls within 24 hours, and any reported concerns or issues will be immediately responded to and resolved within seven days.
Client Councils/Advisory Groups: Each Division will develop and maintain a council or an advisory group consisting of program participants who will meet regularly to provide feedback and identify program quality issues, including gaps in services and complaints, as well as suggestions for improvement. Information collected during these meetings will be documented and reviewed by the respective Program Director and a Quality staff member, and identified concerns addressed through the improvement planning process.
The organization implements a program logic model that describes how resources and program activities will support the achievement of positive outcomes.
We implement and use the CANS and YOQ to get baseline and change overtime metrics for client functioning. QA calls will be implemented on a quarterly basis and weekly HFW Team meetings and supervisions are spaces created for documentation review and feedback review and support. Continuous quality improvement drives our program and system monitoring and evaluation.
2.6 Stable and Least Restrictive Living Environment
Important data regarding client outcomes, Client satisfaction, employee satisfaction, management and operations outcomes, etc. will be collected, cleansed and analyzed on a regular basis (monthly, quarterly, annually). It is the responsibility of the VP of Organizational Quality and Impact to ensure Quality staff coordinate and manage the collection and analysis of data, and the responsibility of Program Directors and Department Heads to ensure their respective program/department is collecting and submitting the data by the established deadline. This includes youth permanency and stability
CQI Metrics
In order to ensure the systematic collection of data, Program Directors and Department Heads will submit data on a monthly or quarterly basis to the Quality Department in the form of CQI metrics, which are identified measures that satisfy contract and licensing requirements, as well as CQI purposes. These measures have been identified and selected by agency stakeholders through a process of engagement in order to ensure participation and reflection of stakeholder insights. These numbers will be entered for tracking by the respective department, and the Quality Department will then perform cleansing, aggregation and analysis to prepare and present quarterly outcome summaries for further analysis.
Stakeholder Participation (From CQI Plan pg. 7)
In order to ensure comprehensive continuous quality improvement, it is imperative that efforts involve all agency stakeholders to gain broad insight and feedback from individuals connected to St. Anne’s in a variety of ways. For the purpose of identifying participants in the CQI process, “stakeholders” shall include the following: Program Participants, Employees, Community Partners, and Board of Directors.
Client Satisfaction Surveys: In order to obtain feedback from clients, each Program will administer client satisfaction surveys. Surveys will include standardized tools as required by various contracts, and questions related to benchmarking and program-specific topics. Surveys will be distributed at least annually, and in some cases more frequently. Results will be cleansed and aggregated by the Quality Department and provided to programs for review in Quarterly Program Outcomes Meetings.
Safety and Helpline: All St. Anne’s program participants are encouraged to provide feedback, including concerns, issues, and questions, to the agency Safety and Helpline, available at extension 520. The QA Director or designee will respond to all Safety and Helpline calls within 24 hours, and any reported concerns or issues will be immediately responded to and resolved within seven days.
Client Councils/Advisory Groups: Each Division will develop and maintain a council or an advisory group consisting of program participants who will meet regularly to provide feedback and identify program quality issues, including gaps in services and complaints, as well as suggestions for improvement. Information collected during these meetings will be documented and reviewed by the respective Program Director and a Quality staff member, and identified concerns addressed through the improvement planning process.
The organization implements a program logic model that describes how resources and program activities will support the achievement of positive outcomes.
We implement and use the CANS and YOQ to get baseline and change overtime metrics for client functioning. QA calls will be implemented on a quarterly basis and weekly HFW Team meetings and supervisions are spaces created for documentation review and feedback review and support. Continuous quality improvement drives our program and system monitoring and evaluation.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Important data regarding client outcomes, Client satisfaction, employee satisfaction, management and operations outcomes, etc. will be collected, cleansed and analyzed on a regular basis (monthly, quarterly, annually). It is the responsibility of the VP of Organizational Quality and Impact to ensure Quality staff coordinate and manage the collection and analysis of data, and the responsibility of Program Directors and Department Heads to ensure their respective program/department is collecting and submitting the data by the established deadline. This includes behavioral health stability and visits to inpatient and/or emergency departments.
CQI Metrics
In order to ensure the systematic collection of data, Program Directors and Department Heads will submit data on a monthly or quarterly basis to the Quality Department in the form of CQI metrics, which are identified measures that satisfy contract and licensing requirements, as well as CQI purposes. These measures have been identified and selected by agency stakeholders through a process of engagement in order to ensure participation and reflection of stakeholder insights. These numbers will be entered for tracking by the respective department, and the Quality Department will then perform cleansing, aggregation and analysis to prepare and present quarterly outcome summaries for further analysis.
Stakeholder Participation (From CQI Plan pg. 7)
In order to ensure comprehensive continuous quality improvement, it is imperative that efforts involve all agency stakeholders to gain broad insight and feedback from individuals connected to St. Anne’s in a variety of ways. For the purpose of identifying participants in the CQI process, “stakeholders” shall include the following: Program Participants, Employees, Community Partners, and Board of Directors.
Client Satisfaction Surveys: In order to obtain feedback from clients, each Program will administer client satisfaction surveys. Surveys will include standardized tools as required by various contracts, and questions related to benchmarking and program-specific topics. Surveys will be distributed at least annually, and in some cases more frequently. Results will be cleansed and aggregated by the Quality Department and provided to programs for review in Quarterly Program Outcomes Meetings.
Safety and Helpline: All St. Anne’s program participants are encouraged to provide feedback, including concerns, issues, and questions, to the agency Safety and Helpline, available at extension 520. The QA Director or designee will respond to all Safety and Helpline calls within 24 hours, and any reported concerns or issues will be immediately responded to and resolved within seven days.
Client Councils/Advisory Groups: Each Division will develop and maintain a council or an advisory group consisting of program participants who will meet regularly to provide feedback and identify program quality issues, including gaps in services and complaints, as well as suggestions for improvement. Information collected during these meetings will be documented and reviewed by the respective Program Director and a Quality staff member, and identified concerns addressed through the improvement planning process.
The organization implements a program logic model that describes how resources and program activities will support the achievement of positive outcomes.
We implement and use the CANS and YOQ to get baseline and change overtime metrics for client functioning. QA calls will be implemented on a quarterly basis and weekly HFW Team meetings and supervisions are spaces created for documentation review and feedback review and support. Continuous quality improvement drives our program and system monitoring and evaluation.
2.8 Reduction in Crisis Visits
Important data regarding client outcomes, Client satisfaction, employee satisfaction, management and operations outcomes, etc. will be collected, cleansed and analyzed on a regular basis (monthly, quarterly, annually). It is the responsibility of the VP of Organizational Quality and Impact to ensure Quality staff coordinate and manage the collection and analysis of data, and the responsibility of Program Directors and Department Heads to ensure their respective program/department is collecting and submitting the data by the established deadline. This includes behavioral health stability and crisis interventions.
CQI Metrics
In order to ensure the systematic collection of data, Program Directors and Department Heads will submit data on a monthly or quarterly basis to the Quality Department in the form of CQI metrics, which are identified measures that satisfy contract and licensing requirements, as well as CQI purposes. These measures have been identified and selected by agency stakeholders through a process of engagement in order to ensure participation and reflection of stakeholder insights. These numbers will be entered for tracking by the respective department, and the Quality Department will then perform cleansing, aggregation and analysis to prepare and present quarterly outcome summaries for further analysis.
Stakeholder Participation (From CQI Plan pg. 7)
In order to ensure comprehensive continuous quality improvement, it is imperative that efforts involve all agency stakeholders to gain broad insight and feedback from individuals connected to St. Anne’s in a variety of ways. For the purpose of identifying participants in the CQI process, “stakeholders” shall include the following: Program Participants, Employees, Community Partners, and Board of Directors.
Client Satisfaction Surveys: In order to obtain feedback from clients, each Program will administer client satisfaction surveys. Surveys will include standardized tools as required by various contracts, and questions related to benchmarking and program-specific topics. Surveys will be distributed at least annually, and in some cases more frequently. Results will be cleansed and aggregated by the Quality Department and provided to programs for review in Quarterly Program Outcomes Meetings.
Safety and Helpline: All St. Anne’s program participants are encouraged to provide feedback, including concerns, issues, and questions, to the agency Safety and Helpline, available at extension 520. The QA Director or designee will respond to all Safety and Helpline calls within 24 hours, and any reported concerns or issues will be immediately responded to and resolved within seven days.
Client Councils/Advisory Groups: Each Division will develop and maintain a council or an advisory group consisting of program participants who will meet regularly to provide feedback and identify program quality issues, including gaps in services and complaints, as well as suggestions for improvement. Information collected during these meetings will be documented and reviewed by the respective Program Director and a Quality staff member, and identified concerns addressed through the improvement planning process.
The organization implements a program logic model that describes how resources and program activities will support the achievement of positive outcomes.
We implement and use the CANS and YOQ to get baseline and change overtime metrics for client functioning. QA calls will be implemented on a quarterly basis and weekly HFW Team meetings and supervisions are spaces created for documentation review and feedback review and support. Continuous quality improvement drives our program and system monitoring and evaluation.
2.9 Positive Exit from HFW
Important data regarding client outcomes, Client satisfaction, employee satisfaction, management and operations outcomes, etc. will be collected, cleansed and analyzed on a regular basis (monthly, quarterly, annually). It is the responsibility of the VP of Organizational Quality and Impact to ensure Quality staff coordinate and manage the collection and analysis of data, and the responsibility of Program Directors and Department Heads to ensure their respective program/department is collecting and submitting the data by the established deadline. This includes successful completion of HFW program and exits from Wraparound.
CQI Metrics
In order to ensure the systematic collection of data, Program Directors and Department Heads will submit data on a monthly or quarterly basis to the Quality Department in the form of CQI metrics, which are identified measures that satisfy contract and licensing requirements, as well as CQI purposes. These measures have been identified and selected by agency stakeholders through a process of engagement in order to ensure participation and reflection of stakeholder insights. These numbers will be entered for tracking by the respective department, and the Quality Department will then perform cleansing, aggregation and analysis to prepare and present quarterly outcome summaries for further analysis.
Stakeholder Participation (From CQI Plan pg. 7)
In order to ensure comprehensive continuous quality improvement, it is imperative that efforts involve all agency stakeholders to gain broad insight and feedback from individuals connected to St. Anne’s in a variety of ways. For the purpose of identifying participants in the CQI process, “stakeholders” shall include the following: Program Participants, Employees, Community Partners, and Board of Directors.
Client Satisfaction Surveys: In order to obtain feedback from clients, each Program will administer client satisfaction surveys. Surveys will include standardized tools as required by various contracts, and questions related to benchmarking and program-specific topics. Surveys will be distributed at least annually, and in some cases more frequently. Results will be cleansed and aggregated by the Quality Department and provided to programs for review in Quarterly Program Outcomes Meetings.
Safety and Helpline: All St. Anne’s program participants are encouraged to provide feedback, including concerns, issues, and questions, to the agency Safety and Helpline, available at extension 520. The QA Director or designee will respond to all Safety and Helpline calls within 24 hours, and any reported concerns or issues will be immediately responded to and resolved within seven days.
Client Councils/Advisory Groups: Each Division will develop and maintain a council or an advisory group consisting of program participants who will meet regularly to provide feedback and identify program quality issues, including gaps in services and complaints, as well as suggestions for improvement. Information collected during these meetings will be documented and reviewed by the respective Program Director and a Quality staff member, and identified concerns addressed through the improvement planning process.
The organization implements a program logic model that describes how resources and program activities will support the achievement of positive outcomes.
We implement and use the CANS and YOQ to get baseline and change overtime metrics for client functioning. QA calls will be implemented on a quarterly basis and weekly HFW Team meetings and supervisions are spaces created for documentation review and feedback review and support. Continuous quality improvement drives our program and system monitoring and evaluation.
Engagement
3.1 Orientation
(a) During intake and the first Child and Family Team (CFT) meeting, roles and services are reviewed with the family. All components (A–D) should be covered and lead by the facilitator to ensure clarity and shared understanding. (b) This process begins at the first point of contact with the family and is further reviewed during the initial CFT meeting. This allows the family to fully understand the Wraparound process, build buy-in, and clarify expectations as goals are being formulated. this is reviewed, discussed and tracked by the Assistant Director during weekly teams meetings, individual supervision, and case conference. (c) Legal considerations are addressed at intake when all required documents are reviewed and signed, lead by the facilitator and therapist. These considerations are revisited throughout services to ensure families remain informed, supported, and not caught off guard by any requirements or processes. All documents are tracked on 5, 14, and welcome checklists and added to youth chart. (d) Roles and expectations are introduced during intake and the initial CFT meeting. They are further reinforced during individual sessions, particularly as strengths are identified and action plans are developed to support goal attainment. Goals, outcomes, and progress are assessed with the Assistant Director, Clinical supervisor, and documents uploaded into youth charts by program assistants.
3.2 Safety and Crisis stabilization
(a) The 5-day and 14-day checklists, along with the 4-Step process (completed by the Facilitator), are reviewed and completed within the first two weeks of intake. Additionally, a safety plan is developed immediately and completed in the youth’s chart within the first 30 days for all clients to address current safety risks and identify potential concerns. This is completed more quickly by the therapist and facilitator if youth and family are experiencing an immediate crisis.(b) The Family Safety Crisis plan serves as a tool to proactively manage and respond to safety concerns, ensuring that both the team and family are prepared to address risks effectively. (c) Families are provided with 24/7 crisis response information at intake, (see Welcome letter,) which is reviewed ongoing to ensure awareness of after-hours support. Assistant Directors (AD) rotate on-call responsibilities to respond to crisis calls and provide support. AD’s have access to crisis plans, are familiar with assigned caseloads, and participate in weekly consultations with the team to ensure continuity of care and appropriate response and follow up.
3.3 Strengths, Needs, Culture and Vision Discovery
(a) The facilitator ensures that the family vision is explored during the initial Child and Family Team (CFT) meeting and confirmed during the engagement phase. It is documented in the Plan of Care, which is uploaded into the electronic health record system(EHR) EXYM. Monthly CFT meeting notes are also uploaded to the youth’s chart to ensure ongoing documentation of progress and alignment with the family’s vision. (b) The Strengths, Needs, and Culture Discovery is initiated with the youth and family by the Child and Family Specialist. This document is uploaded into the EHR and is regularly reviewed during team meetings to support alignment with the youth’s needs, goals, and overall Plan of Care.
3.4 Engage All Team Members
(a) Facilitator completes 4 Step Model upon receiving referral. Facilitator conducts Staff Engagement with CSW and/or Probation Officer assigned to the case and explores both formal and informal supports. Facilitator then completes Family Engagement where they discuss the CFT process and help the family and youth identify formal and informal supports. (b) CSW/PO are engaged in the process. They are notified by AD and team once the referral is received as well as once the youth is enrolled. The Facilitator will then conduct Staff Engagement to ensure that they are a part of the process. CSWs/POs are invited to participate in CFTs that occur every 4-6 weeks. (c) As Wraparound Team engages with the family and links youth to additional resources, they are constantly exploring if informal/formal supports should be included. This is also discussed at the end of every CFT in preparation for the next planned CFT if there is anyone else that should be included. (d) Facilitator completes either an EcoMap and/or Timeline with the family, which is documented and uploaded to their EHRS. This provides an opportunity to learn more about the youth and systems involved. (a-d) Family Safety Crisis Plan also includes friends and family names and numbers that youth can call when encountering a crisis. This document is created with youth, family and/or tribe participation to identify support systems available as well as coping activities to complete.
3.5 Arrange Meeting Logistics
(a) Refer to job descriptions for salary staff- Facilitator, Therapist II and Child and Family Specialist. Parent Partners are hourly and have a set schedule of 10am-7pm. Assistant Directors rotate ON-CALL phone to provide support and assist in managing crises after hours and on weekends and holidays. Facilitator engages with youth and family upon receiving referral to discuss the Wraparound Program entails. Facilitator conducts 4 Step Model and further explores with CSW/Probation Officer and family about CFTs and meetings. Upon intake/enrollment family’s sign off on FBS Client’s Rights and Responsibilities Form to discuss meetings. Wraparound Team is community based and able to meet with youth and family in the home, school and community. Wraparound Team also is able to facilitate CFTs in office to accommodate larger families if needed. In addition to honoring family voice and choice, Wraparound Team is also available via telephone and telehealth. (b) Wraparound Staff complete Onboarding Training as well as DMH Wraparound Training that highlights the importance of addressing youth’s unmet and underlying needs. Wraparound Team respects family’s voice and choice.
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
(a)Throughout engagement, before the full Plan of Care is completed, the Facilitator with support of CFS, PP, and Therapist, and family develop team agreements clearly explaining how each person will show up and engage during the different services to be delivered. With a focus on setting clear expectations for all members of the child and family team, formal and informal. This is documented in meeting minutes as well as in progress notes in the youth’s chart, as well as final versions in the completed Plan of Care document. This is tracked by the Assistant Director (AD), who reviews each document before it is entered into the youth’s chart. (b) The Wraparound team begins identifying strengths as early as during the review of the referral, and are consistently elicited and brainstormed for and with the youth and family at each meeting. The Plan of Care is a living document and is expected to be updated and revised as frequently as necessary with any changes, improvements, or newly identified strengths, and maintained in the youth’s chart. Progress notes kept in the youth’s chart are also utilized to document strengths in real time. Each team member is encouraged to seek out and share each strength that is identified. Weekly team meetings, individual supervision, and case conferences run by the AD’s, are utilized to review timelines, deadlines, and pending items and to provide coaching and training if needed.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
(a) Facilitator begins the 4 Step Model approach for Plan of Care and services upon receiving referral. Facilitator conducts a thorough review of youth referral and accompanying documentation, then completes Staff Engagement and Family Engagement. This enables the Facilitator to obtain a comprehensive view of youth, family, and unmet/underlying needs. Facilitator is able to problem solve and engage in discussion with CSW/Probation officer during Staff Engagement to seek more specific information about youth stated and observed needs. Facilitator conducts Family Engagement and creates space and time for youth and family to share their story, goals, and underlying needs. This is in preparation to youth’s initial Plan of Care, which occurs within 30 days after enrollment date. During this time Facilitator is able to gather information and formalize an individualized plan to help support youth with is reflective of family voice. (b) Facilitator attends Underlying Needs Training (DMH) and learns to effectively formulate needs statements, which will be used in CFTs to develop measurable goals and outcomes. AD’s further review CFTs to assist and problem solve with underlying needs as needed. (c) Goals are developed in direct response to youth’s collaboration with Wraparound Team beginning immediately and carries forward through all goal development and service delivery. (d) Plan of Care includes sections for documenting and brainstorming ideas prior to assigning specific tasks aimed at addressing underlying needs. This is reflected in progress notes, minutes, and discussed in all supervisions and team meetings. (e) Facilitators attend all DMH Wraparound Trainings that provide support in learning the role and how to facilitate and document CFTs, to gather effect assessment of underlying needs. (f) CFTs are conducted with the Wraparound Team, youth, formal and informal supports, it is a living document that is expanded upon and revised each CFT meeting.
4.3 Develop an Individualized Child or Youth and Family Plan
(1)Plan of Care(formerly CFT Matrix) is created in conjunction with the youth, family and formal supports (CSW/PO) and informal support where needed. Therapist completes CANS and Parent Partner completes PSC-35 to further assist in identifying youths’ needs.(2) Facilitator completes thorough review of case upon receiving referral and conducts Staff Engagement and Family Engagement prior to Plan of Care (CFT Matrix) and creation of Family Safety Crisis Plan which assists in covering any impacted life domains. (3) Plan of Care (CFT Matrix) is a living document that establishes youth underlying needs and is updated every 4-6 weeks to track action items and outcomes. Due dates are reviewed in team meetings and individual supervisions facilitated by Assistant Directors to ensure timely completion of service delivery, brainstorm and problem solve as needed. (4)All service delivery is provided around family voice and preference for schedules, culture and trauma history. Wrapround team members engage across all involved systems of care to ensure effective teaming and participation and effectiveness. (5) The family engagement form helps to ensure all types of connections are explored for inclusion in services and opportunities and interventions to increase informal supports can be detailed here as well. (6) The team works hard with the family to begin preparing for transition since the beginning of services, with clear measurable goals. With clear goals and highlighting growth and improvement weekly and in CFTs the family movement towards less intensive services can be seen by all participants. (a) Facilitators have a Relias Training Tracker, county trainings, and ongoing opportunity for in house training refreshers. They have 3 weekly supervisions and teams meetings to receive coaching and feedback as needed. (b) 4 Step Model is completed prior to development of Plan of Care (CFT Matrix) to integrate goals and objectives. (c) Plan of Care (CFT-Matrix) is sent out to all in attendance and CSW/PO via email to ensure everyone has a current copy and is aware of plan established. (d) Assistant Directors (AD) review Plan of Care prior to uploading into youth’s chart and provides direct feedback and coaching to Facilitator. AD meets with Wraparound Team weekly to further discuss questions, develop strategies and brainstorm additional ideas to support the youth and their family.
4.4 Develop a Crisis and Safety Plan
(a) The facilitator and therapist collaborate with the youth and family to develop the Family Safety Crisis Plan beginning at intake. Assessment of safety, risk factors, crisis triggers for the youth and family are identified with protective factors and strengths combined. Steps, support, but proactive and reactive are documented. The Wraparound welcome letter includes all clinical emergency contact information for the team, on call phone, and county/city emergency numbers. The department on call phone is available 24/7 for crisis support. (b) Facilitator and therapist ensure that youth and family voice are actively engaged in this development. These documents and youth and family needs are reviewed in weekly supervision, clinical supervision, team meetings and case conference run by ADs to provide as needed coaching and support. (c) During these same supervisions and meetings discussions are fostered and coaching is provided to create opportunity for ongoing review and revision of the plan and each youth’s needs, improvement, and evolving relationships and support system.
Implementation
5.1 Implement The Plan of Care
(a) The Facilitator ensures that team meetings are held monthly to support engagement and goal progress. During each meeting, previously identified strategies are reviewed to assess outcomes, determine effectiveness, and identify any needed adjustments. Action items from prior meetings are revisited, and responsibilities are assigned to appropriate team members, including both formal and informal supports, based on the needs of the team and family. New action items are established at the end of each meeting and documented in the Plan of Care. Outcomes from the previous meeting are reviewed at the beginning of the next meeting to ensure continuity and accountability. In addition to monthly Child and Family Team (CFT) meetings, the Wraparound team utilizes weekly team meetings and team consultations to monitor progress and provide ongoing support. This includes regular 1:1 contact with the youth and family/caregivers. Strategies are adjusted as needed with flexibility, ensuring continuous family involvement both within and outside of CFT meetings. (b) Staff are required to attend Wraparound 101 and Plan of Care trainings through UC Davis to ensure foundational knowledge and fidelity to the model. In addition, monthly in-service trainings are implemented to reinforce the Wraparound principles and support ongoing skill development. Training materials are sourced from UC Davis and are supplemented with team-building opportunities to strengthen collaboration and engagement among staff. Staff participate in weekly clinical supervision, administrative supervision, team meetings, and case conferences. Each of these forums includes embedded training components to support continuous learning, reinforce best practices, and ensure alignment with Wraparound values and expectations.
5.2 Review and Update The Plan of Care
(a) The Plan of Care is used to maintain accurate documentation of strategies, progress, and action items. At the end of each team meeting, the facilitator reviews action steps and distributes the updated Plan of Care to families and stakeholders; families also receive a hard copy. (b) The facilitator and team review and adjust the Plan of Care monthly with the family, and updates may also occur outside of team meetings as needs arise. (c) Documenting and reviewing the Plan of Care is a core part of the meeting structure. Attendance is also reviewed to identify and document informal support opportunities. (d) The Plan of Care is updated monthly during team meetings, with a focus on outcomes driven by the individualized needs of the family.
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
(A) Team agreements are consistently revisited during team meetings to ensure that youth and families remain in agreement and are actively leading the process. (B) Facilitators receive ongoing training through weekly administrative supervision, team meetings, and case conferences. These spaces provide coaching on building, engaging, and maintaining effective teams. (C) During weekly team meetings, supervisors review both past and upcoming Child and Family Team (CFT) meetings, including attendance and engagement. As needs and strategies are discussed, the team actively explores the role and importance of natural supports to promote long-term stability beyond formal services. (D) The current process for orienting new team members involves supporting the youth and family in identifying appropriate supports. Facilitators also use this opportunity to reach out to potential team members, invite them to CFT meetings, and explain the team process. New members are welcomed through both team meetings and one-on-one engagement with the caregiver and youth to support established goals.
Transition
6.1 Develop a Transition Plan
(a) The Wraparound process is driven by the family’s goals and needs, with the phases of Wraparound guiding the work. Families are viewed as the experts, and the team supports progress toward their goals and DCFS/Probation case closure. When goals are met and CSW/PO involvement is consistent, families should be considered for graduation, this reflects the model working as intended. Indicators of readiness include decreased symptoms, increased ownership of strategies, and reduced reliance on the team. (b) The facilitator guides the family and team through transition planning during CFT meetings and encourages all team members to support preparation in their 1:1 sessions, ensuring the family and youth’s voice is central in the transition process. (c) Facilitators participate in role-specific trainings to effectively lead transition meetings, with ongoing reinforcement provided through weekly administrative supervision. (d) The team provides families with referrals to community-based services aligned with their needs, ensuring they have access to sustainable supports. These resources are reviewed with caregivers and youth to promote confidence and continued success post-transition.
6.2 Develop a Post-Transition Safety Plan
(a) Based on the client’s needs and any identified safety concerns, a safety plan is developed to ensure families are aware of supports available during times of crisis, particularly as Wraparound services transition. As behaviors decrease with support, some interventions may still remain in the safety plan in case behaviors re-emerge. Natural and formal supports are identified to gradually replace Wraparound team involvement. (b) Child and Family Team (CFT) meetings, held monthly, are used to review and adjust the safety plan as needed. The Therapist and CFS can also reinforce and practice these interventions during sessions. Ongoing conversations with families help ensure the strategies are realistic and sustainable, with adjustments made to align with the family’s ability to follow through during the transition period. (b) Crisis and safety plans are reviewed during CFT meetings and revisited following any incidents to assess their effectiveness. Youth and families are regularly asked whether the plan is in a language and format that is accessible and usable for them.
6.3 Create a Commencement and Celebrate Success
(A) During the transition phase, team meetings actively include discussion and review of celebrations and cultural considerations with the family. These are revisited regularly to ensure confirmation and alignment with the youth and family’s preferences. ADs facilitate discussions around each of these topics in supervision and team meetings, and track progress from week to week. (B) Throughout transition, the team uses meetings to explore prior supports and identify current ways to access support in the absence of formal services. Strength summaries or youth story narratives are incorporated to highlight resilience and progress, and are often shared during graduation/transition celebrations. Graduations are planned and celebrated in a manner that is most meaningful to the youth and family. This may include sharing a meal during a team meeting or utilizing flex funds to purchase a transitional or commemorative item.
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
From CQI Plan (pg 7)
Stakeholder Participation
In order to ensure comprehensive continuous quality improvement, it is imperative that efforts involve all agency stakeholders to gain broad insight and feedback from individuals connected to St. Anne’s in a variety of ways. For the purpose of identifying participants in the CQI process, “stakeholders” shall include the following:
• Program Participants
• Employees
• Community Partners (including but not limited to licensing and regulatory bodies, contract funders, foundations and private donors, and advocacy groups)
• Board of Directors
Client Feedback
Client Satisfaction Surveys
In order to obtain feedback from clients, each Program will administer client satisfaction surveys. Surveys will include standardized tools as required by various contracts, and questions related to benchmarking and program-specific topics. Surveys will be distributed at least annually, and in some cases more frequently. Results will be cleansed and aggregated by the Quality Department and provided to programs for review in Quarterly Program Outcomes Meetings.
Safety and Helpline
All St. Anne’s program participants are encouraged to provide feedback, including concerns, issues, and questions, to the agency Safety and Helpline, available at extension 520. The QA Director or designee will respond to all Safety and Helpline calls within 24 hours, and any reported concerns or issues will be immediately responded to and resolved within seven days.
Client Councils/Advisory Groups
Each Division will develop and maintain a council or an advisory group consisting of program participants who will meet regularly to provide feedback and identify program quality issues, including gaps in services and complaints, as well as suggestions for improvement. Information collected during these meetings will be documented and reviewed by the respective Program Director and a Quality staff member, and identified concerns addressed through the improvement planning process.
7.2 Community Leadership Team
This is still pending for our agency as LA County has not yet begun to roll out a Community Leadership Team. We look forward to participating once this is available. We are in the process of identifying a few potential candidates to serve as representative.
7.3 Eligibility and Equal Access
(a)Agency clinical screening and intake procedures ensure that each youth who meets eligibility criteria receive access to services and are not excluded based on severity or nature of their specific needs. (b)Staffing is developed to meet the DMH contract caseload size parameters. Service access is tracked through our Master roster and each department’s administration. Our agency maintains an On-Call phone structure, with each department management team holds a 24/7 crisis phone line which provides access for all youth to access support services at any time 24/7.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
(a)While there is a significant amount of change pending in California and LA County right now, the currant rates allow for the appropriate amount of individualized services be provided to each youth in wraparound. Program Director and Vice President of Community Based programs meet monthly for a “Line of Sight” meeting to review currant funding allocations, trends, and flex fund expenditures to ensure that all services, procurement, and spending meet high fiscal standards and back up documentation in our finance tracking system Micriox. Budget verses actual expenditures are reviewed along with projections for each fiscal year, adjustments are made whenever necessary. (b) Wrapround staffing standard 9.3 are met and maintained. Program Director, Assistant Directors, and Human Resources meet monthly to ensure staffing and workforce support are held to a high standard and vacancies are filled with high quality candidates. (c) We utilize multiple data management systems to ensure effective and transparent data collection. Micriox for finance, Youth charts in EXYM our EHRS for program services, DocTract and Relias Learning Management system for our policies and procedures and training are maintained by our quality team. We are in the beginning stages of working with PowerBI for other data tracking and collection.
8.2 Equitable Funding Across System Partners
A) Agency development, program, and operational departments regularly evaluate the funding environment and any possible supplemental funding sources that could be used to leverage current operations.
B) St. Anne’s finance department collaborates with all programs and departments to develop a zero-based budget that is based on necessary operating expenditures, known contracts and anticipated revenue from other sources, improving efficiency and outcomes, and the changing economic climate. The finance department will also conduct an annual cost analysis of programs and services to ensure that funds are being utilized effectively in order to achieve the highest degree of client outcomes. Fiscal results are jointly reviewed on a monthly basis to ensure funds are being utilized properly, and any necessary action plans are implemented timely.
C) St. Anne’s allocates expenses according to its approved cost allocation plan and all relevant contract terms and regulations (e.g., 2 CFR, A-C handbook). All costs are charged directly or indirectly to operational cost centers according to proportional benefit received, and must be allowable, allocable, reasonable, and necessary for agency operations.
D) St. Anne’s offers a wide array of program service departments, including Early Childhood Education, Residential Treatment, and Supportive Housing, in addition to Mental Health and Family Based Services. Youth are referred as appropriate to departments which could provide services relevant to each youth’s needs.
8.3 Cost Savings are Reinvested
St. Anne’s chart of accounts provides for the segmentation of all agency revenues and expenditures via individual cost centers in order to ensure that all fiscal activities are assigned to the appropriate department or funding source. This structure ensures that gains or losses are clearly identifiable for all contracts, grants, and other operational cost centers.
P&L reports are documented and reviewed with leadership on a monthly basis in order to monitor program performance and ensure proper allocation of agency resources. Results are also shared quarterly with the BOD to review performance and action plan regarding agency needs, including investment of any net program revenues. This strategization is also included in the annual budgeting process, and a capital/infrastructure budget is developed, with priority projects to move forward if savings are available.
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.
St. Anne’s has provided a staff wrap training, created internal wrap guidelines, and recorded DMH case rate services support training. Staff are trained in program standards and best practices in order to ensure funds are distributed in accordance with client needs and program requirements. When funds are requested by the program team, the finance department processes and completes the request in accordance with internal controls. Fiscal performance is reviewed by the program and finance team on a monthly basis, along with discussions ensuring that client disbursements are being provided and accounted for in a timely and accurate manner. When denials occur, the teams work to address reason for claim denial so that the client may access the required resources.
8.5 Collaborative Oversight of Flex Funds
All flex funds are reviewed by ADs, who then add requests to an internal tracking log. The completed request file is submitted to the Program Assistant responsible for submitting claims monthly and documenting requests in an internal monthly tracker (flex fund summary). The log includes relevant information such as payment method, service area, expense description, client name, expenditure date and amount, unique tracking number, and warrant info. The log is provided to the finance team on a monthly basis and is further reconciled against actual payments disbursed and verification of individual claims accepted for reimbursement.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
Flex funds are disbursed in accordance with program requirements and in consideration of other potentially available resources. (b)If client need exceeds available funding levels or funding limitations impact agency ability to address those needs, other funding sources may be considered to cover gaps in service provision or expenditure assistance. (c) No agency contract or policy serves to limit or prohibit clients’ ability to access flex funds.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
St. Anne’s Family Services Discrimination Policy and Procedure states: St. Anne’s, an equal opportunity employer, is committed to equal opportunity for all employees and applicants. St. Anne’s recruits, hires, trains, promotes, pays, and administers all personnel actions without regard to race, religious creed, color, national origin, ancestry, citizenship status, physical disability, mental disability, medical condition (including cancer or genetic characteristics), genetic information, marital status, sex (including pregnancy, childbirth and medical conditions related to pregnancy, childbirth, or breastfeeding), sex stereotyping (including assumptions about a person’s appearance or behavior, gender roles, gender expression, or gender identity), gender, gender identity, gender expression, age, sexual orientation, military or veteran status, political activities, reproductive health decision-making, any other legally protected basis, or any combination of any statuses protected by applicable law. We interpret these protected statuses broadly to include both the actual status and also any perceptions and assumptions made regarding these statuses.
This policy extends to all areas of employment, including recruitment, testing, screening, hiring, selection for training, upgrading, placement, transfer, promotion, demotion, layoff, discipline, termination, compensation, working conditions and all other privileges, terms, and conditions of employment. This policy and the law prohibit employment discrimination against any employee or applicant on the basis of any legally protected status outlined above.
St. Anne’s Family Services Client Rights Policy and Procedure 7 and 8 states: St. Anne’s will ensure each Program takes all necessary steps to accommodate any special needs to ensure program participants are able to access services. Each Program will accommodate the written and oral communication needs of all clients by providing services in the primary language of each client, or by securing a translator for services.
9.2 Tribally Responsive Workforce
St. Anne’s Family Services Discrimination Policy and Procedure states: St. Anne’s, an equal opportunity employer, is committed to equal opportunity for all employees and applicants. St. Anne’s recruits, hires, trains, promotes, pays, and administers all personnel actions without regard to race, religious creed, color, national origin, ancestry, citizenship status, physical disability, mental disability, medical condition (including cancer or genetic characteristics), genetic information, marital status, sex (including pregnancy, childbirth and medical conditions related to pregnancy, childbirth, or breastfeeding), sex stereotyping (including assumptions about a person’s appearance or behavior, gender roles, gender expression, or gender identity), gender, gender identity, gender expression, age, sexual orientation, military or veteran status, political activities, reproductive health decision-making, any other legally protected basis, or any combination of any statuses protected by applicable law. We interpret these protected statuses broadly to include both the actual status and also any perceptions and assumptions made regarding these statuses.
This policy extends to all areas of employment, including recruitment, testing, screening, hiring, selection for training, upgrading, placement, transfer, promotion, demotion, layoff, discipline, termination, compensation, working conditions and all other privileges, terms, and conditions of employment. This policy and the law prohibit employment discrimination against any employee or applicant on the basis of any legally protected status outlined above.
St. Anne’s Family Services Client Rights Policy and Procedure 7 and 8 states: St. Anne’s will ensure each Program takes all necessary steps to accommodate any special needs to ensure program participants are able to access services. Each Program will accommodate the written and oral communication needs of all clients by providing services in the primary language of each client, or by securing a translator for services. When working with an Indian child and family, the wraparound staff are prepared and encouraged to seek out collaboration with tribal representatives and participation in services. Flexible timing and location of service delivery is always offered to representatives to increase likelihood and ability for engagement with these informal supports.
9.3 Flexible and Creative Work Environment
(a – d) We have bi-monthly All Staff meetings that promote agency culture, highlight and integrate mission moments, and reinforce continuous quality improvement. A strong foundation of our mission is covered in New Hire Orientation and reinforced at bi-monthly All Staff meetings.
(FROM ANNUAL PERFORMANCE EVALUATION)
It is an expectation of all staff to Identify key learnings, demonstrate a growth-mindset, and (when applicable) implement improvements as a way to promote Continuous Quality Improvement.
9.4 Hiring, Performance Evaluation, and Job Descriptions
(a-c)St Anne’s has the following job descriptions that fulfill the functions of HFW: Clinical Supervisor in FBS and MHS (fulfill the functions of both a HFW Clinical supervisor and a HFW Fidelity Coach), Wraparound Facilitator (fulfills HFW Facilitator functions), Child and Family Specialist (fulfills HFW Family Specialist functions), MHS and FBS Assistant Director positions (fulfill functions of HFW Manager), MHS and FBS Program Director (fulfill functions of HFW Manager and Fidelity Coach), Wraparound and FSP Parent Partners (fulfill functions of HFW Parent Partner), Peer Support Specialist (Fulfills functions of HFW Youth Partner). Job descriptions reflect HFW skill, knowledge, responsibilities, functions, experience. (d) Human Resources and Program management work closely and collaboratively to create and provide interviews that encourage opportunity to demonstrate the skills and character vital to each role. (e) Agency Annual Evaluations are reviewed and link directly to each staff’s job description so transparency of performance expectations are clear to all. The goal is that there is no new feedback or coaching in an annual evaluation, it is a reflection of a years worth of supervision feedback and coaching.
9.5 Workforce Stability
(a) St. Anne’s Human Resources and Finance departments collaborate to complete compensation analysis, annually or as needed to ensure that wages are reflective of cost of living changes within our community. We participate in industry and local benchmarking initiatives to ensure we remain aligned with market rates. (b) Within clinical programs, our screening and intake procedures are set up and implemented to ensure caseloads match staffing capacities. (c) The agency maintains an internal transfer and promotion procedures which allows for accessibility and opportunities for all staff. (d)Our agency maintains an annual evaluation process which is linked to merit-based wage increases. Built into this evaluation is a section for personal, professional, and agency goal development for each staff and their supervisor to be working towards throughout the year.
9.6 High Fidelity Training Plan
(a) We plan to have all staff attend the Statewide Standardized Foundational HFW training through the UC Davis RCFFP. We will explore the possibility of attending train the trainer and developing something internal in the future. We have been able to get 3 managers into the trainings offered so far. We have a large number of staff currently on the waitlist. (b) All current staff have attended the LA County provided 12 foundational wraparound trainings. Each wraparound role has a specific training plan maintained in our Learning management system Relias. (see training plans in supporting documents for section 9). Relias tracking allows us to stay consistent and anticipate training needs, it sends out reminders to each staff, their Assistant Directors and Program Director. We have a robust supervision expectation for each staff. (see Supervision Framework and Supervision template). Staff each meet weekly for individual supervision with their Assistant Director, individual supervision and group supervision with their clinical supervisor, attend weekly team meetings and case conference. These spaces are utilized for ongoing training, coaching, and support for staff growth and development and safety for our families and youth. Our agency and Department New Hire onboarding also includes peer shadowing by the role they were hired for to ensure consistency and fidelity.(c) Staff receive booster trainings annually using (Wrapround Principles – Alignment and a staff guide) to ensure fidelity to the wraparound model. These trainings are updated as policies or county/state expectations change. (d) All managers and supervisors working with Wraparound staff have historically also attend all 12 wrapround foundational trainings and are waitlisted for UC Davis High Fidelity Wraparound 101. This is also tracked in Relias. (e) We are in the process of identifying a new ICWA and Tribal sovereignty training for staff and will track attendance and completion in Relias. All agency staff attend cultural humility training annually. Assistant Directors and Program directors ensure new or specific population trainings are identified and attended whenever needed. In the past that has included, but is not limited to, CSEY, SUD, eating disorder, IPV, and DEI.
9.7 Community-based Training Program
We are in the process of adding community member collaboration to our Wrapround training process in accordance with this standard. We have identified youth and community partners and have begun to reach out to assess interest, availability, accommodations needed to incorporate this into our internal training opportunities.
9.8 Coaching and Supervision
(a) Each wrapround new wraparound staff attend a 2 week New Fire Orientation for the agency and 1-2 week department onboarding process. The Assistant Director leads the department onboarding using our new hire training binder which includes, but is not limited to, program expectations, policies and procedures, on call reporting, incident reporting, wraparound principles, clinical documentation, wraparound documentation, and ensure they are enrolled in upcoming wraparound and role specific trainings provided by the county or state. A peer shadowing and supervision schedule is developed and overseen by the Assistant Director and clinical supervisor. (b)SAFS supervision structure and expectations ensure weekly individual, team, and group clinical supervision occur and provide support/training and coaching. Team meetings and case conferences are maintained weekly for additional support and to ensure program fidelity. All staff have access to our 24/7 on call phone maintained by management for support at any time.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
10.2 Evaluation Metrics & Outcomes
(a-b)Our agency CQI system integrates collection, review, feedback, and improvement into program outcomes, reviews and survey results. Each program hold quarterly reviews of their program outcomes to review outcome progress, strengths, and opportunities for improvement in how we serve our families. The Quality department partners with Programs to provide outcomes in a way that promotes discussion, documents, data reviews, and supports improvement plans as applicable. (c) Our Quality Team reports out system barriers or opportunities for improvement to our Leadership Team on a quarterly basis in Management meetings and in individual department meetings.
Fidelity Indicators
1.1 Timely Engagement and Planning
(a) HFW Facilitator calls family within 24 hours to schedule a session to gather information and prepare to develop Plan of Care (see page 1, Plan of Care, see page 7, Ecomap, see page 8, Timeline) no later than 10 days after intake session.
(b) HFW Facilitator schedules a day and time for child/family, HFW team, and other paraprofessionals/natural supports involved in the child’s care to meet and complete a HFW Plan of Care within 30 days from start of services. HFW Facilitator also calls other paraprofessionals involved in the child’s care to gather information in preparation for the HFW meeting (see page 9, Staff Engagement Worksheet) no later than 10 days after intake session.
(c) HFW staff meets monthly with family (30-45 days) to review Plan of Care to ensure each team member is engaged, evaluating progress, and maintaining appropriateness of care plan.
(d) Throughout the duration when services are provided, HFW Facilitator updates, distributes, and documents changes in the Plan of Care at least every 90 days or earlier as needed. All parties involved received the newest plan as updates are made.
(e) HFW staff and supervisors receive feedback from the child/family to maintain/track efforts to meet timelines for CQI purposes.
(f) Through agency trainings, staff meetings, and supervision, HFW staff receive trainings and coaching on problem solving to ensure generalization of trainings provided (see page 10, WRAP Training Plan).
1.2 Led by Youth and Families
(a) The HFW Facilitator begins the meeting reviewing the agenda of the meeting, which includes the family vision and team mission. This allows opportunity for the family and team to be aware that they will have opportunity to express their perspectives in the meeting. In addition, the team routinely gathers characteristics of the family in efforts to honor family voice and choice (see page 13, Plan of Care Agenda).
(b) The HFW Facilitator documents all characteristics of the child/family (values, strengths, skills, interests, expertise) explored and shared in the HFW team meeting in the Plan of Care and EHR. (see page 1, Plan of Care).
(c) The Supervisor/Coach attend HFW team meetings monthly to observe how to enhance the teams’ skills and maintain fidelity to the practice. Information gathered through the observations is shared during supervision and team meetings.
(d) The HFW Team provides formal (client satisfaction surveys and quality assurance phone calls) and informal ways (in person discussion) to routinely elicit feedback from our families, which are reviewed to enhance the HFW process and update the HFW Standards (see page 57, client satisfaction survey).
1.3 Strength-Based
(a) The IP-CANS is utilized with our families. A list of resources in the family’s service area is developed, updated, and distributed to families on a regular basis to help meet basic needs (see page 14, IP-CANS, see page 110, LA County Resources).
(b) The HFW team incorporates strengths identified within the team and in the IP-CANS, which are functional in nature and drive decision making and service planning. (see page 14, IP-CANS, see page 1, Plan of Care).
(c) All staff in the HFW team complete the IP-CANS certification training through the Praed Foundation as well as related strengths-based, solution-focused training to support families towards transition. All staff meet individually with their supervisor weekly and attend weekly team meetings where they receive ongoing coaching and support. Supervisors receive ongoing support and coaching through their individual supervision as well (see page 14, IP-CANS, see page 10, WRAP Training Plan).
(d) The HFW Team provides formal (client satisfaction surveys and quality assurance phone calls) and informal ways (in person discussion) to routinely elicit feedback from our families about providing strengths-based services, which are reviewed to enhance the HFW process and maintain the HFW Standards. In weekly supervision, the HFW staff integrates all sources of information/feedback to assess and further develop training (see page 57, Client Satisfaction Survey).
1.4 Needs Driven
(a) The HFW Facilitator meets with the family prior to first HFW meeting to identify underlying needs. In the HFW team meeting, the needs are discussed again thus allowing all participants to reevaluate and confirm priority needs (see page 14, IP-CANS).
(b) All staff in HFW team complete Plan of Care, Underlying Needs, Trauma Informed Care trainings to enhance ability to identify, develop, draft, and revise underlying needs that reflect the concerns and behaviors displayed at the given time. All staff meet individually with their supervisor weekly and attend weekly team meetings where they receive ongoing coaching and support. (See page 10, WRAP Training Plan).
(c) To ensure a holistic understanding of the family’s needs, underlying needs are identified and reviewed through objective reports (IP-CANS) and through family and informal supports (DCFS). (see page 14, IP-CANS, see page 1, Plan of Care).
(d) During the monthly meeting, feedback is elicited from the team to assess readiness for transition when it is agreed that needs have been sufficiently met. Transition is planned once needs are sufficiently met using the IP-CANS and resources/linkage are utilized to complete the transition and the family is capable to move forward without the team (see page 14, IP-CANS, see page 1, Plan of Care).
1.5 Individualized
(a) The HFW Facilitator develops and creates the Plan of Care with families that reflect their individual situations and can be edited at any time to reflect the most current plans and concerns (see page 1, Plan of Care, see page 7, Ecomap, see page 8, Timeline)
(b) All staff in the HFW team complete Plan of Care trainings to enhance their ability to develop individualized plans that reflect the families’ concerns and behaviors displayed throughout the HFW process. All staff meet individually with their supervisor weekly and attend weekly team meetings where they receive ongoing coaching and support. (see page 10, WRAP Training Plan).
(c) All HFW Facilitators receive trainings on how to lead HFW team meetings in an effective, productive manner that support individualized needs. All staff meet individually with their supervisor weekly and attend weekly team meetings where they receive ongoing coaching and support. The supervisor attends monthly HFW team meetings to provide feedback. (see page 10, WRAP Training Plan).
(d) In the weekly meetings, the Plan of Care is used as a roadmap to ensure meeting the needs of the family (i.e., reviewing strategies, identifying strengths, discussing outcomes). All members of the team receive a copy of the Plan of Care to ensure each member has accountability, fidelity to the plan, and keep everyone on the same page about the plan/progress/outcomes. In monthly HFW meetings, team members review the Plan of Care to ensure it is appropriate.
(e) The HFW Team provides formal (client satisfaction surveys and quality assurance phone calls) and informal ways (in person discussion) to routinely elicit feedback from our families about providing customized services, which are reviewed to enhance the HFW process and upkeep the HFW Standards in the service. In weekly supervision, the HFW staff is integrating all sources of information/feedback to assess and further develop training. (see page 57, client satisfaction survey).
1.6 Use of Natural and Community Based Supports
(a) A list of resources addressing natural/community supports in the family’s service area is developed, updated, and distributed to families on a regular basis to help meet basic needs (see page 110, SA1 and SA2 Resources). The facilitator utilizes the Ecomap to identify natural supports and resources in the area to support the family. The family also utilizes contributions from the natural supports of the youth and family.
(b) We recognize the importance of natural supports and engage them in every phase. All staff meet individually with their supervisor weekly and attend weekly team meetings where they receive ongoing coaching and support. By the transition phase, the natural supports take on a lead role in supporting the family (see page 10, WRAP Training Plan).
(c) In the weekly team meetings, the Plan of Care is reviewed to ensure that natural supports are included, and community resources are being utilized in order to complete action items. In the HFW meeting, natural supports are assigned action items that reflect the family’s needs. All members of the team receive a copy of the Plan of Care to ensure each member has accountability, fidelity to the plan, and keep everyone on the same page about the plan/progress/outcomes. In monthly HFW meetings, team members review the Plan of Care.
(d) The HFW Team provides formal (client satisfaction surveys and quality assurance phone calls) and informal ways (in person discussion) to routinely elicit feedback from our families about providing natural supports, which are reviewed to enhance the HFW process and maintain HFW Standards. In weekly supervision, HFW staff integrate all sources of information/feedback to assess and further develop training. (see page 57, Client Satisfaction Survey).
1.7 Culturally Respectful and Relevant
(a) The HFW Facilitator meets with the family prior to initial HFW meeting to gather information about the family’s culture, needs, and strengths, heritage, traditions, which is documented in the child’s file in the EHR to ensure that the plan of care is grounded in the family’s cultural practice/heritage. (see page 7, Ecomap, see page 8, Timeline, see page 14, IP-CANS)
(b) Through agency trainings, staff meetings, and supervision, HFW staff receive trainings and coaching on providing services that demonstrate sensitivity to the family’s culture and utilize strategies that will help families towards successfully transitioning (see page 10, WRAP Training Plan).
(c) The HFW Team provides formal (client satisfaction surveys and quality assurance phone calls) and informal ways (in person discussion) to routinely elicit feedback from our families about their experiences receiving culturally mindful services and strategies, which are reviewed to enhance the HFW process and maintain HFW Standards. In weekly supervision, HFW staff integrates all sources of information/feedback to assess and further develop training (see page 57, client satisfaction survey).
1.8 High-Quality Team Planning and Problem Solving
(a) The HFW Facilitator guides the HFW staff, family, natural supports, and paraprofessional to develop and agree on the team agreement. The team agreement is developed through utilization of the ICPM Model (staff engagement, family engagement). The team agreement is documented in the child’s file in the EHR. (see page 1, Plan of Care).
(b) All staff meet individually with their supervisor weekly and attend weekly team meetings where they receive ongoing coaching and support. The HFW Team provides formal (client satisfaction surveys and quality assurance phone calls) and informal ways (in person discussion) to routinely elicit feedback from our families about their experience engaging and collaborating in the meetings, which are reviewed to enhance the HFW process and maintain HFW Standards. The Supervisor observes the team meetings to ensure that the HFW staff promote team engagement with the family and other paraprofessionals. (see page 10, WRAP Training Plan, see page 57, client satisfaction survey).
(c) The HFW staff and supervisors utilize feedback from families and coaches to enhance their work. The discussions about the feedback are reviewed in individual and group supervision to inform HFW staff about ways to improve and/or maintain quality.
(d) The HFW Facilitator documents the outcome of the meetings which are distributed to all HFW team members to ensure their input and accountability for strategies and action items. Supervisors regularly review and assess the Plans of Care/meeting minutes before the HFW Facilitator distributes the plan to all HFW Team members to ensure accountability that strategies and actions item are known (see page 1, Plan of Care).
1.9 Outcomes Based Process
(a) The HFW Facilitator collaborates and elicits ideas from the HFW team to develop plans, establish action items that meet the family needs. Actionable objectives are documented in the plan of care (see page 1, Plan of Care).
(b) The HFW Facilitator routinely reviews action items assigned to all team members to document outcomes and updates in the plan of care in real time as needed.
(c) The Plan of Care is in “fillable” formats that allow for immediate amendments during the HFW meetings. The HFW Facilitator discusses the changes made in the action items to the HFW Team during the meeting. The strategies and action items can be changed based on outcomes and/or the assessment of needs during and after the HFW team meetings as needed. (see page 1, Plan of Care).
(d) The HFW Facilitator completes the IP-CANS and distributes the results to the HFW team members. (see page 14, IP-CANS).
(e) The HFW staff, family, and paraprofessionals utilize the IP-CANS as well as other informal processes (discussion/collaboration/documentation in meetings) to track and monitor the family’s progress towards transition (see page 14, IP-CANS).
1.10 Persistence
(a) The HFW staff collaborate with the child and family to address barriers to process and brainstorm on strategies to continue to engage and instill hope. During these collaborations, the HFW staff honor the families’ expression of needs and desires regarding continuing or ending services (see page 1, Plan of Care).
(b) The HFW staff are trained and informed in their weekly supervision to contact supervisor when assistance to support families with engagement, collaboration, and funding as needed (see page 60, Flex Fund Request Forms).
(c) Through individual supervision, coaching, and agency trainings, HFW Facilitators receive trainings and coaching on providing crisis management, problem solving strategies, and ongoing collaboration and brainstorming to address any challenges that occur. (see page 58, WRAP Safety Plan, see page 10, WRAP Training Plan).
1.11 Transitions as a part of the Fourth Phase of HFW
(a) Discussions about transition is ongoing from beginning of the HFW process to ensure that the plan of care is developed with transition in mind, which includes documentation of milestones so that the family is prepared and ending services does not feel abrupt. Once needs are met, HFW staff collaborate with all team members in the final HFW meeting to review and confirm plans to support families with transition. This includes linkage to resources in their community and collaboration with their natural supports to prevent negative response to services ending.
(b) The HFW staff highlight progress, aspirations, goals, values, culture, and efforts of the family that led to successful transition. The celebrations are planned in collaboration with the family to ensure they are grounded in the family’s culture, preferences, and values. This includes utilization of flex funds, engaging in the community, and scheduling days and times for all team members to be present the celebrate the family.
Expected Outcomes
2.1 Youth and Family Satisfaction
The HFW staff utilize formal and informal methods to evaluate families’/tribes of Indian child’s satisfaction with the service, such as client satisfaction surveys and quality assurance phone calls and in person discussion to ensure quality of services. The QI department distributes the client satisfaction surveys and provides feedback to the HFW staff as well as guides continuous quality improvement (see page 57, client satisfaction survey).
2.2 Improved School Functioning
The HFW Facilitator completes the IP-CANS, PSC- 35, FSP OMAs (Baseline, 3M OMA, and/or Key Event Change (KEC)) which records the client’s school behavior, academic performance, and attendance. After a Release of Information form is complete, the HFW staff follow procedures to collaborate with the family and school personnel to evaluate, plan, and document progress in this area. Other procedures include, utilizing formal and informal methods to evaluate families’ satisfaction with the service, such as client satisfaction surveys and quality assurance phone calls and in person discussion (see page 14, IP-CANS, see page 1, Plan of Care, see page 17, PSC-35, see page 18, FSP OMAs, see page 57, client satisfaction survey).
2.3 Improved Functioning in the Community
The HFW Facilitator completes the IP-CANS, PSC- 35, FSP OMAs (Baseline, 3M OMA, and/or Key Event Change (KEC)) which assesses the client’s community involvement and the degree to which is a strength. HFW staff follow procedures to collaborate with the family, natural supports, and community resources to evaluate, plan, and document progress in this area. Other procedures include, utilizing formal and informal methods to evaluate families’ satisfaction with the service, such as client satisfaction surveys and quality assurance phone calls and in person discussion to ensure quality of services (see page 14, IP-CANS, see page 1, Plan of Care, see page 17, PSC-35, see page 18, FSP OMAs, see page 57, client satisfaction survey).
2.4 Improved Interpersonal Functioning
The HFW Facilitator completes the IP-CANS, PSC- 35, FSP OMAs (Baseline, 3M OMA, and/or Key Event Change (KEC)) which records whether the client’s interpersonal functioning is enabling their everyday activities. The HFW staff follow procedures to collaborate with the family, natural supports, and community resources during treatment to evaluate progress in this area. Other procedures include, utilizing formal and informal methods to evaluate families’ satisfaction with the service, such as client satisfaction surveys and quality assurance phone calls and in person discussion to ensure quality of services (see page 14, IP-CANS, see page 1, Plan of Care, see page 17, PSC-35, see page 18, FSP OMAs, see page 57, client satisfaction survey).
2.5 Increased Caregiver Confidence
The HFW Facilitator completes the IP-CANS, PSC- 35, FSP OMAs (Baseline, 3M OMA, and/or Key Event Change (KEC)) which records whether the caregivers’ resources and needs interfere with functioning and require further action. The HFW staff follow procedures to collaborate with the family, natural supports, and community resources to evaluate progress in this area. Other procedures include, utilizing formal and informal methods to evaluate families’ satisfaction with the service, such as client satisfaction surveys and quality assurance phone calls and in person discussion to ensure quality of services (see page 14, IP-CANS, see page 1, Plan of Care, see page 17, PSC-35, see page 18, FSP OMAs, see page 57, client satisfaction survey).
2.6 Stable and Least Restrictive Living Environment
The HFW Facilitator completes the IP-CANS, SIRs (as needed), PSC- 35, FSP OMAs (Baseline, 3M OMA, and/or Key Event Change (KEC)) which records stability (stable/least restrictive living environment) or fluctuation (detention, psychiatric hospital, treatment center, or STRTP) in their placement. The HFW staff follow procedures to collaborate with the family, natural supports, paraprofessionals to address the client’s living situation and updates Plan of Care. Flex Funds are utilized as needed. Other procedures include, utilizing formal and informal methods to evaluate families’ satisfaction with the service, such as client satisfaction surveys and quality assurance phone calls and in person discussion to ensure quality of services (see page 14, IP-CANS, see page 61, SIR, see page 1, Plan of Care, see page 17, PSC-35, see page 18, FSP OMAs, see page 57, client satisfaction survey).
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
The HFW Facilitator completes the IP-CANS, SIRs (as needed), PSC- 35, FSP OMAs (Baseline, 3M OMA, and/or Key Event Change (KEC)) which records the frequency of hospital visits. The HFW staff follow procedures to collaborate with the family, natural supports, and paraprofessionals to address the client’s behavioral health and updates the Plan of Care. Other procedures include, utilizing formal and informal methods to evaluate families’ satisfaction with the service, such as client satisfaction surveys and quality assurance phone calls and in person discussion to ensure quality of services (see page 14, IP-CANS, see page 61, SIR, see page 1, Plan of Care, see page 17, PSC-35, see page 18, FSP OMAs, see page 57, client satisfaction survey).
2.8 Reduction in Crisis Visits
The HFW Facilitator completes the IP-CANS, SIRs (as needed), PSC- 35, FSP OMAs (Baseline, 3M OMA, and/or Key Event Change (KEC)) which records the frequency of crises and professional collaboration and support to address the event. The HFW staff follow procedures to collaborate with the family, natural and community supports, and paraprofessionals to address the client’s behavioral health and updates the Plan of Care. Other procedures include, utilizing formal and informal methods to evaluate families’ satisfaction with the service, such as client satisfaction surveys and quality assurance phone calls and in person discussion to ensure quality of services. (see page 14, IP-CANS, see page 61, SIR, see page 1, Plan of Care, see page 17, PSC-35, see page 18, FSP OMAs, see page 57, client satisfaction survey).
2.9 Positive Exit from HFW
Discussions about transition is ongoing from beginning of the HFW process to ensure that the Plan of Care is developed with transition in mind, which includes documentation of stabilization and progress in meeting the child and family’s needs. The HFW Facilitator utilizes IP-CANs and leads HFW team meetings documenting the families progress transitioning out of the program in the Plan of Care. The HFW staff follow procedures to collaborate with the family, natural and community supports, and paraprofessionals to ensure a smooth exit from HFW. Other procedures include, utilizing formal and informal methods to evaluate families’ satisfaction with the service, such as client satisfaction surveys and quality assurance phone calls and in person discussion to ensure quality of services (see page 14, IP-CANS, see page 1, Plan of Care, see page 57, client satisfaction survey).
Engagement
3.1 Orientation
(a) Within 24 hours of receiving the referral, the HFW Facilitator schedules a session to speak with the family about the HFW process, which includes discussion of the HFW standards, principles, and phases, explanation of the HFW team members (staff, family, natural supports, paraprofessionals, and Tribes of an Indian child) duties, and legal and ethical considerations (see page 63, current WRAP brochure). Current WRAP brochure will be to reflect HFW.
(a) The HFW Facilitator guides child and family with understanding the HFW principles and phases in accordance with the California High Fidelity Wraparound Standards (see page 63, current WRAP brochure). Current WRAP brochure will be updated to reflect HFW.
(b) The HFW Facilitator helps the family understand legal and ethical considerations (i.e., confidentiality and limits of confidentiality, release of information).
(c) The HFW Facilitator explains the purpose and duties of the HFW staff (Facilitator, Family Specialist, Parent Partner, Youth Partner, Fidelity Coach, Supervisors/Manager), natural supports, and Tribes in case of Indian Child.
3.2 Safety and Crisis stabilization
(a) At the initial meeting with the child and family, the HFW Facilitator assess crisis and safety concerns with the family to address throughout services. A safety plan is completed and given to the family and documented in the child’s EHR. If at the time of the session immediate action is necessary, the HFW Facilitator creates a plan for crisis stabilization, which ensures 24/7 crisis response (see page 58, WRAP Safety Plan).
(b) The HFW Facilitator utilizes the crisis plan developed with the family alongside the safety plan that includes risk behaviors, coping skills, de-escalation steps for caregiver, phone numbers to contact the team to receive 24/7 crisis response (see page 58, WRAP Safety Plan).
(c) The HFW Facilitator emphasizes the contact information on the safety plan, which include phone numbers of the 24/7 Crisis HFW Staff in addition to the traditional crisis support lines (Hotlines/Crisis Centers/988/911) to ensure 24/7 crisis response.
3.3 Strengths, Needs, Culture and Vision Discovery
(a) During the initial meeting with the child and family, the HFW Facilitator discusses the families’ goals and aspirations to achieve during the HFW process, which is documented in the Family Vision section of the Plan of Care and recorded in the child’s chart in the EHR (see page 1, Plan of Care).
(b) The HFW Facilitator documents the child and youth’s demographics/characteristics (culture, strengths, needs) in the Plan of Care during the first meeting and in follow up meetings that occur at least every 90 days with any updates to these areas. The HFW Facilitator will then distribute the Plan of Care to the team members (new or previous) with all the updates (see page 1, Plan of Care).
3.4 Engage All Team Members
(a) The HFW Facilitator works with the child and family to identify their natural supports (friends, neighbors, local clubs) and have their information available to them for smooth access throughout the HFW process. The HFW Facilitator then documents the natural supports inventory in the Plan of Care and in the EHR (see page 9, Staff Engagement Worksheet, see page 7, Ecomap).
(b) At the beginning of the HFW meeting, the HFW Facilitator introduces all team members including the Children’s System of Care partners who are part of the team to ensure engagement, participation, and collaboration (see page 1, Plan of Care).
(c) The child and family collaborate with the HFW staff and paraprofessionals to select natural supports previously identified from the inventory to be part of the HFW team and discuss their roles and impact on the team (see page 1, Plan of Care).
(d) All interventions to enhance team bonding and cohesiveness in the team meetings are documented in the Plan of Care/meeting minutes and EHR.
3.5 Arrange Meeting Logistics
(a) The HFW Facilitator coordinates with other HFW staff and paraprofessionals to schedule team meetings with awareness to change/adapt their schedule to accommodate the family’s availability and desired location.
(b) Through agency trainings and individual supervision and coaching, HFW staff receive support and training about teaming and scheduling meetings with families that that honor the family’s availability, culture, needs, trauma, and voice and choice.
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
(a) The Care Coordinator shall conduct a structured strengths discovery process over multiple meetings, typically two to three sessions. This process includes interviewing the youth, caregiver, and identified natural supports to understand family culture, values, traditions, past successes, informal support networks, and long-term aspirations. The strengths summary shall be documented in the EHR and used as the foundation for team planning. The process will be youth-guided and family-driven, ensuring the narrative reflects family voice rather than system-identified deficits (see page 1, Plan of Care).
(b) Any additional strengths identified during engagement are updated in the client’s EHR. The IP-CANS and PSC-35 is utilized for strengths identification (see page 14, IP-CANS, see page 17, PSC-35).
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
(a) The HFW Facilitator meets with the family prior to first HFW meeting to gather and discuss underlying needs to be focused on throughout the process and is documented in the child’s EHR (see page 1, Plan of Care).
(b) Goals and outcomes reflect needs identified in the IP-CANS and PSC-35 and previous discussions of the underlying needs (see page 14, IP-CANS, see page 17, PSC-35).
(c) The HFW staff, family, and paraprofessionals work together to identify goals that are achievable based on the identified needs through IP-CANS and PSC-35 and prioritized underlying needs. This is to ensure that the family will be aware of goals throughout the process and feel capable to reach them (see page 14, IP-CANS, see page 1, Plan of Care, see page 17, PSC-35).
(d) The HFW Facilitator documents all the plans and strategies discussed with the HFW team (child, family, tribes in case of an Indian child, paraprofessionals) in the Plan of Care and progress notes in the child’s EHR.
(e) The HFW Facilitator receives training on how to lead meetings that promote engagement, planning, and collaboration when developing action items in formal and informal ways (see page 10, WRAP training Plan).
(f) The HFW staff utilize the procedures to identify needs, make goals, and create action steps to maintain a teaming environment in which all team members can share their input to support the child and family.
4.3 Develop an Individualized Child or Youth and Family Plan
(a) The HFW Facilitator receives training and coaching (DMH trainings, agency trainings, supervision) on how navigate discussion about the planning process that promotes all team members’ ability to share their thoughts and create strategies that align with the HFW standards and principles.
(b) The HFW Facilitator elicits information from the Children’s System of Care partners that will contribute to the plan/goals/objectives on the Plan of Care.
(c) The HFW Facilitator documents the Plan of Care that meets criteria in the EHR and distributes the Plan of Care to all team members within 48 hours (see page 1, Plan of Care).
(d) Supervisors continue to review the Plan of Care with the HFW staff and provide feedback to ensure continuous quality improvement and that documentation of the plans discussed reflect HFW standards. Supervisors receive ongoing support and coaching through their individual supervision as well. Other procedures include client satisfaction surveys and quality assurance phone calls to ensure quality of services.
4.4 Develop a Crisis and Safety Plan
(a) From the time the HFW process begins, clients and their families are assessed for safety and crisis needs which is documented in the client’s EHR.
(b) A written safety plan is developed collaboratively by the team, the client, the family and natural supports, as soon as possible and within the first 30 days of treatment outlining the possible safety and crisis issues, the triggers to escalated behaviors and systematic plans to respond to the needs of the client.
(c) These plans are revised whenever new dangerous behavior becomes apparent or the plan needs revisions for other reasons. Whenever possible, the client and family are educated/coached to meet their own needs within the family and accessing their personal networks of support. In cases where client’s mental health needs exceed these interventions, the HFW Team members are available 24/7 to respond to the family’s needs. Clients and families are provided with each team member’s cell phone numbers at the first team meeting. Clients and families are also given written information on how to access the Psychiatric Mobile Response Team and 911 (see page 58, WRAP Safety Plan, see page 10, WRAP Training Plan).
Implementation
5.1 Implement The Plan of Care
(a) The HFW Facilitator guides the team to identify needs, make goals, and create action items to track individual assignments, check-in to support meeting timelines and deliverables, and adjust strategies and action items as needed.
(b) All staff meet individually with their supervisor weekly and attend weekly team meetings where they receive ongoing coaching and support. The trainings ensure that staff understand how to help families identify progress and celebrate accomplishments throughout services.
5.2 Review and Update The Plan of Care
(a) The HFW Facilitator reviews all components of the Plan of Care in the HFW team meetings to monitor progress and appropriateness.
(b) The HFW Facilitator initiates the HFW team meeting and updates the plan as any additional strengths identified, accomplishment occur, and action items are completed and is documented in the child’s EHR.
(c) As HFW Facilitator updates the Plan of Care and informs the HFW team of completed tasks and strategies to accomplish new tasks.
(d) The HFW Facilitator uses the Plans of Care in “fillable” formats that allow for immediate amendments based the team’s changing needs (see page 1, Plan of Care).
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
(a) The HFW Facilitator guides the HFW staff, family, natural supports, and paraprofessional to develop and review team agreements regularly at team meetings (see page 13, Plan of Care Agenda).
(b) The HFW Facilitator receives ongoing training and coaching on how to lead meetings that promote engagement, planning, and collaboration through individual supervision and formal trainings (see page 10, WRAP Training Plan).
(c) Supervisors continue to review the Plan of Care with the HFW staff and provide feedback to ensure the use of natural supports are being utilized throughout the HFW process to assist the child and family meet their goals and transition.
(d) The HFW Facilitators introduces and explains the HFW process to new team members and informs them of the current Plan of Care. Various strategies and interventions are utilized to engage team members in team bonding.
Transition
6.1 Develop a Transition Plan
(a) The HFW Facilitator leads team discussions about the family’s readiness for transition. Transition is planned once needs are sufficiently met using the IP-CANS, PSC-35, and resources/linkage are utilized to complete the transition and the family is capable to move forward without the team (see page 14, IP-CANS, see page 17, PSC-35, see page 1, Plan of Care).
(b) Once the needs are met, then HFW staff collaborate with all team members in the HFW meeting to ensure, review, and confirm plans to support families with transition. This is documented in the child’s EHR.
(c) The HFW staff collaborate to develop a transition plan to maintain a teaming environment in which all team members can share their input to support the child and family. The HFW staff receives training and ongoing coaching on developing and implementing transition plans.
(d) The HFW staff ensure linkage to resources and services in their community and collaboration with their natural supports is in place to ensure continual positive outcomes after transition.
6.2 Develop a Post-Transition Safety Plan
(a) The HFW Facilitator updates the crisis and safety plan that was developed/utilized throughout the HFW process to include steps for the family to follow if a crisis occurred after transition. The procedures are developed with the family’s input and includes ways to seek help from their natural supports, contact the hotlines/crisis centers/988/911, and utilize skills learned during the HFW process. The plan is documented in the child’s EHR (see page 58, WRAP Safety Plan).
(b) The HFW Facilitator engages the HFW team to identify concerns and list strategies in the crisis/safety plan to maintain a teaming environment in which all team members can share their input to support the child and family. The HFW Facilitator receives training on how to lead meetings that promote engagement, planning, and collaboration when developing crisis plans in formal and informal ways (see page 10, WRAP Training Plan).
(c) Supervisors often review the crisis and safety plans developed to ensure that what’s documented includes all necessary components (strategies, contact information of resources, cultural sensitivity) for proper transition that is specifically tailored towards the family. Supervisors receive ongoing support and training as well to ensure continuous quality improvement regarding post-transition crisis plan.
6.3 Create a Commencement and Celebrate Success
(a) The HFW staff ensure to highlight progress, aspirations, goals, values, culture, and efforts of the family that led to successful transition. The celebrations are planned in collaboration with the family to ensure they are grounded in the family’s culture, preferences, and values.
(b) Team members utilize flex funds, engage community resources and partnerships, and schedule accordingly with family and team members to celebrate the success.
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
(a) The HFW team encourages the family’s voice and choice regarding ways to get involved with HFW implementation in the county.
(b) The HFW Team will encourage families to provide feedback to enhance the HFW process and maintain the HFW Standards in the service.
7.2 Community Leadership Team
(a) Upon county policy being released, the Clinical Supervisor will participate in the Community Leadership Team meeting hosted by the county and relays information received to the HFW team.
7.3 Eligibility and Equal Access
(a) The agency verifies that referrals requesting HFW meet the criteria for the program, which includes consideration of the families’ needs at the time of the referral.
(b) The Clinical Supervisor ensures that HFW staff are assigned cases with the ability to provide necessary support to families throughout the process and be available to provide 24/7 crisis intervention.
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
Upon county rates and policy being released, the contracts will include:
(a) How HFW services and supports engage and collaborate with the family to meet needs.
(b) Documentation of the HFW staff’s job descriptions and approaches to enhance overall employment retention, training, and support (see page 91, California WRAP Role Overview/Job Descriptions). Agency is currently updating Job Descriptions to align with HFW roles and functions.
(c) Procedures to collect, review, and track data on families’ experiences and progress receiving HFW (client satisfaction surveys, quality assurance phone calls, and in person discussion).
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) The agency provides HFW services incorporating utilization of flex funds to meet families’ needs
(b) 1) HFW staff are provided with credit cards to readily address family needs at any given time.
(b) 2) The HFW staff consult with the Supervisor about spending flex funds that is appropriate, will meet families’ needs, promote stability and sustainability, highlight the families’ strengths and natural/community supports. Once an expense is approved, staff make necessary purchases.
(b) 3) The HFW staff will attempt to seek resources in the community to help families if flex funds requests are denied. If there are no additional resources in the community and the flex fund requests are denied, the HFW staff communicate the denial with the family and collaborate on how to meet the families’ needs that led to the request initially.
8.5 Collaborative Oversight of Flex Funds
(a) Once an expense is approved, HFW staff complete flex fund request forms, provide receipts, and complete expense reports to accurately document the utilization of flex funds. The flex funds forms report the costs and reasons that the request was made (see page 60, Flex Fund Request Form). Forms and receipts are submitted to the funders monthly.
(b) The agency ensures that flex funds are available throughout the fiscal year to meet the needs of the families.
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
(a) The HFW Program incorporates other funding and community resources to ensure families can receive support.
(b) The HFW Program seeks other funding sources to help families continue receiving the needed support when all their efforts are exhausted.
(c) The HFW Program is provided to families with integrity and does not prohibit utilization of flex funds due to any single funding source.
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
(a) The HFW Program represents and tracks the trends of populations served and hires staff with qualifications and experience that will meet the populations’ needs.
(b) When faced with recruitment challenges, the current HFW staff engage, plan, and collaborate with families and their natural supports to meet their needs for cultural representation.
(c) The agency contracts translation services when staff members or natural supports are not able to provide services in the families’ language.
9.2 Tribally Responsive Workforce
(a) All HFW staff are trained on working with Indian children which respects the tribes’ traditions and values (see page 10, WRAP Training Plan).
(b) All HFW staff ensure that aspects and traditions of the tribe are included in the HFW process.
9.3 Flexible and Creative Work Environment
Our program supports a flexible and creative workforce that is responsive to the individualized needs of youth and families.
(a) Staff are encouraged to think creatively when developing strategies and supports, ensuring services are tailored to the family’s strengths, culture, and circumstances to ensure program quality improvement.
(b) Team members collaborate with families, natural supports, and community partners to identify practical and innovative solutions that help achieve the goals identified by the HFW Team. This flexibility allows staff to adapt approaches, schedules, and supports as needed to effectively engage families and promote successful outcomes.
(c) Staff are encouraged to share ideas, feedback, and challenges openly during team meetings, supervision, and case consultations.
(d) Our program promotes a clear sense of mission and compliance by ensuring that all staff understand and adhere to all HFW standards, principles, and program requirements.
9.4 Hiring, Performance Evaluation, and Job Descriptions
(a) The HFW roles, job descriptions, and functions will align with the HFW standards.
(b) Each HFW job description, roles, and functions are specifically tailored to HFW and described in the job postings (see page 91, California WRAP Role Overview/Job Descriptions). Agency is currently updating Job Descriptions to align with HFW roles and functions.
(c) The job descriptions are tailored to recruit individuals who will be successful in the position (see page 91, California WRAP Role Overview/Job Descriptions).
(d) During the interviewing process, individuals are encouraged to demonstrate qualities specific to the role.
(e) Upon hiring, each individual is aware of the role and function within the HFW process. Staff are evaluated three times a year in addition to weekly supervision where ongoing feedback and coaching is given (see page 107, Tri-annual Performance Evaluation).
9.5 Workforce Stability
The agency has implemented a comprehensive set of human resources strategies and procedures designed to support workforce stability, employee satisfaction, and equitable career growth. These practices include:
(a) The agency conducts regular market analyses to ensure wages remain competitive and aligned with the cost of living in the service area considering that the agency is a nonprofit/ social services This includes annual compensation reviews through participation in the salary survey conducted by the local Association of Community Human Service Agencies (ACHSA) and the salary survey conducted by the CA Alliance, adjustments to pay scales as needed to remain competitive and retain staff, consideration of inflation trends and local economic conditions during budget planning and transparent communication with staff regarding compensation philosophy and any adjustments.
(b) The agency actively monitors and manages staff workloads through established caseload or workload guidelines by role and based on contract and best practices guidelines, regular supervision meetings to assess workload capacity and redistribute tasks as needed, use of staffing ratios and scheduling tools to ensure equitable distribution of work, processes for staff to raise concerns about workload, including anonymous feedback options, i.e. annual staff survey and complaint procedures as well as open door policy and regular townhalls, and periodic review of workload data by leadership to make informed staffing decisions.
(c) The agency is committed to providing clear and inclusive career pathways that are accessible to all employees, including those with lived experience. Procedures include
clearly defined job descriptions and promotion criteria that are documented and readily available, internal posting of all advancement opportunities to encourage career growth from within, leadership development and training programs designed to prepare staff for advancement, recognition of lived experience as a valuable qualification in hiring and promotion decisions, and mentorship and coaching opportunities to support professional development.
(d) Recognizing that not all employees wish to change roles to advance, the agency offers alternative pathways for growth and recognition, including structured pay increases based on annual budget planning, potential stipends based on expertise, i.e. licensure, being bi-lingual etc., opportunities to take on leadership responsibilities (e.g., mentoring, project leadership, committee participation) without formal title changes, professional development plans tailored to individual career goals, and recognition programs that reward expertise, initiative, and contributions to the agency (stipends based on exceptional performance reviews) (see page 107, Tri-annual Performance Evaluation).
9.6 High Fidelity Training Plan
(a) All staff are trained or in the process of being trained by Wraparound 101: Foundations for Fidelity training available through the UC Davis RCFFP.
(b) Ongoing professional development is provided through coaching, supervision, case consultation, and additional training opportunities to strengthen staff skills and maintain fidelity to the HFW model.
(c) All staff will receive annual booster trainings specific to their role.
(d) Supervisors/Managers are trained or in the process of being trained by Wraparound 101: Foundations for Fidelity training available through the UC Davis RCFFP. Ongoing professional development is provided through coaching, supervision, case consultation, and additional training opportunities to strengthen Supervisors/Managers skills and maintain fidelity to the HFW model.
(e) All staff receive ICWA and Tribal sovereignty training (see page 10, WRAP Training Plan, see page 65, Tribal Engagement Guide).
9.7 Community-based Training Program
(a) Upon county policy being released and Medi-Cal HFW Center of Excellence updates, the agency will ensure that community members and families are offered the appropriate trainings.
(b) Upon county policy being released and Medi-Cal HFW Center of Excellence updates, the agency will encourage community members and families to attend appropriate trainings to strengthen their role in the HFW process.
9.8 Coaching and Supervision
(a) All HFW staff are trained in the various HFW principles, phrases, and activities related to HFW, including use of flex funds. New staff are also required to shadow current HFW staff as part of their initial training (see page 10, WRAP Training Plan).
(b) All HFW staff have access to supervisors 24/7 in order to address and support any needs that arise.
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
N/A
10.2 Evaluation Metrics & Outcomes
(a) The HFW staff utilize formal and informal methods of data collection, such as client satisfaction surveys, quality assurance phone calls, and in person discussions to ensure quality of services.
(b) The QI department distributes the client satisfaction surveys and provides feedback to the HFW staff as well as guides continuous quality improvement.
(c) Upon county policy being released, the Clinical Supervisor will participate in the Community Leadership Team meeting hosted by the county and share data identifying barriers.
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
a) The HFW Facilitator initiates contact with the youth and family within 10 calendar days of referral, as evidenced by dated outreach documentation in the electronic health record (EHR). See Policy 1.1, Page 1, section A.
Supporting Documents: Therapist Timeline
b)The HFW Team(HFW Facilitator, Parent/Caregiver Peer Partner, or Family Specialist) develops and documents a completed Plan of Care within 30 days of service initiation that includes (1) family vision, (2) strengths and needs, (3) measurable goals, and (4) assigned action steps, as verified through Plan of Care review. See Policy 1.1, Page 1 & 2, section B.
Supporting Documents: Plan of Care
c) The HFW Team conducts team meetings at least every 30–45 days to review progress, action steps, and emerging needs. See Policy 1.1, Page 2, section C.
Supporting Documents: Plan of Care
d) The HFW Team updates the Plan of Care at least every 30-45 days, or sooner based on family needs, and distributes the updated HFW Plan of Care to team members within two (2) business days. See Policy 1.1, Page 2, section D.
Supporting Documents: Plan of Care
e) Program leadership aggregates and reviews timeliness and engagement data through CQI processes at regular intervals, using findings to inform staff coaching, training, and program improvement. See Policy 1.1, Page 2 & 3, section E
f) HFW staff receive initial training and annual training on timely engagement practices, including the use of multiple outreach strategies (e.g., phone, text, email, in-person visits) and alternative engagement approaches when contact is difficult. See Policy 1.1, Page 3, section E
1.2 Led by Youth and Families
a) The HFW Facilitator elicits and documents youth and family strengths -including tribes- cultural values, priorities, and preferences during the Engagement phase and prior to the initial CFT meeting (within 10–14 days of enrollment) using culturally responsive and trauma-informed practices. For Indian children, the HFW Facilitator engages Tribal representatives early and ensures they participate as equal partners in all planning and decision-making. Information is documented in the EHR and reviewed in supervision.
See policy 1.2, page 1 & 2, section A & C.
Supporting Documents: Plan of Care
b) The HFW Facilitator and Family Team develop a Family Vision and Team Mission during the Engagement and Planning phases, which are documented and reviewed during Family Team Meetings (at least every 30–45 days) to ensure alignment with family priorities. See policy 1.2, page 2, section B.
Supporting Documents: Plan of Care
c) The Supervisor and Fidelity Coach monitor practice through supervision, observation of team meetings, and documentation review, with compliance tracked through CQI processes. Program leadership ensures staff receive ongoing training in family voice and choice, cultural humility, trauma-informed care, and facilitation of family-led practice, tracked through workforce development processes. See policy 1.2, page 2 section D & F.
d)Staff and QA personnel collect and review family feedback using tools such as WFI-EZ and TOM, and results inform CQI, training, and coaching .The Supervisor and QA staff review documentation and conduct quarterly case reviews (minimum 10%) to ensure family voice and cultural responsiveness are reflected and aligned with decisions.
See policy 1.2, page 2 & 3 section D, E & F.
Supporting Documents: WFI-EZ, TOM 2.0. Crittenton has not started using the WFI-EZ, or TOM 2.0 but will do so before July 1st.
1.3 Strength-Based
a) The HFW Facilitator develops a Strengths Needs Cultural Diversity (SNCD) inventory for the youth, family members, team members, natural supports, and community/Tribal partners at the initiation of services and updates it during each CFT meeting or when new strengths are identified. The SNCD includes functional strengths identified through engagement and the IP-CANS assessment and is visibly displayed and referenced during team meetings to guide planning discussions.
See policy 1.3, pages 1-2, section A.
Supporting Documents: Strengths Need Cultural Diversity tool.
b) The HFW Team utilizes the IP-CANS assessment as a primary tool to identify and validate strengths, which are then integrated into the HFW Plan of Care, including the Family Vision, Team Mission, Needs Statements, and Goals and Strategies. The HFW Plan of Care demonstrates clear linkage between identified strengths and selected strategies and action steps. This tool will be used at intake and as needed
See policy 1.3, page 2, section B.
Supporting Documents: Plan of Care.
c) The Clinical Supervisor and Fidelity Coach monitor fidelity to strengths-based practice through routine observation of HFW team meetings, review of HFW Plans of Care, Strengths Inventories, case documentation, and the use of fidelity tools such as the DART when applicable. Feedback is provided during weekly supervision and documented in supervision notes, and completion is tracked in CQI processes. See policy 1.3, page 2 Section C&D, page 3 section E.
Supporting Documents: Plan of Care tool, Strengths Need Cultural Diversity tool, Document Assessment Review (DART), WFI-EZ, TOM 2.0. Crittenton has not started using the DART, WFI-EZ, or TOM 2.0 but will do so before July 1st.
d) The program collects and reviews family feedback regarding their experience of strengths-based practice through fidelity tools such as the WFI-EZ and TOM 2.0. Feedback is reviewed in supervision and aggregated at the program level to inform coaching, training priorities, and continuous quality improvement activities. See policy 1.3, page 3, section E.
Supporting Documents: WFI-EZ and TOM 2.0. Crittenton has not started using the WFI-EZ, or TOM 2.0 but will do so before July 1st.
1.4 Needs Driven
a) The HFW Facilitator engages the youth, family, caregivers, natural supports, and Tribal partners (when applicable) to identify and describe underlying needs that reflect the conditions necessary for the youth and family to be successful. This is identified before developing goals, strategies, or services. This process begins during Engagement and continues across all phases of Wraparound. Prioritized needs are documented in the HFW Plan of Care and serve as the foundation for all team decision-making. Needs are reviewed and updated during each HFW team meeting, occurring at least every 30–45 days or more frequently based on team needs. See policy 1.4, page 1 & 2, section A.
Supporting Documents: Plan of Care
b) The Clinical Supervisor and Fidelity Coach monitor fidelity to needs-driven practice through observation of HFW team meetings and structured review of HFW Plans of Care, IP-CANS assessments, and case documentation to ensure that: (1) needs are written in functional terms, (2) needs are prioritized by the team, and (3) goals and strategies are clearly linked to those needs. Supervisors provide specific, actionable coaching during supervision, document feedback, and track compliance through CQI processes and chart audits. See policy 1.4, page 2, section D.
Supporting Documents: IP-CANS and Plan of Care.
c) The HFW Team uses the IP-CANS as a standardized tool to identify, validate, and prioritize actionable needs. IP-CANS is completed at intake and as needed. IP-CANS results are reviewed with the team and used to inform shared understanding of needs. Needs identified through the IP-CANS are clearly documented and linked to prioritized needs in the HFW Plan of Care, with direct alignment to goals and strategies. Changes in identified needs or IP-CANS ratings result in updates to the Plan of Care during the next CFT meeting. See policy 1.4, page 2, section B.
Supporting Documents: IP-CANS and Plan of Care.
d) The HFW Team determines readiness for transition based on team consensus that prioritized underlying needs have been sufficiently met and that the youth and family have the skills, supports, and conditions necessary to sustain progress. Transition planning documents the needs addressed, ongoing supports, and strategies for maintaining stability. Transition is not based on length of service but on achievement of identified needs and outcomes. See policy 1.4 page 3, section F.
1.5 Individualized
a) The HFW Facilitator and CFT develop highly individualized Plans of Care that reflect youth and family strengths, needs, cultural values, and preferences. This is initiated during the Engagement and Planning phases and updated every 30–45 days. Plans are documented in the EHR and reviewed through supervision. See policy 1.5, pages 1-2, section A.
Supporting Documents: Plan of Care.
b) The HFW Program provides initial and ongoing training and coaching to Facilitators and CFT members on individualized planning, creative problem-solving, and culturally responsive practices, with participation tracked and reinforced through supervision and fidelity monitoring. See policy 1.5, page 2, section D.
c) The HFW Facilitator receives ongoing training to lead CFT meetings. Training includes documentation of individualized needs, strengths, cultural values, preferences, and customized strategies in the HFW Plan of Care using flexible, narrative documentation to avoid reliance on generic or pre-packaged services. See policy 1.5, page 2, section B & C.
Supporting Documents: Plan of Care.
d) The HFW Team designs and implements individualized strategies that are flexible, creative, strengths-based, and culturally responsive, and that build on family, community, and informal supports. Strategies are developed to fit the specific context of the youth and family unless clearly linked to prioritized needs. See policy 1.5, page 2, section B.
e) The program collects and reviews family feedback regarding whether services and strategies are individualized, culturally responsive, and reflective of their preferences and priorities. Feedback is gathered through satisfaction surveys and fidelity tools (WFI-EZ, TOM 2.0, DART, PSC-35 and IP-CANS), reviewed in supervision, and aggregated for Continuous Quality Improvement (CQI) to inform coaching, training, and program improvement. See policy 1.5, page 3, section E.
Supporting Documents: PSC-35, IP-CANS, Document Assessment Review (DART), WFI-EZ, TOM 2.0. Crittenton has not started using the DART, WFI-EZ, or TOM 2.0 but will do so before July 1st.
1.6 Use of Natural and Community Based Supports
a) The HFW Facilitator, with the youth and family, identifies and engages natural supports (e.g., extended family, friends, community members, and Tribal partners when applicable) as active Wraparound team members beginning in the Engagement phase and throughout all phases of Wraparound. The HFW Facilitator develops a Natural & Community Supports Inventory within the first 30 days of enrollment and updates it during each team meeting or as new supports are identified. The Inventory is reviewed and referenced during team meetings to guide planning and strengthen natural support involvement. See policy 1.6, page 2, section A.
Supporting Documents: Natural and Community Supports Inventory.
b) The Clinical Supervisor and Fidelity Coach monitor integration of natural supports through observation of HFW team meetings and structured review of Plans of Care and documentation to ensure that natural supports are actively engaged, strategies are community-based, and roles are clearly defined. HFW then receives ongoing training and coaching on identification, engagement and integration of natural supports to reduce reliance on formal supports. See policy 1.6, page 2, section B.
Supporting Documents: Plan of Care.
c) HFW staff document natural support involvement, including identified supports, assigned roles in strategies, and use of community-based resources, in the HFW Plan of Care and team meeting notes. Documentation is reviewed through routine chart audits to ensure active and ongoing integration of natural supports, with results tracked in the CQI system. See policy 1.6, page 3, section E.
Supporting Documents: Plan of Care.
d)The program collects and reviews family feedback regarding the extent to which natural supports are meaningfully engaged and strategies reflect the family’s community and cultural context. Feedback is gathered through satisfaction surveys and fidelity tools (WFI-EZ, TOM 2.0, DART, and IP-CANS), reviewed in supervision, and aggregated for Continuous Quality Improvement (CQI). See policy 1.6, page 2-3, section E.
Supporting Documents: IP-CANS, WFI-EZ, TOM 2.0 and DART Crittenton has not started using the DART, WFI-EZ, or TOM 2.0 but will do so before July 1st
1.7 Culturally Respectful and Relevant
a) The HFW Facilitator completes Strengths, Needs, and Culture Discovery (SNCD) with the youth and family during the Engagement phase and prior to development of the initial Plan of Care. Cultural identity, values, traditions, language, and community connections are elicited, documented, and used to guide all planning and team processes. When serving an Indian child, the HFW Facilitator invites and engages Tribal representatives as equal partners in team planning and decision-making, and ensures that Tribal protocols, values, and guidance are reflected in the Plan of Care and team process. See policy 1.7, page 2, section A and section D
Supporting Documents: Strengths, Needs, and Culture Discovery (SNCD).
b) The HFW Team integrates cultural information into the Plan of Care, including the Family Vision, Team Mission, needs, goals, strategies, team composition, and meeting structure. Strategies are culturally relevant, reflect the family’s values and daily life, and avoid approaches that conflict with cultural beliefs or practices. Team receives on going training to achieve this. See policy 1.7, page 3, section E.
Supporting Documents: Plan of Care
c) The program collects and reviews family feedback regarding whether services are culturally respectful and relevant through fidelity tools (WFI-EZ, TOM 2.0) and satisfaction surveys. Feedback is reviewed in supervision and aggregated for Continuous Quality Improvement (CQI) to inform training, coaching, and program improvement. See policy 1.7, page 3, section F.
Supporting Documents: WFI-EZ, TOM 2.0. Crittenton has not started using the DART, WFI-EZ, or TOM 2.0 but will do so before July 1st.
1.8 High-Quality Team Planning and Problem Solving
a) The HFW Facilitator leads structured HFW team meetings that promote full participation of the youth, family, natural supports, and team members in creating a team agreement. Meetings follow a consistent process that includes review of strengths, prioritized needs, progress, and action planning. See policy 1.8, page 2, section A.
Supporting Documents: Plan of Care
b) The program collects and reviews family feedback ongoing regarding their participation in team meetings and satisfaction with the planning and problem-solving process through observation, fidelity tools (WFI-EZ, TOM 2.0). Feedback is used in supervision and aggregated for Continuous Quality Improvement (CQI). See policy 1.8, page 2, section D.
Supporting Documents: Document Assessment Review (DART), WFI-EZ, TOM 2.0. Crittenton has not started using the DART, WFI-EZ, or TOM 2.0 but will do so before July 1st.
c) The Clinical Supervisor and Fidelity Coach monitor quality of team planning and problem solving through observation of HFW team meetings and review of documentation to ensure structured facilitation, active participation, and effective problem-solving processes. Feedback is provided in supervision and tracked through CQI processes.
See policy 1.8, page 2 section D
d) The HFW Team reviews progress toward goals and effectiveness of strategies at each team meeting and modifies the Plan of Care based on data, team feedback, and changing needs. Updated strategies and action steps are documented and redistributed to team members. See policy 1.8, page 2, section B.
Supporting Documents: Plan of Care
1.9 Outcomes Based Process
a) The Facilitator and CFT develop a Plan of Care with measurable outcomes for each prioritized need, including clear success criteria, assigned responsibilities, and timeframes. Plans are documented in the EHR and monitored a minimum of 30-45 days. See policy 1.9, page 2, section A.
Supporting Documents: Plan of Care
b) The Facilitator and CFT maintain and review an Action Log at each CFT meeting (every 30–45 days) to monitor strategy implementation and task completion, including updates to barriers, timelines, and ownership. Progress is documented and reviewed, at minimum, during CFT meeting, or as needed. See policy 1.9, page 2, section B.
Supporting Documents: Action Log
c) The CFT reviews progress toward outcomes, strategy effectiveness, and task completion at each meeting, and updates the Plan of Care at least every 30-45 days during the CFT meeting. Updates are documented in the EHR. CFT uses forms that allow strategies and action items to be adjusted as needed and changes are communicated to CFT. See policy 1.9, page 2, section C and page 3, section F.
Supporting Documents: Plan of Care
d) The Clinician completes the IP-CANS at intake and at significant change, and shares results with the CFT to inform planning. Findings are documented in the EHR, monitored, and used in planning. See policy 1.9, page 3, section D.
Supporting Documents: IP-CANS
e) The Supervisors, Fidelity Coaches, and QA Team review Plans of Care, Action Logs, IP-CANS data, and outcome metrics (e.g., action completion, update timeliness) at least quarterly to ensure tracking and team decision-making, nut does not replace or substitute tracking of needs, completion of goals and action outcomes. See policy 1.9, page 3, section E.
Supporting Documents: Plan of Care, Action Log, IP-CANS
1.10 Persistence
a) The HFW team maintains persistent engagement with youth and families, continuing services through setbacks and not closing cases due to missed appointments or limited progress (with family preference given). Reengagement efforts are initiated within 7 days and documented in the EHR. See policy 1.10, page 1, section A.
b) The HFW team accesses additional supports (coaching, supervision, flex funds, leadership consultation) when barriers arise. Requests and outcomes are documented and reviewed in supervision to ensure ongoing progress. See policy 1.10 page 2, section B
c) Supervisors and fidelity coaches provide Facilitator with on-going training and coaching of post crisis safety plans and strategies following crises, including follow-up within 24–72 hours, and uses problem-solving and conflict resolution strategies to maintain progress. Activities are documented and reviewed through team meetings and CFT meetings (30-45 days or as needed)-. See policy 1.10, page 1 purpose section, and page 2, section C.
Supporting Documents: Plan of Care and Safety Plan
1.11 Transitions as a part of the Fourth Phase of HFW
a) The Facilitator and CFT plan transitions 30–60 days in advance based on documented readiness, including achievement of prioritized needs, outcomes, and established natural and community supports. The HFW Team and Supervisors ensure transitions do not occur due to adverse events or administrative reasons and pause transition to stabilize and revise the plan when needed Readiness is documented in the Plan of Care and EHR and reviewed in supervision. See policy 1.11, page 1 and 2, section A. Page 2, section D .
Supporting Documents: Plan of Care
b) The Facilitator coordinates a culturally responsive transition celebration, guided by family voice and supported through flex funds and team participation. Activities are documented in the EHR. See policy 1.11, page 2, section C. Page 3, section E.
Supporting Documents: Flex Funds Request Form
Expected Outcomes
2.1 Youth and Family Satisfaction
a) The HFW Program collects youth, family and when applicable, Tribal representatives’ satisfaction data throughout the Wraparound process, including during Child and Family Team (CFT) meetings, informal check-ins, and through standardized fidelity tools such as the Wraparound Fidelity Index (WFI-EZ). Feedback includes satisfaction with services, experience of family voice and choice, perceived progress, and cultural responsiveness. See policy 2.1, page 1, section A and Page 2, section B.
Supporting Documents: WFI-EZ. Crittenton has not started using the WFI-EZ, but will do so before July 1st.
b) Youth, families, and when applicable, Tribal representatives are provided ongoing opportunities to share feedback regarding their experience with services and outcomes. Tribal partners are included as active team members and their feedback is documented and incorporated into service planning and program improvement efforts. See policy 2.1, page 2, section B
c) The Clinical Supervisor and Fidelity Coach ensure satisfaction feedback is integrated into supervision and coaching to improve practice and fidelity to the Wraparound model. See policy 2.1, page 2, section F.
d)The program maintains documentation of satisfaction outcomes, Tribal feedback (when applicable), CQI reports, and evidence of program improvements made in response to feedback to demonstrate compliance with HFW standards. See policy 2.1, page 2, section G.
2.2 Improved School Functioning
a) The HFW Facilitator and CFT assess and address educational and vocational needs during the Engagement and Planning phases, including strengths, challenges, and career interests, and develop measurable school and vocational goals. Goals are documented in the Plan of Care (updated every 30–45 days). See policy 2.2, page 1 & 2, section A, B and page 2, section C.
Supporting Documents: Plan of Care
b) The HFW Team monitors educational and vocational outcomes (e.g., attendance, behavior, academic progress, participation in employment or training) during each CFT meeting (every 30–45 days), with updates documented in the EHR and Plan of Care. This information is used to inform ongoing planning and adjustments to strategies. See policy 2.2, page 2, section C & D.
Supporting Documents: Plan of Care
2.3 Improved Functioning in the Community
a) The HFW Facilitator and Team assess youth functioning in the community at entry and throughout services using Strengths, Needs, Culture Discovery, youth and family input, and the IP-CANS. Assessment includes participation in community activities, peer relationships, cultural/community involvement, barriers to engagement, and level of justice involvement. The Plan of Care is updated as needed based on progress and team input. See policy 2.3, page 1, section A, C, D & E.
Supporting Documents: Strengths, Needs, Culture Discovery and IP-CANS
b) The HFW Team incorporates community functioning into the Plan of Care by developing individualized, measurable goals and strategies that promote participation in community activities, positive peer relationships, and connection to supportive adults and natural supports. See policy 2.3, page 1 & 2, section B.
Supporting Documents: Plan of Care
2.4 Improved Interpersonal Functioning
a) The HFW Facilitator and Team assess youth and family interpersonal functioning at entry and throughout services using Strengths, Needs, Culture Discovery, IP-CANS, and youth and family input. Assessment includes family relationships, peer connections, communication skills, emotional regulation, and caregiver stress/strain. See policy 2.4, page 1, section A.
Supporting Documents: Strengths, Needs, Culture Discovery and IP-CANS
b) The HFW Team incorporates interpersonal functioning into the Plan of Care by developing individualized, measurable goals and strategies to improve communication, relationship skills, develop and maintain family functioning, and peer interactions. Goals include clear action steps, responsible parties, and timelines and are reviewed every 30–45 days. See policy 2.4, page 1& 2, section B and page 2, section E.
Supporting Documents: Plan of Care
c) The HFW Team identifies and engages natural supports (e.g., family members, mentors, community members) to support relationship-building and improved interpersonal functioning and includes them as active participants in team meetings and strategies when appropriate. See policy 2.4, page 2, section D.
2.5 Increased Caregiver Confidence
a) The HFW Facilitator and Team assess caregiver strengths, confidence, and support needs at entry and throughout services using Strengths, Needs, Culture Discovery, IP-CANS, and caregiver input. Assessment includes caregiver confidence in managing youth needs, effectively addressing crisis, ability to navigate systems, connectedness to supports, and stressors impacting capacity. See policy 2.5, page 1, section A.
Supporting Documents: Strengths, Needs, Culture Discovery, IP-CANS
b) The HFW Team incorporates caregiver needs into the Plan of Care by developing individualized, measurable goals and strategies to increase caregiver confidence, skills, and access to supports. Caregivers actively participate in all planning and decision-making, and goals include clear action steps, responsible parties, and timelines. See policy 2.5, page 1& 2 section B and page 2, section E.
Supporting Documents: Plan of Care
c) The HFW Team reviews caregiver progress during each team meeting, including increased confidence, participation in decision-making, and connection to supports. The Plan of Care is updated based on caregiver feedback and changing needs. See policy 2.5, page 2, section F.
Supporting Documents: Plan of Care
2.6 Stable and Least Restrictive Living Environment
a) The HFW Facilitator and Team assess the youth’s living environment and placement stability at entry and throughout services using Strengths, Needs, Culture Discovery, IP-CANS, and youth and family input. Assessment includes current placement, risks for disruption, caregiver capacity, environmental stressors, and available supports. See policy 2.6, page 1, section A.
Supporting Documents: Strengths, Needs, Culture Discovery, IP-CANS
b) The HFW Team incorporates placement stability into the Plan of Care, collaborates with caregivers, natural supports, and service providers to implement strategies that maintain stability, strengthen caregiver capacity, and address underlying needs contributing to risk of disruption. Strategies prioritize community-based supports and reduce reliance on restrictive placements whenever safely possible. The Plan of Care is updated as needed to maintain safety and stability. See policy 2.6, page 1 & 2, section B, and page 2, sections C & E.
Supporting Documents: Plan of Care
c) When risk of placement disruption is identified, the HFW Team conducts rapid problem-solving, convenes the Child and Family Team, and implements stabilization strategies, including crisis and safety planning, coordination with providers, and increased supports to maintain placement continuity. See policy 2.6, page 2, section D.
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
a) The HFW Team assess behavioral health needs and crisis risk factors at intake and throughout services, including history of crises, triggers, and protective factors. The HFW Team integrate crisis prevention and stabilization strategies into the Plan of Care. Findings are documented in the EHR and reviewed in team meetings and supervision. See policy 2.7, page 1, section A and page 2, sections B & C.
Supporting Documents: Plan of Care
b) The HFW Team, youth, and caregiver develop and maintain a crisis prevention and safety plan that includes de-escalation strategies, crisis contacts, and steps to decrease emergency or inpatient care. Plans are updated regularly and as needed Plans are documented in the EHR and reviewed ongoing in CFT meetings. In an effort for client to experience stability. See policy 2.7, page 2, section C.
Supporting Documents: Safety Plan
c) The HFW Team coordinates behavioral health and community-based services and supports caregiver and youth skill-building to reduce crisis events. Service coordination and supports are documented and monitored through team meetings and supervision. See policy 2.7, page 2, sections D & F.
2.8 Reduction in Crisis Visits
a) The HFW Team assess crisis risk and behavioral health needs at intake and throughout services, including history of crisis utilization, triggers, and protective factors. Findings are documented in the EHR and assessments and reviewed in team meetings. See policy 2.8, page 1, section A
b) The HFW Team integrate crisis prevention strategies into the Plan of Care, including identifying early warning signs, triggers, and skill-building goals for youth and caregivers. Plans are updated every 30–45 days. See policy 2.8, page 2, sections B & F.
Supporting Documents: Plan of Care
c) The HFW Team, youth, and caregiver develop and maintain a crisis prevention plan that includes coping strategies, caregiver responses, connection to community-based services, natural supports and steps to stabilize situations prior to crisis service use. Plans are documented in the EHR and reviewed ongoing in CFT meetings. See policy 2.8, page 2, sections C, D, E & F.
Supporting Documents: Safety Plan
2.9 Positive Exit from HFW
a) The HFW Team assesses readiness for transition throughout services based on goal progress, stability, caregiver confidence, natural supports, and IP-CANS scores. Assessments are documented in the EHR and reviewed in team meetings and weekly supervision. Policy 2.9, page 1, section A, and page 2, sections D & E.
Supporting Documents: Plan of Care, IP-CANS
b) The HFW Team integrates transition planning into the Plan of Care. The transition plan identifies ongoing supports, resources to prepare families for discharge. Plans are updated every 30–45 days and monitored through supervision and chart audits. See policy 2.9, page 2, sections B, C and page 3 section G.
Supporting Documents: Plan of Care, Transition plan
Engagement
3.1 Orientation
A) The HFW process is thoroughly explained to every family, within 14 days of enrollment, including its core principles and phases, relevant legal and ethical considerations, and the roles and responsibilities of all team members—encompassing the family, natural supports, and Tribes when the youth is an Indian child. See policy 3.1, page 1 and 2, section A and page 2, sections E and F
Supporting Documents: Therapist Timeline
a) The HFW process is clearly and comprehensively explained to every family, with a strong emphasis on providing a clear and accessible overview of the HFW principles and phases, along with relevant legal and ethical considerations and the roles of each team member— including the family, natural supports, and Tribes when the youth is an Indian child. See policy 3.1, page 2, section A #3.
b) The HFW process is clearly and comprehensively explained to every family, with a strong emphasis on relevant legal and ethical considerations, along with an overview of the process and the roles of each team member—including the family, natural supports, and Tribes when the youth is an Indian child. See policy 3.1, page 2, section A #3 and section C
c) The HFW process is clearly and comprehensively explained to every family, emphasizing the roles and responsibilities of each team member—including the family, natural supports, and Tribes when the youth is an Indian child—along with an overview of the process. See policy 3.1, page 2, section B
3.2 Safety and Crisis stabilization
a) During engagement, initial crisis and safety concerns are addressed. When urgent concerns are identified, the team develops an immediate crisis response plan, ensures it is provided to the family, and documents it in the youth’s chart. See policy 3.2, page 1-2, section A.
Supporting Documents: Safety Plan
b) The crisis plan is used to guide and inform the process but does not replace the HFW Safety Plan developed during the Plan Development phase. See policy 3.2, page 1-2, section A and page 2, section B, D.
c) All HFW families are provided with comprehensive information and guidance to ensure timely access to 24/7 crisis response services when needed. See policy 3.2, page 2, section C
Supporting Documents: On-Call Team Flyer
3.3 Strengths, Needs, Culture and Vision Discovery
a) The CFT collaborates with each family during the Engagement phase to develop a Family Vision that reflects their unique strengths, needs, and goals, and documents it in the youth’s chart to guide individualized support. See policy 3.3, page 1, section A.
Supporting Documents: Plan of Care
b) A Strengths, Needs, and Culture Discovery document is developed for every youth and family, maintained in the youth’s chart, and updated at least every 90 days to capture evolving strengths, needs, and cultural preferences. It is shared with new team members as they join to promote continuity, shared understanding, and effective collaboration. See policy 3.3, page 1 section B and page 2, section C and D.
Supporting Documents: Strengths, Needs, and Culture Discovery
3.4 Engage All Team Members
a) The facilitator completes a Natural and Community Supports Inventory with each youth and family during the Engagement phase and updates it on an ongoing basis, referencing it during CFT meetings. The inventory is documented in the youth’s case file to support the identification and engagement of informal supports that strengthen and sustain the youth and family’s needs. See policy 3.4, page 1, section A.
Supporting Documents: Natural and Community Support Inventory
b) The HFW team identifies and actively engages Children’s System of Care partners, including formal supports, natural supports, and Tribes when applicable, who are committed to supporting the youth and family. The facilitator promotes their meaningful participation by clearly defining roles and responsibilities and fostering a collaborative, team-based environment. See policy 3.4, page 1, section B.
c) The HFW team collaborates with the youth and family to identify and engage potential team members, including formal supports, natural supports, and Tribes when applicable, who can support their goals. The facilitator ensures that CFT roles and responsibilities are discussed for each CFT member. See policy 3.4, page 2, section C.
d) The HFW Facilitator and CFT intentionally engage in and implement team-building activities, which are documented in the youth’s file through meeting minutes or case notes. This documentation reflects efforts to promote active participation, clarify roles, and foster a positive, collaborative team environment. See policy 3.4, page 2, section D
Supporting Documents: Plan of Care
3.5 Arrange Meeting Logistics
a) HFW staff maintain flexibility in scheduling meetings to ensure they occur at times and locations that are convenient and accessible for all team members, with priority given to family voice and choice. The team also considers family schedules, culture, and potential barriers, and arranges necessary logistics—such as transportation, interpretation, or telehealth—to support full participation. See policy 3.5, page 1 section A and page 2, section B.
b) HFW Facilitators and team members are trained to actively partner with families to coordinate meeting times and locations that reflect family voice, choice, and availability. Scheduling practices incorporate cultural considerations and potential barriers, while ensuring necessary support—such as transportation, interpretation, and telehealth—are arranged to promote full participation. See policy 3.5, page 1, section A and page 2, section C .
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
a) Prior to developing the HFW Plan of Care, the facilitator leads the team in establishing team agreements, identifying and documenting strengths of the youth, family, team members, and community, and creating a team mission statement aligned with the family’s vision. These components are documented in the youth’s file to guide the planning process. See policy 4.1, page 1 & 2, section A
b) Strengths identified during the engagement phase for the youth, family, Community, and CFT members are continually reviewed and updated to include newly discovered strengths of the youth, family, team members, and community, and are documented in the youth’s file. Strengths provide the foundation for building strategies that actually fit the youth and family. Instead of generic services, the team uses what the family already does well to meet needs. See policy 4.1, page 2 , section B.
Supporting Documents: Strengths Need Cultural Diversity (SNCD)
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
a) Prior to developing the HFW Plan of Care (within first 30 days of service), the facilitator guides the CFT in reviewing and prioritizing underlying needs identified during engagement, including any newly identified needs, and documents them in the youth’s file to inform goal development and strategy planning. By prioritizing underlying needs the CFT addresses the root causes of challenges—not just the surface behaviors. See policy 4.2, page 1, section A
b) Measurable goals and outcomes are developed based on the prioritized underlying needs, ensuring planning is needs-driven rather than focused on behaviors or deficits. The Facilitator and CFT will ensure that the goals and outcomes align with the team mission, strengths, culture, family vision and preferences as this will make the process clear, accountable and effective. See policy 4.2, page 2, section B.
Supporting Documents:: IP-CANS and Plan of Care
c) The development of goals and outcomes occurs through a collaborative team process that actively engages the youth, family, and all HFW CFT members. This collaborative approach ensures that the plan is meaningful, effective, and sustainable by reflecting the shared perspectives and commitment of the entire team. See policy 4.2, page 2, section B.
Supporting Documents: IP-CANS and Plan of Care
d) Multiple individualized strategies are developed through team brainstorming, enabling the CFT to move beyond standard services and create creative, tailored solutions. These strategies are documented in the youth’s file (e.g., within the HFW Plan of Care, meeting minutes, or progress notes) and maintained for ongoing reference and implementation. See policy 4.2, page 2, section C and page 3 section D.
Supporting Documents: Plan of Care
e) HFW Facilitators are equipped through training to effectively guide the team in identifying and prioritizing needs, developing and selecting strategies, and assigning clear action items to support implementation. This training supports consistent, effective practice and ensures fidelity to the HFW model. See policy 4.2, page 2, section C
f) These processes take place through a coordinated team effort to create a comprehensive and individualized HFW Plan of Care. This approach promotes alignment among team members and ensures the plan reflects the full needs, strengths, and perspectives of the youth and family. See policy 4.2, page 2, section D.
Supporting Documents: Plan of Care
4.3 Develop an Individualized Child or Youth and Family Plan
a) HFW Facilitators are provided with ongoing training and coaching to effectively lead a high-quality team planning process that incorporates multiple perspectives, fosters trust and a shared vision, and aligns with HFW principles. See policy 4.3, page 2, section A
b) The Plan of Care incorporates and aligns the goals and objectives of all Children’s System of Care partners, ensuring a coordinated, comprehensive, and unified approach to supporting the youth and family. This integration strengthens effectiveness by promoting consistency, reducing fragmentation, and ensuring all supports work together toward shared outcomes. See policy 4.3, page 3, section D
c) The Plan of Care is documented in the youth’s file, distributed to all team members, and includes all required components—such as alignment with the family vision, identified needs, goals, strategies, and coordinated supports across systems—ensuring a clear, cohesive, and actionable plan. This process ensures that all team members share a common understanding of roles, expectations, and direction, promoting consistent and coordinated implementation. See policy 4.3, page 1& 2, section A.
Supporting Documents: Plan of Care
d) Established procedures guide the ongoing review of Plans of Care to promote quality, fidelity, and continuous improvement, while providing structured feedback to staff, supervisors, and coaches to strengthen practice and inform training and coaching. This approach supports consistency and alignment with HFW standards by enabling early identification and correction of gaps, such as missing components, ineffective strategies, or lack of alignment. See policy 4.3, page 3, section D and page 3&4 section F.
Supporting Documents: Plan of Care
4.4 Develop a Crisis and Safety Plan
a) The HFW Facilitator develops an initial crisis response plan with the youth and family within 1–2 weeks of service initiation and facilitates the development of a comprehensive, individualized Crisis and Safety Plan within 30 calendar days, integrated into the HFW Plan of Care. See policy 4.4, page 1, section A.
Supporting Documents: Safety Plan and Plan of Care
b) The HFW Facilitator reviews and updates the crisis and safety plan with the Child and Family Team at least every 30–45 days, integrating natural supports, culturally relevant strategies, and family feedback; Supervisors verify completion and quality through documentation review and coaching. See policy 4.4, page 2, section B & C.
Supporting Documents: Safety Plan
c) The Child and Family Team review and update the crisis and safety plan at least every 30–45 days, integrating natural supports, culturally relevant strategies, and proactive and reactive de-escalation approaches; updates are documented in the youth’s case file and incorporated into the Plan of Care to ensure it is individualized.
See policy 4.4, page 2, section D.
Supporting Documents: Safety Plan
Implementation
5.1 Implement The Plan of Care
a) The HFW Facilitator leads the Child and Family Team in implementing the HFW Plan of Care and reviews progress, action steps, timelines, and measurable outcomes during CFT meetings held at least every 30–45 days, using agendas, minutes, and IP-CANS data to track completion and adjust based on youth and family voice. See policy 5.1, page 1& 2, section A and page 3, section C.
Supporting Documents: Plan of Care, IP-CANS
b) Staff receive ongoing training and coaching on implementing the HFW Plan of Care in alignment with HFW principles, including strategies for monitoring progress, adjusting action steps, and celebrating successes as they occur; Supervisors and Fidelity Coaches reinforce these practices through observation, feedback, and documentation review. See policy 2.1, page 2, sections B & C
5.2 Review and Update The Plan of Care
a) The HFW Facilitator leads the Child and Family Team in reviewing and updating the HFW Plan of Care during CFT meetings held at least every 30–45 days, ensuring all changes, progress, strategies and action items reflect cultural relevancy, collaboration across Children’s System of Care partners, and measurable outcomes from the IPCANS. See policy 5.2, page 1, section A.
Supporting Documents: Plan of Care and IP-CANS
b) The HFW Facilitator documents all updates—including revised goals, strategies, action steps, natural supports, and Tribal input when applicable—and communicates these changes such as new needs, successes, new strategies and actions are selected, to all CFT members through meeting minutes or other communication methods to maintain shared ownership and alignment. See policy 5.2, page 2, section B & C.
Supporting Documents: Plan of Care
c) The HFW Facilitator ensures that all updates to the Plan of Care—including revised goals, strategies, action steps, and natural support involvement—communicated to all CFT members through meeting minutes or other communication methods, maintaining shared ownership and alignment across the team. See policy 5.2, page 2, section B & C
Supporting Documents: Plan of Care
d) The HFW Facilitator uses flexible, updatable Plan of Care forms that allow individualized changes based on the youth, family, and team’s evolving needs; team members receive ongoing training and coaching on using these tools to ensure updates remain personalized, culturally relevant, and responsive to changing circumstances.
See policy 5.2, page 2, section B & C.
Supporting Documents: Plan of Care
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
a) The HFW Facilitator ensures that CFT agreements are present, reviewed, and actively utilized at every HFW team meeting (at least every 30–45 days) to support cohesion, trust, shared ownership, and commitment among all members, including formal and natural supports; reviews and adjustments are documented and communicated to the full team. See policy 5.3, page 1, section A.
b) The HFW Facilitators receive ongoing training and coaching on building, engaging, and maintaining effective CFTs, including strategies for strengthening cohesion, trust, collaboration, and cultural relevance; supervisors reinforce these skills through observation, feedback, and coaching. See policy 5.3, page 2, section B, C.
c) The HFW Facilitator monitors the use and effectiveness of natural supports over time, maintaining an updated inventory in the youth’s case file and integrating natural supports into the Plan of Care; supervisors provide feedback through coaching and documentation review to strengthen natural support involvement and sustainability.
See policy 5.3, page 2, section C.
Supporting Documents: Plan of Care
d) When new members join the CFT, the HFW Facilitator orients them by explaining the HFW process, reviewing current plans, strategies, CFT agreements, and the team mission, and engaging in teambuilding activities to maintain cohesion and trust; orientation activities are documented and shared with the team.
See policy 5.3, page 2, section D.
Transition
6.1 Develop a Transition Plan
a) The HFW Facilitator guides the CFT in determining when the youth and family are ready for transition by reviewing the benchmarks and indicators (IP-CANS) that have been continuously monitored and adjusted throughout the HFW process. See policy 6.1, page 1& 2, section A.
Supporting Documents: IP-CANS
b) Once readiness for transition has been established, the facilitator leads the CFT in developing an individualized transition plan that outlines the youth and family’s needs, services, and supports, ensures the plan is shared with all team members, and documents it in the youth’s file. See policy 6.1, page 2, section B.
Supporting Documents: Transition Plan
c) The individualized transition plan is developed through a collaborative, team-based process, with facilitators receiving training and coaching to support effective implementation. See policy 6.1, page 2, section C.
d) The team confirms that all services and supports outlined in the transition plan are sustainable beyond the conclusion of formal HFW involvement and that the family has the ability and knowledge to access them, including post‑adoption services when applicable. See policy 6.1, page 3, section E.
Supporting Documents: Transition Plan
6.2 Develop a Post-Transition Safety Plan
a) The HFW Facilitator leads the Child and Family Team in developing or updating an individualized post transition crisis and safety plan prior to discharge, identifying potential crisis situations that may occur after transition and including proactive and reactive strategies chosen by the youth and family; the plan maximizes natural supports, incorporates cultural and Tribal perspectives when applicable, and is documented in the youth’s case file as part of the transition plan. See policy 6.2, page 1& 2, section A.
Supporting Documents: Safety Plan and Transition Plan
b) The development of the post transition crisis and safety plan occurs in a team based, collaborative environment that includes formal and natural supports across the Children’s System of Care; HFW Facilitators receive ongoing training and coaching to lead this collaborative process, ensuring strategies reflect youth and family voice, cultural relevance, and shared ownership. See policy 6.2, page1-2, section A, and page 2, section B.
Supporting Documents: Safety Plan and Transition Plan
c) Processes are in place to routinely review post transition crisis and safety plans for individualized strategies, proactive and reactive progression, cultural relevancy, and integration of natural supports; supervisors use these reviews for continuous quality improvement, training, and coaching, with family feedback incorporated quarterly to strengthen practice. See policy 6.2, page 2, sections C and page 3, section F.
6.3 Create a Commencement and Celebrate Success
a) The HFW Facilitator leads the Child and Family Team in planning a culturally relevant commencement/transition that celebrates the youth and family’s transition out of Wraparound in a manner that is aligned with their culture, values, preferences, and strengths; celebrations incorporate youth and family voice, natural supports, and Tribal traditions when applicable, with all details documented in the youth’s case file and transition plan. See policy 6.3, page 1 & 2, section A, and page 2, sections B and C.
Supporting Documents: Transition Plan
b) Administrative structures support meaningful celebrations by providing access to flex funds, time for community resourcing, community partnerships, and ensuring staff availability to attend; facilitators receive ongoing training and coaching to incorporate family culture and natural supports into celebrations, with supervisors reviewing documentation and family feedback for continuous quality improvement. See policy 6.3, page 1, section A, and page 2, sections D and E.
Supporting Documents: Flex Funds Request Form
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
a) Crittenton maintains multiple structured mechanisms for youth, families, and Tribal partners to participate in local HFW implementation. Participation is supported through transportation, childcare, interpretation, virtual access, and other accessibility supports, and is documented and reviewed quarterly to ensure meaningful and representative involvement. See policy 7.1, page 1& 2, section A and page 2, section B.
Supporting Documents: HFW Advisory Committee, HFW Advisory Committee Sign In Sheet.
b) Family and Tribal feedback gathered through advisory structures, satisfaction tools (WFI/TOM), listening sessions, focus groups, and partner reports is systematically analyzed and used to guide service planning, policy and procedure development, workforce development, and continuous quality improvement; resulting actions, updates, and training adjustments are documented, assigned timelines and outcomes, and communicated back to families and Tribal partners. See policy 7.1, page 2, section B.
Supporting Documents: Crittenton has not started using the WFI-EZ, or TOM 2.0 but will do so before July 1st.
7.2 Community Leadership Team
a) Program Leadership designates a primary and backup Crittenton representative to actively participate on the Community Leadership Team (CLT), ensuring consistent agency involvement in system level decision making; representatives are oriented to HFW Standards, Tribal engagement, cultural responsiveness, and CLT responsibilities, and their attendance and participation are documented. See Policy 7.2, page 1, sections A, B, C and D.
Supporting Documents: Training, POC, Flex Fund Request
7.3 Eligibility and Equal Access
a) Crittenton ensures equitable access to HFW by screening youth using standardized eligibility protocols and accepting all youth who meet County criteria, without exclusion based on severity, acuity, behavioral complexity, disability, or system involvement; intake processes prioritize youth and family voice, cultural and Tribal considerations, and timely engagement, with referral outcomes and timelines documented in the case record. See policy 7.3, page 1, section A and page 2, section B.
Supporting Documents: HFW Caseload Report
b) Program Leadership maintains staffing levels and caseload assignments that support the intensity and frequency of HFW services, including weekly caseload reviews, redistribution of cases when needed, and maintenance of 24/7 oncall coverage with backup support; staffing plans ensure facilitators can meet families’ complex needs and respond to crises at any time. See policy 7.3, page 2, section C.
Supporting Documents: On Call Flyer, HFW Caseload Report
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
a) Program leadership allocates funding to support high‑fidelity direct services and individualized supports identified through the Child and Family Team process, including flexible and non‑traditional strategies that meet the immediate needs of youth and families. See policy 8.1, page 2, section D.
b) Budgets and contracts allocate resources to support required High‑Fidelity Wraparound staffing and workforce development, including Facilitators, Parent Partners, Youth Partners, supervision, fidelity coaching, and training aligned with Workforce Development standards. See Policy 8.1, Page 1 section A, and page 2, section B &2
c) Program leadership allocates funding to maintain data collection and data management systems used to monitor fidelity, service delivery, and outcomes, and to support reporting and Continuous Quality Improvement activities required by the CA HFW model. See Policy 8.1, Page 2, section C, E, and F.
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) Flexible funds are included as part of the High‑Fidelity Wraparound program funding structure to ensure youth and families have timely access to individualized resources when urgent or unique needs cannot be met through other services or funding sources. See policy 8.4, page 1, section A
b) The HFW program maintains a clearly defined process to access and manage flexible funds that includes timely review of requests, evaluation based on Child and Family Team recommendation using established criteria (alignment with the team mission and Plan of Care, strengths‑based, culturally relevant, builds natural supports or community capacity, cost‑effective, and includes sustainability considerations), and communication of approval, denial, or appeal options to teams and families. See Policy 8.4, Page 1&2, section B, and page 2 section C, D,E, and F.
Supporting Documents: Flex Fund Request Form
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
a) Program leadership monitors youth and family demographic data on a routine basis and uses this information to guide recruitment and workforce development strategies to ensure cultural and linguistic responsiveness. See policy 9.1, page 1, section A&B
b) HFW Team Members deliver services that incorporate family voice, cultural values, traditions, and community context, and utilize qualified interpreters or Language Line Services when services cannot be provided in the family’s preferred language. CFT also engages natural an d formal supports to meet the family’s needs. See policy 9.1, page 1, section C and page 2, section E
c) All HFW Team Members complete required foundational, annual, and ongoing trainings related to cultural humility, equity. However, if Crittenton is unable to provide a CFT member who can provide services in the family’s language, the Language Line Services are used. See policy 9.1, section D
9.2 Tribally Responsive Workforce
a) All HFW Team Members receive training on tribal sovereignty, tribal traditions and values, and culturally respectful communication, collaboration, and advocacy when serving American Indian and Alaska Native youth and families, with training completion tracked by program leadership. See policy 9.2, Page 1, section A
b) When serving an Indian child, the HFW team builds and maintains partnerships with tribal representatives, encourages participation in tribal traditions and ceremonies when desired by the family, and collaborates with the Tribe to incorporate culturally rooted supports and services into the Wraparound process. See Policy 9.2, Page 1, sections B and C, and page 2 sections D, E, and F.
9.3 Flexible and Creative Work Environment
a) Program leadership engages HFW Team Members in program quality and improvement activities through regular team meetings, reflective supervision, and CQI processes, creating shared responsibility for monitoring fidelity and strengthening program effectiveness. See policy 9.3, page 1, section A
b) Supervisors and program leadership foster team member cohesion by promoting a positive team environment through regular team meetings, peer consultation, and cross‑role collaboration that reinforces collective responsibility for program outcomes. See Policy 9.3, Page 1, section B
c) Crittenton maintains open and transparent communication structures by encouraging staff to share feedback, raise concerns, and participate in discussions related to program operations and service delivery, with leadership responding through supervision and team forums. See policy 9.3, page 1, section C
d) Supervisors and program leadership reinforce a clear sense of mission and compliance with the High‑Fidelity Wraparound philosophy by emphasizing Wraparound principles, values, phases, and activities during supervision, training, and team discussions, while supporting flexible and creative practice aligned with HFW standards. See policy 9.3, page 2, section D, E, and F,
9.4 Hiring, Performance Evaluation, and Job Descriptions
a) Program leadership ensures that all required High‑Fidelity Wraparound roles and functions (Youth Partner, Parent Partner, HFW Facilitator, Family Specialist, Fidelity Coach, Clinical Supervisor, and HFW Supervisor/Manager) are fulfilled within the program structure, either through distinct positions or combined roles with clearly defined responsibilities. See policy 9.4, page 1, section B
b) Program leadership maintains role descriptions for each Wraparound function that clearly define the role purpose, functions, and required qualities, including skills, competencies, and attributes specific to High‑Fidelity Wraparound practice. See Policy 9.4, Page 2, section C
c) Job descriptions for all HFW positions are specific to High‑Fidelity Wraparound and reflect the attitudes, skills, knowledge, and experience necessary to successfully implement Wraparound principles, phases, and activities. See policy 9.4, page 2, section C.
Supporting Documents: HFW Clinical Supervisor, HFW Facilitator, HFW Family Specialist, HFW Fidelity Coach, HFW Parent Partner, HFW Supervisor, HFW Youth Partner.
d) Structured hiring processes include opportunities for candidates to demonstrate attitudes and skills essential to Wraparound practice, including strengths‑based engagement, collaboration, family voice and choice, and team‑based problem solving. See policy 9.4, page 1, section A
e) Supervisors provide team members with clear performance expectations and ongoing feedback, coaching, and formal performance evaluations to support professional development and ensure fidelity to the High‑Fidelity Wraparound model. See policy 9.4, page 2, section D, E, and F
9.5 Workforce Stability
a) Program leadership and Human Resources regularly review and maintain competitive compensation practices informed by market conditions and organizational considerations to support recruitment and retention of qualified High‑Fidelity Wraparound staff. See policy 9.5, page 1, section A
b) Program leadership monitors caseload size, meeting demands, crisis response responsibilities, and documentation expectations to ensure team members maintain manageable workloads that support continuity of care and fidelity to the Wraparound model. See Policy 9.5, Page 1, section B
c) Program leadership provides team members with professional growth, advancement, and leadership development opportunities through mentoring, training facilitation, CQI involvement, and participation in program development activities to support workforce engagement and retention. See policy 9.5, page 2, section C, D, and E.
d) Program leadership and Human Resources monitor workforce stability indicators, including turnover rates, caseload distribution, and team member feedback, and use this information within CQI processes to strengthen workforce support strategies and promote long‑term team member retention. See policy 9.5, page 2, section F and G.
9.6 High Fidelity Training Plan
a) All HFW Team Members complete initial High‑Fidelity Wraparound training by attending the Statewide Standardized Foundational HFW training through the UC Davis Resource Center for Family Focused Practice prior to independently delivering services. See policy 9.6, page 1, section A.
Supporting Documents: HFW Training Plan.
b) Program leadership ensures all team members receive ongoing training in general Wraparound practice and their specific roles through formal trainings, team meetings, coaching, reflective supervision, and peer learning opportunities. See Policy 9.6, Page 1, section B and page 2, section C.
Supporting Documents: HFW Training Plan.
c) All HFW Team Members participate in booster trainings at least annually to reinforce Wraparound principles, phases, and role‑specific competencies and to address emerging practice needs. See policy 9.6, page 2, section D.
Supporting Documents: HFW Training Plan.
d) Clinical Supervisors and Wraparound Supervisors/Managers receive general Wraparound training as well as initial, ongoing, and booster trainings specific to their leadership, supervisory, and fidelity oversight roles. See policy 9.6, page 2, section E.
Supporting Documents: HFW Training Plan.
e) All HFW Team Members receive ICWA and Tribal sovereignty training, and program leadership identifies and provides additional specialized training as needed to support populations with unique or complex needs. See policy 9.6, page 2, section F, and H.
Supporting Documents: HFW Training Plan.
9.7 Community-based Training Program
a) Program leadership meaningfully incorporates youth, family members, Parent Partners, and Youth Partners with current or prior High‑Fidelity Wraparound experience into the delivery of Wraparound trainings as co‑trainers, panel participants, or presenters to provide lived‑experience perspectives. See policy 9.7, page 1, section A.
b) Wraparound trainings are promoted to and offered for community and system partners within the Children’s System of Care, including child welfare, behavioral health, probation, education, community‑based organizations, and Tribal partners when applicable, to strengthen their understanding of and participation in HFW teams. See Policy 9.7, Page 1&2, sections B and C, and page 2, sections D,E, and F.
9.8 Coaching and Supervision
a) All HFW staff participate in an initial apprenticeship period that includes structured coaching, shadowing, and guided practice focused on High‑Fidelity Wraparound values, principles, phases, activities, and the effective use of flex funds to meet family‑identified needs. See policy 9.8, page 1, section A.
b) Supervisors and program leadership ensure staff have access to coaching and supervision on a 24/7 basis as needed to support flexible scheduling, crisis response, and timely decision‑making consistent with the High‑Fidelity Wraparound model. See Policy 9.8, Page 1&2, sections B and C and page 2D, sections D and E.
Supporting Documents: On-call Flyer
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
n /a
10.2 Evaluation Metrics & Outcomes
a) HFW Supervisors review youth‑ and family‑level data, including CANS results, with HFW Facilitators during regularly scheduled supervision to provide feedback on practice and identify staff training or coaching needs. Informed Program Practice Policy. See policy 10.2, page 1, section A
b) HFW Program Leadership reviews aggregate outcome and service data on a routine basis to identify program needs, evaluate overall effectiveness, and guide quality improvement activities. See policy 10.2, page 1, section B and Page 2, section C. Supporting tool attached: Fidelity Indicators and Expected Outcomes Table, page 1.
c) HFW Program Leadership uses program‑level data to identify system barriers impacting service delivery and shares these data trends with the Community Leadership Team to support system‑level problem‑solving related to HFW implementation. See Community Leadership Team Policy. See policy 10.2, page 2, section D and page 3, section E and F.
Fidelity Indicators
1.1 Timely Engagement and Planning
a) The assigned case carrying clinician for makes contact with the client and/or family supports within 7-10 days of referral. See:
SCFS Policy MHSU 3 – Assessment/Reassessment
SMHS Contract Exhibit A , Sec. E, P.4, i (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
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 – SMHS Contract – Exhibit A , Sec. D, pt.7 i(F)[Page 34]
SCFS – MHSU 4 – Service Planning and Monitoring
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;
SCFS Policy MHSU 3 – Assessment/Reassessment;
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
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
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 1.01 Logic Model;
SCFS – MSHU 5.04 Clinical Counseling- Family Therapy;
SCFS – MHSU 4 – Service Planning and Monitoring
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;
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 1.01 Logic Model
SCFS – MHSU 4 – Service Planning and Monitoring;
SCFS TS 3, HR 6 Supervision Procedures_Framework
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
SCFS MHSU 3- Assessment and Reassessment
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
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 – MHSU 1.01 Logic Model
SCFS TS1 Training and Supervision: Personnel 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]
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
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 – MHSU 1.01 Logic Model
SCFS TS1 Training and Supervision: Personnel Development
c) All SCFS staff are CANS certified at onboarding and yearly recertification. See:
SCFS – MHSU 1.01 Logic Model
SCFS TS1 Training and Supervision: Personnel Development
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
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- SMHS Contract-9034, Exhibit A, sec D, pts – 7-9 [page 34-37]
SCFS – MHSU 4 – Service Planning and Monitoring
(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 Employee Orientation_MIssion.Vision.Values
SCFS TS1 Training and Supervision: Personnel Development
(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
SCFS TS1 Training and Supervision: Personnel Development
SCFS – MHSU 4 – Service Planning and Monitoring
(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 1.01 Logic Model;
SCFS-MHSU 10 Care Coordination;
SCFS – MHSU 4 – Service Planning and Monitoring
(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]
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 3.03-3.07- Assessment and Reassessment;
SCFS-MHSU 10 Care Coordination;
SCFS MHSU 11- Support Services Referral Procedures;
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;
SCFS TS1 Training and Supervision: Personnel Development;
SCFS-MHSU 10 Care Coordination;
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;
SCFS – MHSU 4 – Service Planning and Monitoring
(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;
SCFS – MHSU 1.01 Logic Model; 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
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
(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
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
(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
SCFS-MHSU 10 Care Coordination
(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
(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 – Assessment and Reassessment
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 – Assessment and Reassessment
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,
SCFS MHSU 3- Assessment and Reassessment;
SCFS-MHSU 10 Care Coordination
SCFS-MHSU 11 Support Services Referral Process
(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
SCFS-MHSU 11 Support Services Referral Process
SCFS -TS 3, HR – Supervision Framework
(c) SCFS HFW facilitators will receiving 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
SCFS TS1 Training and Supervision: Personnel Development
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
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
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]
SCFS MHSU 3.03-3.07- Assessment and Reassessment
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 – SMHS Contract – P.47 – Exhibit A , Sec. F, pt.4(d)
SCFS – SMHS Contract – P.56 – 79 Attachment A-4 PAF, 3M, KET
SCFS MHSU 3.03-3.07- Assessment and Reassessment.
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 – SMHS Contract – Exhibit A , Attachment A-4 PAF, 3M, KET [page 58-79]
SCFS MHSU 3.03-3.07- Assessment and Reassessment
SCFS – MHSU 4 – Service Planning and Monitoring
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 – SMHS Contract – Exhibit A , Sec. D, pt.7 i(F) [page 34]
SCFS – MHSU 4 – Service Planning and Monitoring
SCFS MHSU 3.03-3.07- Assessment and Reassessment.
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 – SMHS Contract – Exhibit A , Sec. F, pt.4(d) page 47]
SCFS – SMHS Contract – Exhibit A , Attachment A-4 PAF, 3M, KET [page 58, 74]
SCFS MHSU 3.03-3.07- Assessment and Reassessment
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 MHSU 3.03-3.07- Assessment and Reassessment.
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]
2.8 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 – SMHS Contract – Exhibit A , Attachment A-4 PAF, 3M, KET [page 58-79]
SCFS MHSU 3.03-3.07- Assessment and Reassessment
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
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
SCFS – MHSU 4 – Service Planning and Monitoring
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
SCFS – MHSU 4 – Service Planning and Monitoring
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
SCFS MSHU 4.02 Crisis Management/ Trauma Informed Care
c) Youth and families are provided with information for how to access 24/7 crisis response services when needed. See:
MSHU 4.02 Crisis Management/ Trauma Informed Care
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
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
SCFS – MHSU 4 – Service Planning and Monitoring
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
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
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 3.03-3.07- Assessment and Reassessment
SCFS-MHSU 10.01-10.05 Care Coordination
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]
SCFS – MHSU 4 – Service Planning and Monitoring
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 , Exhibit A, sec D, pts – 10 [page 38]
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 Employee Orientation_MIssion.Vision.Values
SCFS TS1 Training and Supervision: Personnel Development
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
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 3.03-3.07- Assessment and Reassessment
SCFS – MHSU 4 – Service Planning and Monitoring
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;
b) HFW team develop measurable goals based on identified needs. See:
SCFS – MHSU 1.01 Logic Model
c) Goals and outcomes are developed in collaboration between HFW team, child, and family. See:
SCFS – MHSU 1.01 Logic Model
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 ;
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
SCFS TS1 Training and Supervision: Personnel Development
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
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
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
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
d) Plans of Care are reviewed for feedback and training opportunities during routine chart audit and review processes. See:
SCFS TS1 Training and Supervision: Personnel Development
SCFS -TS 3 and HR – Supervision Framework
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:
SCFS MSHU 4.02 Crisis Management/ Trauma Informed Care
SCFS – MHSU 4 – Service Planning and Monitoring
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
SCFS MSHU 4.02 Crisis Management/ Trauma Informed Care
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
SCFS MSHU 4.02 Crisis Management/ Trauma Informed Care
SCFS -TS 3 and HR – Supervision Framework
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
SCFS-MHSU 10 Care Coordination
SCFS TS policy – High Fidelity Wrap Training
b) Staff receive training and coaching on implementation of Plan of Care with HFW principles. See:
SCFS TS1 Training and Supervision: Personnel Development
SCFS TS policy – High Fidelity Wrap Training
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
SCFS-MHSU 10 Care Coordination
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
SCFS-MHSU 10 Care Coordination
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
SCFS-MHSU 10 Care Coordination
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
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
SCFS-MHSU 10 Care Coordination
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
SCFS TS policy – High Fidelity Wrap Training
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
SCFS -TS 3 and HR – Supervision Framework
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
SCFS TS policy – High Fidelity Wrap Training
SCFS-MHSU 10 Care Coordination
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
SCFS-MHSU 10 Care Coordination
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
SCFS-MHSU 10.01-10.05 Care Coordination
SCFS MHSU Aftercare and Follow Up 12.04, 12.05
c) Transition plan development occurs in a team based collaborative environment and facilitators are trained to ensure this process. See:
SCFS TS1 Training and Supervision: Personnel Development
SCFS-MHSU 10.01-10.05 Care Coordination
SCFS MHSU Aftercare and Follow Up 12.04, 12.05
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 10 Care Coordination
SCFS MHSU Aftercare and Follow Up 12.04, 12.05
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-transition. See:
SCFS-MHSU 10.01-10.05 Care Coordination
SCFS MHSU Aftercare and Follow Up 12.04, 12.05
MSHU 4.02 Crisis Management/ Trauma Informed Care
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
SCFS-MHSU 10 Care Coordination
SCFS MHSU Aftercare and Follow Up 12.04, 12.05
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:
MSHU 4.02 Crisis Management/ Trauma Informed Care
SCFS -TS 3 and HR – Supervision Framework
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
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
SCFS -TS 3 and HR – Supervision Framework
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]
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 1.01 Logic Model
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
SCFS – HR 2 Recruitment & Selection Policy and Procedures
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, Exhibit B, sec A “Rates “(page 80)
b) SCFS utilizes resources for workforce development and staffing to meet HFW needs. See:
SCFS – HR 1 Assessment of Workforce Needs
SCFS – HR 2 Recruitment & Selection Policy and Procedures
c) Contracts include rates that reflet inclusion of data handling tasks and procedures. See:
SCFS- SMHS Contract-9034, Exhibit B, sec A “Rates “(page 80)
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 Exhibit A, sec F, pt. 4 “Reporting And Evaluation Requirements’ [page 47]
SCFS – MHSU 1.01 Logic Model
b) SCFS leadership seeks out community resources to obviate shortcoming and amend gaps in program funding. See:
SCFS – MHSU 1.01 Logic Model
c) SCFS works with families to explore all available resources to meet needs including funding sources. See:
SCFS – SMHS Contract-9034 Exhibit A, sec F, pt. 4 “Reporting And Evaluation Requirements’ [page 47]
SCFS – MHSU 1.01 Logic Model
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]
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
SCFS – HR 2 Recruitment & Selection Policy and Procedures
SCFS – HR 6 – Supervision Framework
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
SCFS-MHSU 11 Support Services Referral Process
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;
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
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 HR1 Assessment of Workforce Needs; SCFS HR 2 Recruitment and Selection; 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
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;
SCFS – HR 6 – Supervision Framework
SCFS HR 2 Recruitment and Selection
SCFS HR 4 Performance Review Procedures
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. See:
Sierra Child & Family Services Personnel Manual
SCFS HR1 Assessment of Workforce Needs;
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
SCFS TS1 Training and Supervision: Personnel Development
SCFS -TS 3 and HR – Supervision Framework
SCFS MHSU 2.10 Continuity of Care and Case Assignment.
c) Promotion/advancement structures are clearly communicated through the process of supervision and during hiring. See:
SCFS HR1 Assessment of Workforce Needs
SCFS TS1 Training and Supervision: Personnel Development
SCFS -TS 3 and HR – Supervision Framework
SCFS HR 4 Performance Review Procedures
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 TS1 Training and Supervision: Personnel Development
SCFS HR1 Assessment of Workforce Needs
SCFS HR 2 Recruitment and Selection
SCFS HR 4 Performance Review Procedures
9.6 High Fidelity Training Plan
a) (2) 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
b) Staff receive ongoing training in role specific information and practices as determined by supervisors and provided trough UC Davis RCFFP. See:
SCFS TS policy – High Fidelity Wrap Training
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
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
e) All staff will receive ICWA and Tribal Sovereignty training. See:
SCFS TS1 Training and Supervision: Personnel 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
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
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
b) Staff have access to supervisory support or coaching 24/7 as needed. See:
SCFS – HR 6 – Supervision Framework
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 PQI plan; SCFS – HR 6 – Supervision Framework
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 assigned by the managers upon receipt, within the same day, to a Wraparound Care Coordinator (Facilitator), a therapist, and a Family Advocate (certified Peer Support Specialist). River Oak does not partner with AAP families.
a) Upon receiving the referral, assigned Family Advocate (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 calendar days from referral. Efforts to contact the family are documented in youth’s Electronic Health records. See Intake Process Policy page 1; Timely Access to Service policy; Intake Procedure, page 1; Wrap Intake Session Checklist page 1.
b) Initial Wraparound Team Meeting (WTM), also known as Child Family Team Meeting (CFTM), occurs within 30 calendar days from intake and initial Plan of Care (POC) is developed with team members during this meeting. See Wrap Team Meeting Policy-page 1, HFW Phase 1 Expectations-page 1; HFW Phase 2 Expectations page 1
c) Teams convene for follow up WTMs every 30 calendar days to evaluate progress and/or barriers toward the plan and measure and track accordingly. Teams update the plan together and updated plan is sent to all team members within a week of the meeting occurring. In the event the youth/family has tribal community involvement, 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, HFW-Phase 3- Expectations-page 2, Tirbal engagement Guide-CFTs pages 2, 9, 10+)
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 preference. See HFW-Phase 2 page 1; HFW Phase 3 Expectations –page 2; Explaining HFW Components page 13
e) Our referral process is tracked from the start: both referral 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. 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. See Timely Access to Services Policy pages 1-2, Outcome Methods procedure page 1
f) Each Wraparound staff receives initial two, instructor-led, online training courses provided by NWIC (National Wraparound Implementation Center): Wraparound 101: Practice Essentials (3 full days) and Wraparound 102: Building Partnerships (1 full day) at hire. These training courses provide staff with foundational knowledge, 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. Care Coordinators are provided with High Fidelity Coaching on a weekly basis for 1-1.5 for individual coaching and 1 hour a month for group coaching. (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.) 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 2-hour lab for additional support as needed. They also receive ongoing feedback based on their scoring on Supervisory Checklist, a NWIC tool for coaching. See HFW Training Plan page 3, 6-8, & 11; NWIC Training Catalog/Training Descriptions page 1); Care Coordinator HFW Coaching Log page 1; Sample Booster training ppt; NWIC Coaching Tool Descriptions-Supervisor Checklist item: 1; Job Description: Wraparound Program Fidelity/Training Manager)
1.2 Led by Youth and Families
River Oak Center for Children holds youth and family voice and choice in the highest regard. Family’s, including youth with Tribal community, 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 perspectives, strengths, needs and culture around the referral behaviors and builds their Family Vision with the family. If youth is part of a Tribal Nations 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 Explaining HFW Components: under Family Vision –page 3; HFW Phase 1 Expectations page 1; Tribal Engagement Guide,). At the River Oak, the Team Mission is developed during the initial WTM led by the Care Coordinator with collaboration from the whole team member to ensure that the entire team is working together to work towards positive outcomes. The family Vision and Team Mission are added to the Plan of Care, filed and documented in youth’s electronic health records (EHR). The family and their support people are provided with the Wraparound Process User Handbook to learn more about HFW components and what they should expect from the process. (See HFW-phase 2 Expectations –page 2 under WTM agenda items 5 & 6; Wraparound Process User Guide)
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 to formulate 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) 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 referral behaviors. The family’s support people’s (both natural and formal) perspectives around family’s strengths, needs and culture are elicited as well. Everyone’s strengths are reviewed in WTMs and included in the youth/family Plan of Care. Updated POCs are filed in River Oak Electronic Health Records for each youth/family after each WTM. (See NWIC Coaching Tool Descriptions p. 2 items 10, 11, & 12; Team & Community Strengths Inventory page 1; IP-CANS template; Explaining HFW Components page 3; HFW Phase 1 Expectations page 2)
c) HFW coach and supervisors support team members in Wrap Team Meetings by regularly observing meetings (1-2 WTMs per month per Care Coordinator) and providing timely feedback to Care Coordinators during weekly coaching or schedule de-briefing. HFW coach uses Supervisory Checklist to document the observation. The observation allows the coach to see how the HFW components are being explained and addressed during the WTM and in other sessions. Using the data gathered during the observation, coach provides staff with timely feedback using the CREST (Coaching Response to Enhance Skill Transfer Tool) as a guide to coaching staff during weekly individual coaching and monthly group coaching. Highlights the Care Coordinator’s strengths and conducts role plays and practice activities for the areas of improvement. (See NWIC Coaching Tool Descriptions for CREST and Supervisor Checklist items 1 and 3). Conducts de-briefing session after the WTM to provide the CC with timely feedback and uses the data for further coaching and training. CCs are offered and provided with HFW 2-hour lab as needed. See Care Coordinator HFW Coaching log
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 TOMs, WFI-EZ caregiver and youth template, NWIC Coaching Tool Descriptions for items 1 & 3; HFW Satisfaction Questionnaire and The Wraparound Advisory Dinner Survey)
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 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 a visual, reviewed at each WTM, and new strengths are added accordingly. 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. See Team and Community Strengths Inventory page 1; NWIC Coaching Tool Description for Family Story Tool item 11; HFW Phase 3 Expectations page 2 Agenda; POC/WTM minutes template-page 1 Strengths; Explaining HFW Components-page 4
b) Upon completion of IP-CANS by the assessing clinician within 21 days of intake, (see HFW-Phase 1 Expectations page 2) the clinician and Care Coordinator review the scoring together and highlight the areas of strengths for both youth and caregiver, and the Care Coordinator utilizes the strengths listed in the IP-CANS and reflects them in development of youth and caregiver’s Functional Strengths and Family Story. Strengths from IP-CANS are highlighted at WTMs (see Initial and Continuing Assessment policy page 1, Team & Community Strengths Inventory; IP-CANS blank; POC/WTM template page 1 under Strengths, NWIC Coaching Tools Descriptions item 11)
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 NWIC Coaching Tool Description for CREST & CCRSR items 3 and 9; Care Coordinator HFW Coaching log individual and group sessions; Explaining HFW Components
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 Client Satisfaction Survey Results 2025 page 21 & 22; Outcome Methods Procedure pages 1 & 2; templates for WFI-EZ; TOMs, HFW Satisfaction Questionnaire, Sacramento County Customer Perception Survey Youth and Parent)
1.4 Needs Driven
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 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 a visual, reviewed at each WTM, and new strengths are added accordingly. 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. See Team and Community Strengths Inventory page 1; NWIC Coaching Tool Description for Family Story Tool item 11; HFW Phase 3 Expectations page 2 Agenda; POC/WTM minutes template-page 1 Strengths; Explaining HFW Components-page 4
b) Upon completion of IP-CANS by the assessing clinician within 21 days of intake, (see HFW-Phase 1 Expectations page 2) the clinician and Care Coordinator review the scoring together and highlight the areas of strengths for both youth and caregiver, and the Care Coordinator utilizes the strengths listed in the IP-CANS and reflects them in development of youth and caregiver’s Functional Strengths and Family Story. Strengths from IP-CANS are highlighted at WTMs (see Initial and Continuing Assessment policy page 1, Team & Community Strengths Inventory; IP-CANS blank; POC/WTM template page 1 under Strengths, NWIC Coaching Tools Descriptions item 11)
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 NWIC Coaching Tool Description for CREST & CCRSR items 3 and 9; Care Coordinator HFW Coaching log individual and group sessions; Explaining HFW Components
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 Client Satisfaction Survey Results 2025 page 21 & 22; Outcome Methods Procedure pages 1 & 2; templates for WFI-EZ; TOMs, HFW Satisfaction Questionnaire, Sacramento County Customer Perception Survey Youth and Parent)
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 HFW Plan of Care, Family Story tool, and Need statements are all formatted so that the Care Coordinator can create a plan alongside the family that is uniquely tailored to them. It allows for space to write in exactly what is going to work for each family and track their progress/barriers throughout the Wraparound process across each phase (POC/WTM minutes template for format the template; Developing Need Statements; and NWIC Coaching Tool Descriptions item 11).
b) Each Wraparound staff completes Wraparound 101, 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 HFW Training Plan-page 1). 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 ‘High Fidelity Corner’ during all staff meetings highlighting the operationalization of principles and activities of phases (See NWIC Coaching Tools Descriptions for item 3; Booster training template; Weekly Coaching log, All Staff team Meeting agenda for ‘HiFi’ corner, NWIC Training Catalog for descriptions of the trainings; HFW Training Plan pages 1, 6-8).
c) Care Coordinators gain training and coaching on various methods of engaging youth, families, and team members in creative, flexible (meeting them where they are), individualizing, and incorporating culture. In addition to attending Wraparound 101, 102 training, each Care Coordinator receives ongoing coaching and practices through weekly 1-1.5-hour individual coaching with the HFW coach, and monthly 2-hour group coaching led by HFW coach and supervisors. In addition, all River Oak Wrap 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 by the HFW coach. (See Booster training template; Weekly Coaching log, All Staff team Meeting agenda for ‘HiFi’ corner, NWIC Training Catalog for descriptions of the trainings; HFW Training Plan pages 1; 6-8; 12).
d) Throughout the Implementation and Transition phases, Care Coordinators update the Plan of Care following each WTM (every 30 days) with the most up to date strengths, needs, outcomes, strategies and tasks created at each meeting, based on feedback from the team. It is a living document and new team members, community resources, ideas, strengths, and strategies are always being added during the process. They also ensure progress towards the connection with natural and community support, and adjust the plan as needed. (See Team & Community Strengths Inventory template; POC /WTM minutes template; HFW phase 3 Expectations, HFW phase 4 Expectations)
e) Feedback from families is elicited through TOMs and WFI-EZ administered quarterly, satisfaction surveys administered every 6 months, 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 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 procedure pages 1-2; HFW Satisfaction Questionnaire, TOM, WFI-EZ, Customer Perception Survey)
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. (see Natural, Formal, & Community Support inventory form and NS tracking sheet, POC/WTM template in Brainstorming section-page 6; Explaining HFW Components pages 9-10 )
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 NWIC Coaching Tools Description item 3, HFW Wraparound Training Plan pages 1, 6-8 & 12; Booster Training PPT –Natural Support; Explaining HFW Components pages 9-10)
c) Care Coordinators update the Plan of Care following each WTM (every 30 days) with the most up to date team members, community resources, natural supports and strategies. It is a living document and new team members, community resources, ideas, strengths, and strategies are always being added during the process (see POC / WTM minutes template page 6-7; Explaining HFW Components-pages 9-10)
d) Feedback from families is elicited through TOMs and WFI-EZ administered quarterly; satisfaction surveys administered every 6 months, and County CFT survey administered monthly. CCs are also leading the conversation and tracking natural support involvement during WTMs throughout the Implementation and Transition phases. HFW coach routinely observes WTMs to provide feedback at the next weekly coaching session and updates Natural, Formal, and Community Supports tracking form during coaching. HFW coach conducts HFW Satisfaction Questionnaire (quality assurance) phone calls every 3-6 months to gather families’ feedback on the meetings and uses the date to coach & train staff (See TOMs, WFI-EZ templates, Natural, Formal, and Community Supports tracking, HFW Satisfaction Questionnaire; Outcome Methods procedure-page 1-2 )
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) Care Coordinators gather information in the first 30 days which includes strengths of the family and all team members (natural and formal supports), the family story including their background, strengths, culture, and the underlying need that is driving the referral behaviors. Care Coordinators use tools such as Family Story Tool and Timeline tool to capture all relevant information for their story. These tools are used to organize information not to be used as a questionnaire or checklist. Information gathered is compiled as Family Story and reviewed and confirmed with the family prior to initial WTM. The WRAP Therapist also completes the IP-CANS within the first 21 days, which informs the strengths and needs and coordinates with Care Coordinator about the results of the assessment and reflects relevant information in the family story as well. Parts of the family story that are selected by the family are shared with the team through strengths-based approach at the initial WTM. (See HFW phase 1 Expectations page 1; HFW Phase 2 Expectations page 2-agenda; NWIC Coaching Tool Descriptions for #11, 12, Explaining HFW Components-page 2-3)
b) River Oak Wraparound team has started developing a partnership with Central ICWA field office of Tribal Affairs to receive the most updated training information for our staff education. Staff are required to complete ICWA Echo Trainings annually 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. Care Coordinators are coached on incorporating the families’ unique culture and values. The also receive additional 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 HFW Wraparound Training Plan-page 10, 12, 13, ROCC Training Catalog; Care Coordinator HFW Coaching log, Tribal Engagement Guide).
c) Feedback from families is elicited through TOMs and WFI-EZ administered quarterly, satisfaction surveys administered annually, and County CFT survey administered monthly. HFW coach routinely observes WTMs to provide feedback at the next weekly coaching session. HFW coach participates in quality assurance phone calls to gather families’ feedback on the meetings and review the feedback with CCs and uses in coaching and training (See HFW Satisfaction Quesitonnaire; TOM, WFI-EZ, NWIC Coaching Tools Descriptions, Consumer Perception Annual Survey)
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 (used in River Oak HFW) with the youth and family prior to the initial WTM and enlist more 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 the Agreements as needed with the entire team. This is included in the Plan of Care and filed in youth’s chart every 30 days. (see HFW Phase 1 Expectations page 3; Explaining HFW Components page 4; initial WTM agenda; POC/WTM minutes template-page 1 Ground Rules)
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 tracked at each WTM (every 30 days). It is numerically scaled to track progress on how the team is working together toward the common goal. Feedback from families is elicited during the meeting directly and their voice and choice are reflected along with other team members’ in measuring and tracking the progress. In addition, the families provide the team with feedback through TOMs and WFI-EZ administered quarterly, satisfaction surveys administered annually, and County CFT survey administered monthly. HFW coach conducts HFW Satisfaction questionnaire (quality assurance) phone calls to gather families’ feedback on the meetings and their overall satisfaction with HFW. (See POC/WTM minutes template page 1; Explaining HFW Components page 5; TOM, WFI-EZ, HFW Satisfaction questionnaire)
c) River Oak Quality management team provides results of the TOMs 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, Outcome Methods procedure page 1-2; TOM, WFI-EZ, Weekly Coaching Log, NWIC Coaching Tool Description item 3: CREST)
d) The Care Coordinator reviews the Plan of Care / WTM meeting minutes (strategies and tasks assigned) weekly with both formal (paid) and informal (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 POC/WTM template Strategies portion; Weekly Care Coordination meeting template; Explaining HFW components doc-page 9; HFW Phase 3 Expectations, page 2)
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. (See Plan of Care /WTM minutes template for who/what/where/when-page 5; HFW Phase 3 Expectations page 1; Explaining HFW Components pages 7-8
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 Care Coordination Meeting Structure template page 1; HFW Phase 3 Expectations page 1; Explaining HFW Components pages 9)
c) The Care Coordinator updates the Plan of Care is updated at each WTM (every 30 days) and tracking progress, brainstorming ideas, strategies, and actions steps in the Safety Plan are all included in the updated POC/WTM document. The updated POC is distributed to all team members within 7 days of the WTM. It is also sent to the Health Information Team for filing. The POC template is designed to allow the CC to freely update the POC (add and remove items) (See POC/WTM minutes template; Explaining HFW Components page 13).
d) The WRAP assessing therapist completes the initial IP-CANS assessment within 21 days from intake. The Therapist then coordinates results to the Care Coordinator prior to the initial Wrap Team Meeting (first 30 days). At the Initial Wrap Team Meeting, either the Care Coordinator or the Therapist who administered the IP-CANS will provide the team with the high scoring items to link the items to the referral behaviors, Outcome Statement, and Needs Statement. (See HFW Phase 1 Expectations page 2 –3 for procedure; HFW Phase 2 Expectations page 2 second box; HFW Phase 3 Expectations page 3, Phase 4 Expectations page 1-Transiiton readiness Indicators)
e) The Care Coordinator reviews the IP-CANS items at each Wrap Team Meeting with highest scoring items related to initial conditions (reasons for referral) and Outcome Statements. Care Coordinators explain to the team that the IP-CANS informs the development of underlying Needs Statement, however there are other items tracked over the course of the Wrap process, including the Needs Statement and Family Vision that inform when the family is ready for transition. Care Coordinators track action item completion by following up with team members weekly on their progress related to tasks assigned at the most recent Wrap Team Meeting (See POC/WTM minutes for tracking of Needs page 4; HFW phase 3 Expectations page 3; IP-CANS flyer)
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) WRAP teams 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 CCR fillable template page 1; HFW Phase 3 Expectations for E-WTM Procedure-page 3: Wraparound Team Meeting policy page 2; HFW Satisfaction Questionnaire; Wrap All Staff Meeting Agenda-’HiFi Corner’
b) River Oak WRAP 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 (HR Open Agency Policy; Care Coordinator HFW Coaching Log; Coaching support HFW Phase 1, 2, 3, 4 Expectations, last page of each doc)
c) Care Coordinator are required to attend NWIC Intermediate training, Wraparound 203 to enhance skills around the components of safety planning. (see NWIC Training Catalog for course descriptions page 2) 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 HFW Training Plan page 9; Wraparound Team Meeting Policy page 2; POC/WTM minutes template page 2; HFW Phase 3 and phase 4 Expectations for E-WTM procedure-page 3)
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 4 Expectations page 1-3; Team and Community Strengths Inventory; Discharge and Transition Planning policy pages 1-2)
b) The Care Coordinator works with the family on planning a graduation celebration that aligns with the family’s culture, preferences, and values. 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 certificate. (See HFW Phase 4 Expectations for Graduation Celebration -page 3; Graduation Certificate template; Explaining HFW Components page 11; Flex Funds Policy)
Expected Outcomes
2.1 Youth and Family Satisfaction
Providing quality care for youth and families is a cornerstone of River Oak’s Mission. Our Quality Management team administers several surveys throughout the year to measure the satisfaction of families and their support people including tribal communities if youth is part of a Tribal Nations as defined under Indian Child Welfare Act (ICWA). The surveys consist of TOM (quarterly); WFI-EZ (quarterly) offered and completed by the youth, caregiver, Care Coordinator, and a team member. Annual Consumer Perception Survey also provides critical feedback to the Wraparound team to identify areas off need improvements. The data gathered from TOM and WFI-EZ tool is provided directly to Wraparound Managers on a quarterly basis and utilized as a tool to coach and rain staff on a regular basis during weekly coaching, monthly group coaching and booster trainings. (See Outcome Methods procedure pages 1-2). The Quality management team conducts monthly Utilization Review ensuring the quality of care and service delivery is evidenced by the records of the youth (See Utilization Review policy page 1). In addition, the HFW coach utilizes HFW Satisfaction Questionnaire to enlist feedback from families, every 3-6 months) after WTM observation (in person) or via telephone and uses the feedback to coach staff on an individual basis as well. Families and team members are able to track their satisfaction during ongoing WTM by measuring their success/barriers as a team during review of Team Mission and reduction in IP-CANS scores. IP-CANS assessment is completed every 6 months (see Initial and Continuing Assessment policy-page 1, Assessment Checklist –6 months). In addition, CFT survey administered monthly to all participants of WTMs. Wraparound staff also present the family with two question progress survey in the first week of every month when the families complete the Service Verification forms whether the family sees progress toward their goals for the month. (HFW Satisfaction Questionnaire template; Explaining HFW components page 5- Team Mission)
2.2 Improved School Functioning
At River Oak, school attendance and performance are addressed in Wraparound Team Meetings. In the event IP-CANS items “school achievement” and “school attendance” are elevated, those items are shared with the team during the WTMs and the team develops strategies to address the barriers and needs. The IP-CANS is administered by the Wraparound Therapist within 21 days of intake, then every 6 months to track progress/barriers to all items including school. In addition, the HFW coach conducts a HFW Satisfaction questionnaire for quality assurance with families every 3-6 months to track school attendance and performance. The Wraparound Family Advocate supports the family with resources to address academic needs and ensures that caregivers receive information related to IEPs, 504 Plans, and when to ask for additional support for their children foster youth liaison and school counselor. Wraparound Youth Advocate supports youth ages 12 and up with exploring various clubs, interest groups, sports teams and other activities on campus to motivate and spark their interest in attending school more frequently and improve academic performance. The HFW coach highlights the areas of school attendance and school functioning, when the HFW Satisfaction Questionnaire is conducted (3-6 months). Wraparound staff also present the family with two question progress survey in the first week of every month when the families complete the Service Verification forms (See Intake and Continuing Assessment policy page 1, IP-CANS, HFW Satisfaction Questionnaire, Outcome Methods Procedure page 2, Service Verification Card page 2)
2.3 Improved Functioning in the Community
At the start of the Plan Implementation phase, the Wraparound team brainstorms for ideas towards community resources and connection during WTMs so that the youth and caregiver can build meaningful and sustainable relationships with their community. The team reviews Team and Community Strengths inventory to identify the most helpful connections to them. This includes both formal and informal activities, fun, age-appropriate and creative extracurricular activities, and employment opportunities to empower youth with independent living skills. River Oak Wraparound partners with multiple Transition Age Youth (TAY) many of whom benefit from connections with Sacramento County Independent Living program, Extended Foster Care orientations, volunteer opportunities and many other ways to connect with their community. The Wraparound team explores the most cost-effective and sustainable options for the family and utilizes Flex Funds as needed following the Wraparound Flex Funds policy to overcome financial barriers. (See Team and Community Strengths Inventory form; Flex Funds policy, POC / WTM minutes page 6 for brainstorming for community activities and Flex Fund team decision process; HFW phase 3 Expectations, AB –12 benefit flyer)
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 they hope for (overarching goal). It is developed by the family and the Care Coordinator during the Engagement phase, and only the family can make changes or updates to their Vision. Then the Vision is reviewed, and progress/barriers is tracked at each WTM, every 30 days, and visual tracking is displayed during WTMs either on power point or flip charts. The scores on the Family Vision enlist the family’s voice and their perspectives on their progress. In addition, IP-CANS assessment is monitored and administered every 6 months to track their progress in items like “interpersonal relationships” and “social functioning”. Wraparound Clinician also administers a PSC & Y-PSC (Pediatric Symptoms Checklist) with 35 questions for both youth and caregiver to gauge progress/barriers in interpersonal relationships and uses the data to address the challenges in individual sessions. These scores are also included in the youth Plan of Care to track progress. HFW coach conducts HFW Satisfaction questionnaire every 3-6 months to enlist relevant feedback as well. Administration of quarterly TOM and WFI-EZ alongside annual Consumer Perception Surveys and their results provide the Wraparound team with helpful feedback where coaching and training are designed to support staff. HFW (See Outcome Methods procedure page 1, Explaining HFW Components page 3 Family Vision; IP-CANS template and POC/WTM minutes page 1 tracking Family Vision progress; HFW Satisfaction Survey and Customer Perception Survey, Pediatric Symptoms Checklist, youth-Pediatric Symptoms Checklist)
2.5 Increased Caregiver Confidence
At River Oak, Care Coordinators identify parent/caregiver and/or biological family needs related to the referral behaviors and track progress throughout the Wrap process. The Parent/Caregiver Need Statement is reviewed, and progress is tracked at each WTM in the same manner as the 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 improvement for the caregiver and results are shared with the family. 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 (Explaining HFW components page 5, POC/WTM minutes template-page 4-Parent/caregiver needs and outcome tracking; HFW Satisfaction Survey, Initial and Continuing Assessment policy)
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 in their own community. To ensure stability, the Wrap team focuses on helping the family to identify the right people to be on their team and with a plan that fits the family’s needs. This includes assessing and adjusting the plan as needed during the WTMs or E-WTMs, mobilizing the existing support of people to manage crisis and stabilizing the youth in their living environment. In addition, the team explores additional short-term intensive support such as TBS (Therapeutic Behavioral Services) to stabilize the most concerning behaviors and keep the youth in their home or community. In the event changes in their living environment occur, the movement is tracked and documented in our Electronic Health Records system and in the monthly reports of Cross-Systems (X-systems) which is shared with the Sacramento County. The frequency and type of placement are entered into the health records system by the Care Coordinator within 24 hours, and the aggregated data generated by the EHR system are accessible by the staff and managers to inform each youth’s the frequency of placement changes. The quarterly TOM assessment provides the Wraparound team with data around the number of youth who have experienced movements during their care at River Oak. (See Outcomes Methods procedure page 1, Cross Systems Dashboard page 1, Cross Systems Aftercare template page 1; TOM page 6)
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Ensuring the safety of youth and families is a priority at River Oak. The team develops and updates a thorough Safety Plan for youth and family to follow to prevent or reduce behavior related ER visits and/or hospitalization. Also provide the families with 24/7 access to on-call assistance to minimize the risk of crisis that can lead to admission to behavioral health visits. When/if youth are hospitalized, staff are required to submit Incident Reports (IR) with the reason for hospitalization. Wraparound staff keeps close communication with youth’s treatment team at hospital, including the assigned case manager and treating psychiatrist, and ensure to be part of their discharge and/or safety planning meetings to ensure the youth makes successful transition back home. The hospitalization frequency is tracked in the River Oak Electronic Health Record. In addition, HFW satisfaction Questionnaire tracks any hospitalization during youth’s time in the HFW process, and the data is used to coach/training staff.
Submission of IR alerts the organization’s Executive Management Team and the team reviews both individual incidents and aggregated each month and for the fiscal year. Wraparound specific IR/AIR (Adverse Incident Report) pulled each month to show how many hospital /ER visits each month and sent to Wraparound managers. (See Outcome Methods page 2, Safety Event Policy-page 3 under Incident or Condition Event, On-call Crisis Response System policy pages 3-4, On-Call resources and Guidelines policy pages 1-2, EHR Screen shot of Wrap specific IR/AIR tracking)
2.8 Reduction in Crisis Visits
In Wraparound, the youth and family’s Safety Plan is developed in a way for the immediate family and natural support people to use step by step, proactive and reactive actions to prevent crisis or minimize the risks of potential crisis occurring. The plan also includes other support systems available to provide care during (direct team members) and after business hours including weekends and holidays (on call system or the Source team). When a crisis is reported, all staff are required to write Incident Reports to track any crises that require law enforcement or emergency services. Staff are required to write crisis intervention notes in the Electronic Health Record to record the frequency of responses by River Oak professionals to a crisis. Crisis visits and hospitalizations are tracked in the EHR and Wraparound specific IR/AIR pull each month to show comparison by month (see Outcome Methods page 2, EHR screenshot of Wrap specific IR/AIR tracking and Safety Event policy page 3). The River Oak HFW Team reviews and updates the family’s Safety Plan in WTMs. If a family reports a crisis occurred that was beyond their ability to manage, an (emergency) E- WTM is called by the Care Coordinator, and the team addresses the situation and ensures that the safety plan is updated to meet current and future needs to avoid crisis intervention. The clinician and Care Coordinator also practice the action steps with the family, and the family updates the team whether the plan is working. The clinician conducts assessments of PHQ-9 and Columbia to rule out suicide risks. (See Suicide Risk Assessment policy, On-Call Crisis Respond and Safety Planning policy; POC/WTM minutes for Safety Plan: page 2; Safety Event Policy page
2.9 Positive Exit from HFW
The River Oak HFW Team partners with youth and families to work towards their Family Vision and meet their needs for a better future. The team plans for transition from the very start of the Wraparound process by continuing to assess and adjust the plan until the family’s needs are met and significant progress is being made towards their Vision. River Oak works under the idea that plans fail, not families. HFW does not discharge based on adverse events and instead supports the family until they are ready for transition. (See HFW Phase 4 page 2 for Transition Readiness Indicators.) The start of Transition Phase is based on family voice and choice and improvement and/or maintenance of their scores on the Family Vision, Needs Statement, and Outcome statements (progress tracked at each WTM every 30 days). Wraparound staff uses the ‘whatever it takes’ approach to support the family throughout the process to see positive outcomes. The transition period is individualized for each family, and the period can last from 3-6 months, minimum of at least 60-90 days. The timeframe and manner of discharge are discussed and decided in the WTM setting. 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. At the end of the Transition phase, the team finalizes the Transition Plan and celebrates youth/family’s success. The HFW coach administers HFW satisfaction questionnaire during the Transition phase to gauge their satisfaction and adjust intervention as needed. 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 re ending and transitioning to a lower level of service, 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 Discharge & Transition Planning pages 1-2, HFW Phase 4 Expectations pages 2-3, Outcome Methods page 1 under Reason for Discharge))
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). (See Explaining HFW Components pages 2-5)
A) Upon receiving a new referral, a River Oak Wraparound manager calls the family within the same day to confirm the family’s interest in participating in the WRAP process. Then the Family Advocate/Certified Peer Specialist or Care Coordinator will contact the family to schedule intake within 10 days of receiving the referral and explain the Wraparound components and process and what to expect at intake and in the first 30 days. When the Care Coordinator meets with the family for the first face to face appointment (intake), they further explain the Wraparound process to the family and answer their questions related to components of High-Fidelity Wraparound. (See Intake Process policy page 1, Timely Access to Services policy pages 1-2, Intake Procedure-pages 1-4, Wraparound Intake Checklist)
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 Wraparound Process User Handbook pages 4, 8, 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 form, Informed Consent Policy, Mental Health Expectations and Notice to Clients forms)
c) In the first 30 days, the River Oak WRAP Team explains their title and roles to the youth and family and the Care Coordinator provides the family with a form that lists the team members’ names, titles, contact information, and respective roles. As the team grows, the “who is on my River Oak WRAP team” form grows to include important natural supports, Tribes 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 Team’ form; Wraparound Process User Handbook 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.
a) 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 Initial and Continuing Assessment policy page 1, Intake procedure page 2 (d); Initial Clinical Bundle checklist, HFW-Phase 2 Expectations document). 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 template-page 2)
b) When a crisis occurs, the team convenes to have an E-WTM 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 template page-2, Wraparound Team Meeting policy page 1-2)
c) 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 when needed. Throughout the WRAP process, families are reminded of the On-call number and procedure for 24/7 crisis response (See On-Call Crisis Response policy, On-Call Resources and Guidelines policy, Plan of Care template –page 2-3 for Safety Plan On-call contact information).
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.
a) 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 Explaining HFW Components pages 3-4, Plan of Care / WTM minutes template page 1.
b) 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 NWIC Coaching Tool Description-Family Story Tool and Timeline #1, 10, 11 & 12; Explaining WTM components pages 3 & 5; POC /WTM template –page 1 Strengths, page & page 4 Needs)
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 Coordinators utilize the Family Story Tool and Team and Community Strengths Inventory to identify natural supports that have helped the family in the past and who are then included in the Family Story and the Plan of Care. The documentation is filed in youth’s EHR (Electronic Health Records). Then use the Team Perspectives Tool to engage the support people. 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 NWIC Coaching Tool Descriptions, items 10&11, Team and Community Strengths Inventory page 1, Natural and Formal Support tracking form-excel)
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 POC page 1: involved team members’ strengths & page-7 WTM attendance sheet; NWIC Coaching Tool Descriptions #10, Explaining HFW Components page 10, Natural and Formal Support tracking form-excel)
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 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 POC and a copy is provided to the family. (see POC /WTM minutes template page 2, NWIC Coaching Tools Description #10, Explaining HFW Components pages 9 & 10, Natural and Formal Support tracking form-excel; Who’s on my team template)
d) Care Coordinators set aside time at the start of the Wrap Team Meeting 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 WTM agenda power points for initial and ongoing WTM for icebreaker slide #2; HFW Phase 2 Expectations page 1).
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. (See Remote Work policy pages 1-3), Interpretation Service Policy)
a) 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.) (See Remote Work policy pages 1-3). 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. (Gas Cards –sign out sheet)
b) 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. (See HFW Training Plan for further descriptions, pages 6-8). 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 River Oak Training Catalog; NWIC Training Catalog page 1; HFW Training Plan pages 6-9; NWIC Coaching Tool Description item #3)
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
1. The Wraparound Care Coordinator enlists the family’s voice and choice in development of Ground Rules / Team Agreements prior to the initial WTM. The Care Coordinator then brings the family’s list to the initial WTM to enlist the rest of team members ideas to add to the team agreement and ensures that everyone agrees about what is expected from each team member and how the team will make decisions going forward. The Ground Rules/Team agreement is reviewed/updated at each WTM (every 30 days). During the Wrap Team Meeting, Care Coordinators post the Ground Rules in a place that is visible to all participants. This is included in the WTM minutes and filed in youth’s chart every 30 days. The Care Coordinator connects the agreements to wraparound principles. (See POC WTM minutes template page 1; HFW-phase 1, 2, 3 expectations-page 1; Explaining HFW Components doc-page 4 under Ground Rules, Initial WTM agenda PPT)
2. The Care Coordinator reviews previously identified strengths and adds to each team member’s strengths during the WTM throughout the Plan Development, Implementation and Transition phases. Refers to Team and Community Strengths Inventory to highlight community strengths and adds additional resources available in the area during the brainstorming along with new team members/natural supports. The strengths are used in the development and update of strategies and tasks. Once identified, new support people and their strengths are added to the Plan of Care. Care Coordinators identify new strengths by using the Family story tool with families and the Team Perspective Tool with formal and natural supports outside of the family (See NWIC Coaching Tool Descriptions for items #10 & 11, Team and Community Strengths Inventory form page 1, POC/WTM minutes page 1, HFW Phase 3 Expectations page 1).
3. 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 supports, formal supports, and River Oak staff to follow throughout the WRAP process to help work towards achieving success. The Team Mission is inclusive of the family, 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 initial WTM agenda within HFW Phase 2 Expectations doc; Explaining HFW components doc page 5 under Team Mission)
a) 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) and gathering strengths (see #2 above) through the Family Story Tool and Team Perspectives Tool prior to the WTM and new strengths are added during WTMs . 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 (held within 30 days of intake). 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 HFW Phase 2 Expectations page 2; HFW phase 3 Expectations page 2; Initial WTM agenda PPT; Ongoing WTM agenda PPT pages 2 and on)
b) The Care Coordinator reviews the strengths and Functional Strengths in every Wrap Team Meetings (held at minimum every 30 days) and is documented 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 Family Story Tool with families and the Team Perspective Tool with formal and natural support outside of the family. 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 POC /WTM minutes template page 1, NWIC Coaching Tools Description items 10, 11, Team & Community Strengths Inventory form; Explaining HFW Components page 4)
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. (Developing Need Statements form, HFW Wraparound Phase 1 Expectations page 1-2; Explaining HFW components doc page 5-6)
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 behaviorally tracks progress throughout the WRAP process. This process takes place during the initial WTM. The improvement in outcome is one of the indicators that the youth are making progress toward meeting their needs. The team establishes a baseline and decides whether an increase or decrease is desired. The progress is tracked at each WTM. 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. (POC/WTM minutes page 1 and 4; Explaining HFW components-page 6 under OS)
c) River Oak Wrap Staff only develop 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). (see HFW-Phase 1 Expectations page 2; Initial and follow up WTM agenda on PPT)
d) The Care Coordinator leads the team for a robust brainstorming activity to address the need and documents brainstorming ideas in the Wrap Team Meeting Minutes and then transfers those ideas to the Plan of Care which is uploaded into the youth’s Electronic Health Record. Teams are encouraged to think of at least 10 ideas for each Need Statement. (See Plan of Care / WTM minutes template page 7 for Brainstorming; Explaining HFW Components doc page 6). WRAP support staff (therapist, youth advocate, family advocate, skills trainer) document their brainstorming ideas in their progress notes.
e) In a Wrap Team Meeting, Care Coordinators lead the team in brainstorming ideas to support the family’s Need Statement(s). Out of the possible brainstorming options, strategies are selected by the family based on what will work for them and what they want to prioritize, and the Care Coordinator collaborates with the team to assign tasks to each team member present. (see POC /WTM minutes template pages 4 and 5; Explaining HFW components page 7-8 (see all 3 areas of strategies)). Care Coordinators are trained by NWIC for Wraparound 101, formerly known as Introduction to Wraparound training where they learn the tools and techniques. To improve their skills in leading teams to strategize and develop action items, Care Coordinators have ongoing trainings 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 (see Coaching Log page 1, HFW-phase 2, 3, 4, Expectations for coaching requirements-last page)
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 such as collaboration, family’s voice and choice, team-based, strengths based, and outcome based etc., The initial Plan of Care is created after the initial Wrap Team Meeting and is updated every month (see POC /WTM minutes template). River Oak Wrap staff are coached to not make plans outside of the Wrap Team Meeting where the youth/family are present (see weekly Care Coordination meeting minutes template page 1; Wraparound principles.
4.3 Develop an Individualized Child or Youth and Family Plan
At River Oak, the Care Coordinator collaborates with the youth, family, system partners, natural supports, tribal representatives if youth is part of a Tribal Nations as defined under Indian Child Welfare Act (ICWA), and River Oak WRAP staff to create an initial Plan of Care in the first 30 days. Based on input from all team members in an initial Wrap Team Meeting, the Plan of Care includes: “what is going well” with the team process, a family vision (goal), a team mission (shared vision), 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. (See Explaining HFW Components pages 3-6, POC / WTM minutes template)
2) The Plan of Care highlights a youth and family member’s Need Statement that spans all life domains and suggests that if the need was fully 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. (see POC / WTM minutes template; HFW phase 1 Expectations document-page 1-2; Referral sources contact template page 1-2)
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. (See POC/WTM minutes template for page 4; Explaining HFW Components, pages 7-8). 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 HFW Phase 4 Expectations pages 7-8; weekly coaching log, and Natural and Formal Support tracking log)
4) The Plan of Care has a section where all ideas gathered during brainstorming session in the WTMs, every 30 days. This provides the space for all team members (youth, family, natural supports, system partners, formal services) to provide ideas to address the youth/family need and tailor to their specific family culture. The Care Coordinator reminds the team of their strengths and what the team can offer to support the family. Ideas can be formal services (i.e. trauma therapy, therapeutic behavioral services) 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. (See page 6 of Explaining HFW Components document; HFW Phase 2 Expectations-page 2: agenda and 2nd box) River Oak WRAP formal services and appointments are always offered in locations that best fit the family’s needs and at dates/times that the family agrees upon.
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 Implementation phase using the Team and Community Strengths Inventory 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. (POC/WTM Minutes Template-Brainstorming page 6; Team and Community Strengths Inventory form, Explaining HFW Components page 6)
6) A successful graduation from River Oak Wraparound is when the youth’s living situation is more permanent, less restrictive, and less formal services are in place. River Oak Wraparound is designed to meet families where they are at and go at their pace toward success. At each WTM, which occurs every 30 days, the family is scaling their progress towards their Family Vision, Need, and Outcome throughout the Implementation and Transition phases. As the gradual progress continued and maintained for at least 3-6 months, the team decides whether the family is ready to move from Plan Implementation phase to Transition phase. Ensuring the progress is maintained and based on the team decision, and Transition Readiness Scale, the River Oak WRAP team slowly transitions off formal supports and replaces formal services with natural and/or community supports. The Transition Plan and Post-Transition Safety Plan (both in final Plan of Care) include potential future needs and ways the family can meet those needs following the steps developed prior to Wraparound closure and remaining team members (natural support) are aware of their role and tasks as well. (See HFW Phase 4 Expectations page 2-3; POC/WTM minutes template 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 engagement including reflective listening (see HFW Training Plan page 1 & 7) . 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 NWIC Coaching Tools description for CREST and CCRSR items: 3 & 9). In addition, Care Coordinators meet weekly for 1 hour with their direct supervisor and have monthly 2-hour group coaching led by the HFW coach and WRAP supervisors. River Oak WRAP Staff attend a monthly 1-hour booster meeting to address topics related to HFW ten principles (See Group Coaching Agenda Template; Care Coordinator HFW coaching log).
b) The Care Coordinator skillfully incorporates the agenda and goals of System Partners (i.e. Child Protective Services, probation, school, tribal community, and other identified partners) by inviting them to Wrap Team Meetings so they can collaborate and be part of the HFW Team. System Partners are introduced to the HFW process prior to the initial WTM and share their agenda / goals with the Wraparound Care Coordinator. The Care Coordinator gathers all their input and encourages their participation and collaboration in the WTM to develop one Plan of Care for the family to work on during the initial WTM. The system partners’ voice is incorporated into the plan along with the family’s and everyone contributes to developing a shared Team Mission to work together for the duration of the Wraparound process. Everyone’s ideas and system requirements are reflected into the brainstorming section for the plan creation for the family to work towards meeting their needs. This is all added to the family’s Plan of Care / WTM minutes document that is updated after each WTM occurs every 30 days. (See HFW Phase 2 Expectations, POC/WTM minutes template; Referral Source Contact template)
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 supports, 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. (See POC/TM minutes template; HFW phase 2, 3, 4 Expectations for timely distribution of POC-page 2)
d) Care Coordinators are required to submit their initial Plan of Care to the HFW Coach for review in the first 6 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. (See NWIC Coaching Certification Requirements.) The HFW coach provides feedback to the Care Coordinator weekly and ongoing at each of their 1-1.5-hour individual coaching meetings.
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. The plan is reviewed and updated (as needed) during each follow up WTMs to prevent crisis , crisis visits etc., In the Safety Plan (see MyEvolv Safety Plan template), the Care Coordinator collaborates with the youth/family to list warning signs, triggers and ways to recognize a crisis could be developing. 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. 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), foster urgent response lifeline, Trevor Project, Poison Control, and local mental health urgent care clinics. The Crisis Plan in the Plan of Care has youth triggers and warning signs and provides space to list step by step proactive and reactive actions chosen by the family and solidified in a Wrap Team Meeting. Crisis numbers, 24/7 resources, and emergency support are also listed here. 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 POC / WTM minutes Safety Plan template page 2, Crisis Cycle tool, On Call Resources and Guidelines Policy page 1-2; On Call Crisis Response System policy page 1, Wraparound Team Meeting Policy).
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 each 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 Wrap Intake Checklist page 1, POC/WTM minutes pages 2-3, HFW Phase 1 Expectations page 1-2). 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) (see HFW Training Plan for description of each training), Care Coordinators are also trained in an online WRAP crisis module (see River Oak Training Catalogue page 13) and Safety Overview Orientation (River Oak Training Catalogue page 6, Care Coordinator HFW Coaching Log-page 1)
c) Care Coordinators submit their initial Safety/Crisis Plans to their HFW coach who uses the Supervisory Checklist (See NWIC Coaching Tools Descriptions item 1) and Supervisor Checklist Manual which includes examples and descriptions of each HFW competent/activities.(See NWIC Coaching Tools Descriptions item 1) to ensure the Care Coordinator has included all necessary components including family voice/culture, referral behaviors, 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. Care Coordinators’ direct supervisor reviews their Safety Plans at minimum every 6 months (See Wrap 6 month Bundle Checklist page 1, Wrap Annual Bundle checklist 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 (see Plan of Care /WTM minutes template and HFW Phase 2 for (Initial WTM agenda on page 2) and 3 Expectations ongoing agenda page 2, Explaining HFW Components page 9). 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 CC meeting template; Phase 3 – check yourself page 2, Explaining HFW Components pages 8-9 )
b) In addition to completing, the Wraparound 101, and Wraparound 102, formerly known as Introduction to Wraparound and Engagement in Wraparound, training courses upon hire to learn ways to develop and implement the Plan of Care in alignment with the HFW principles, River Oak 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 HFW Training Plan page 1, 6-9, NWIC Training Catalog pages 1-2). Staff are trained to celebrate successes at every stage, even a small success, (see Phase 3 Expectations page 1 and 2) and address “what is going well” at each Wrap Team Meeting (see POC / WTM minutes template page 1). HFW topics like 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. (Wrap All Staff Meeting Agenda-page1)
5.2 Review and Update The Plan of Care
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 fund 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 is 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. 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 makes sure that everyone is on the same page regarding how the strategies are designed to help 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. (See HFW Phase 2 (page 1) and HFW Phase 3 Expectations page 1-2; Explaining HFW Components page 9, Plan of Care/WTM template pages 4-5)
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 for 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. (Explaining HFW Components page 8, 9; POC/ WTM minutes template for tracking starting page 1-6; ongoing WTM agenda on HFW Phase 3 Expectations page 1-2).
c) The Care Coordinator documents assigned tasks and completion, team meeting attendance (both formal and natural supports), flex fund usage, and updates (brainstorm, needs, strengths) in the Plan of Care and Wrap Team Meeting minutes document. This is updated every 30 days within a week after the Wrap Team Meeting and sent out to all team members. Formal and natural supports are also included in the plan of care in the safety plan, strategies and tasks. (See Plan of Care/WTM minutes template; HFW Phase 2,3, 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 and phase 3- check yourself)
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. (Explaining HFW Components page 4; POC/WTM minutes template page 1; HFW Phase 1 Expectations page 3; HFW Phase 3 Expectations page 2 Agenda)
b) In addition to completing, the Wraparound 101, and Wraparound 102, formerly known as Introduction to Wraparound and Engagement in Wraparound, training courses upon hire to learn ways to develop and implement the Plan of Care in alignment with the HFW principles, River Oak 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 HFW Training Plan page 1, 6-9, NWIC Training Catalog pages 1-2). 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 WRAP staff meeting that includes a “HFW corner” to train and update teams, weekly 1-1.5 hours individual coaching, monthly 2-hour group coaching and monthly booster trainings as well. The NWIC tools used to coach/train staff include CREST, CCRSR, Supervisory Checklist and Manual along with Wraparound Supervision Wheel. (See NWIC Coaching Tools Description for the tools listed here; also see Booster Training Template and Wraparound All Staff Team meeting agenda template)
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. CFT County perception survey is administered to all team members monthly at the conclusion of a Wrap Team Meeting to track if natural support is being invited to the meetings. (See Client Satisfaction /Consumer Perception Survey 2025 Results pages 5, 7, 21-22, POC/WTM minutes page 6 for CFT meeting survey access via link provided; Natural, Formal, and Community Support Tracking form, TOM template)
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 have Tribal community affiliation, the CC ensures that the tribal representatives are orient to the Wraparound process and invited to WTMs with family’s permission. (See NWIC Coaching Tool Descriptions item #10: Explaining HFW components page 10-11, Phase 3 check yourself page 3, Tribal engagement Guide 2, 9, 10). During the Wrap Team meeting, new team members are encouraged to participate in a team building Ice Breaker at the start of the meeting (see WTM agenda on HFW Phase 2 and 3 Expectations-page 2), brainstorming ideas to meet youth/family needs, and included in every aspect of the WTM and Wraparound process. New team members will receive a copy of the updated Plan of Care following the Wrap Team Meeting.
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. In that time, the team identifies and confirms the potential natural, and community supports that will take place of River Oak WRAP team members and other formal supports will follow 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 (see Plan of Care template pages 1 & 4, HFW Phase 3 and 4 Expectations pages 1-2). 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. In addition, the Care Coordinator creates a Care Plan (Sacramento county requirement) at intake with the youth/family where it is determined how the family will know they are ready for transition and their Plan of Care which is developed at the initial WTM Plan of Care integrates this plan to ensure that the family has one plan. 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 team determines the tentative graduation in the WTM setting from 3-6 months to a minimum of 60-90 days out. (See HFW phase 4 Expectations page 1-3) This timeline is determined at a Wrap Team Meeting 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.
c) 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 any 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 into the youth’s Electronic Health Record. All River Oak WRAP staff write a final discharge note to signify the end of formal HFW services and includes a summary of services offered, what worked well throughout the process, future recommendations, and successes. (see Discharge checklist, discharge note template, HFW Phase 4 Expectations pages 2-3, Plan of Care/WTM template, Discharge letter template)
c) Transition is planned when the needs are met and improvements remain consistent for at least 3-6 months during Implementation phase. Transition is agreed upon by the youth, family, and team at a Wrap Team Meeting. Care Coordinators support families into the transition phase for the last 3-6 months of the WRAP process. This timeline and anticipated discharge date is determined at a Wrap Team Meeting based on progress, the maintenance of progress, family voice and choice, and team agreement. (see Plan of Care template- discharge) 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 (see HFW Training Plan pages 1, 6-9, & 12), NWIC Training Catalogue; Care Coordinator HFW Coaching log). 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 NWIC Coaching Tool Descriptions item 3).
d) During final planning (prior to the final Wrap Team Meeting), the Care Coordinator supports the family in confirming each natural support person who will be taking over roles that were previously assigned to River Oak WRAP 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. The Care Coordinator updates the Team and Community Strengths Inventory to ensure that the family refers to it, as needed, to make new connections after Wraparound. In the Discharge Summary Letter, 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 Team and Community Strengths Inventory page 1, River Oak Post-discharge follow up questionnaire).
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 part of 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 people remaining on the team. The plan is focused on reduction in reliance on formal supports and increase natural supports and community resources – proactive and reactive from what worked throughout WRAP process, safety plan updated within 30 days of discharge (See Safety Plan template within POC template page 2; HFW Phase 4 Expectations pages 2-4; Wrap Discharge Bundle Checklist). Care Coordinators prepare families with “forecasting” and planned rehearsals (see Phase 4 – check yourself page 2) to address and document what the team has identified as potential triggers throughout the WRAP process) (see Explaining HFW Components pages 11-13). 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 WRAP 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.
b) Transition Plan which includes the safety plan is updated at a final Wrap Team Meeting based on progress, the maintenance of progress, family voice and choice, and team agreement. (see Plan of Care/WTM minutes template) 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. In addition to utilizing the tools and techniques they learn from NWIC training, staff are also continuing with their weekly coaching, booster trainings and uses River Oak Open Agency policy to reach out to any manager to receive additional support as needed. (See HFW Training Plan pages 1, 6-10). 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 (see Training Catalogue page 13; HFW Training Plan ). 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 NWIC Coaching Tools Description item 3)
c) Care Coordinators submit their initial Safety/Crisis Plans to their HFW coach who uses the Supervisory Checklist (See NWIC Coaching Tool Desc for Supervisory Checklist item 1) and Supervisor Checklist Manual (See NWIC Coaching Tool Desc for Supervisory Checklist item 1) to ensure the Care Coordinator has included all necessary components including family voice/culture, referral behaviors, 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. Care Coordinators’ direct supervisor reviews their Safety Plans at minimum every 6 months (See Wrap 6-month Bundle, Wrap Annual Bundle and Wrap discharge Bundle checklists page 1, NWIC Coaching Tools Descriptions item 3)
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 Care coordinator 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 prior to the celebration. The youth and family are awarded a Wraparound Graduation Certificate at the celebration. (See HFW Phase 4 Expectations page 3: River Oak Flex Funds Policy-page 1-2; POC/WTM minutes –page 6 for Flex Funds Process, Explaining HFW Components page 13, Graduation Certificate template)
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 WRAP Graduation Certificate template; Flex Funds Policy page 1-4, POC / WTM minutes template).
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
River Oak WRAP 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 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 Form pages 1-2)
-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 /Client Satisfaction Survey for YSS, YSS-parent)
-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 TOM template)
-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 template for youth, Caregiver, 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 page1)
-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. (Please see POC/WTM minutes template 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 (Please see HFW Satisfaction Questionnaire).
-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. (Please see Service Verification Call form)
-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. (Please see Questionnaire: The Wraparound Advisory Dinner)
-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 Template, Sacramento County Grievance form page 1-2)
-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 hours is reserved for All-County High Fidelity Wraparound Plan; this session reviews plan elements and operational alignment with Child Protective Services (CPS) and Probation.
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.
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 National Wraparound Implementation Center (NWIC) and staff are trained by NWIC trainers for High Fidelity Wraparound onboarding and ongoing training. (See NWIC training Calendar and Catalog; River Oak HFW Training Plan pages 1, 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 process and the benefits families experience. (See POC/WTM minutes template for team composition)
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 Flex Funds Policy page 1-3).
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 Community Leadership Team are Amy Fierro, Chief Program Officer; Rene Oliver, ICS Division Director; Noelani Villasenor, Lead Clinical Program Manager
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; 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 HFW Training 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)
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
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 in 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. (River Oak Flex Funds policy, BHSA training power point)
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 HFW Training Plan pages 1, 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 Programs & Services brochure page 1-2). Once a month, Wraparound staff participate and regularly co-facilitate booster training via “HFW Corner” in which Wraparound Principles are incorporated within activities. (See Boster Training Structure.) 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 Care Coordinator HFW Coaching Log.) 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 ratio1 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 to provide supportive services unique to the members and family. Peer services shall be in accordance with COUNTY Policy and Procedure and shall adhere to State Peer Certification Requirements.
Data is captured and managed in several different ways; all data collected is securely stored and meets 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. 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 workflows
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.
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 POC/WTM minutes template, page 6, Flex Funds Process Policy, BHSA training PPT-wrap specific slides 21-22)
b) 1. Once the need for Flex Funds has been identified 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.
(b) 2. Please refer to attached Flex Fund Policy
(b) 3. Please refer to attached Flex Fund Policy
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 POC/WTM minutes template, page 6 Flex Fund process) 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 Flex Funds Policy)
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 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.
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 Housing and Homelessness Support policy pages 1, 6-7, Flex Funds Policy, Helping Hands Fund policy, Helping Hands Request form)
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 Housing and Homelessness Support policy pages 1, 6-7, Flex Funds Policy, 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 POC/WTM minutes template, page 6)
Per River Oak Policy: Flex Fund Supports Policy (#CO 6.1),
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’s hired and maintains employment for a minimum of six-months; the referring staff will receive a $500 bonus. (See Recruiting SOP-WRAP, HR 1.0 Recruitment and Selection page 1, HR 1.1 Equal Employment page 1, Open Agency Policy HR 4.6, Neighborhood relations policy)
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, CPS-appointed Cultural Brokers, Tribal representatives, community centers, mentorship programs). These accommodations are discussed and decided as a team in the Wraparound Team Meeting WTM) setting. The Care Coordinator assigns tasks to appropriate team members to ensure proper connections are made. (See Team and Community Strengths Inventory, Interpretation and Translation policy (we only use professionals, Tribal Community Guide – CFTs, POC / WTM minutes template).
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 page 1-2)
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 ICWA field office in the greater Sacramento region and receives the most updated educational information for staff development. Staff members attend the Indian Child Welfare Act (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). 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 HFW Training Plan page 1, 10, 11, Tribal Engagement Guide pages 2-10, Wraparound Process User’s Handbook)
(b) If youth is part of a Tribal Nations 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, we recognize that tribal traditions and ceremonies are used as protective factors. Utilizing tribal resources, we walk with the family to compliment services already in place. (Tribal Engagement Guide page 6-7 for staff educational purposes, Explaining HFW Components)
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 Open Agency Policy, 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 Implementation Workgroup Meeting template)
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. (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 are shared among each other to increase communication during available times. (See Open Agency Policy)
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” where Wraparound managers review the HFW philosophy. 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 (Please see NWIC Coaching Tools Descriptions for items 3 & 9, Care Coordinator HFW Coaching log, Group coaching structure)
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).
b) Each WRAP team member has unique and specific skills, functions, and qualities that contribute to the HFW team (see job descriptions)
c) Each WRAP team job description reflects HFW core principles and aims to recruit those that embody those qualities (see job descriptions)
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.
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. (Performance Evaluation Documents, Interview questions for CC/Therapist, Skills trainer, advocates)
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.
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.
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. (HR policies and position requirements). To support promotions within the agency, River Oak initially offers an internal hiring process prior to seeking outside candidates. (Internal job application template,
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.
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) Initial High Fidelity Wraparound Training, Wraparound 101 (previous title: Introduction to Wraparound), is provided to all employees within one month of hire. Each staff member’s training completion is tracked by the HFW Coach. 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 to 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. All instructor led training are interactive and allow staff to practice what they are leaning in small break out rooms and/or in a large group (see HFW Training Plan, pages 1, 6-7, NWIC training catalog/descriptions, and River Oak Training Attendance Tracking)
b) In addition, all Wraparound Care Coordinators are required to attend additional NWIC instructor-led trainings such as Wraparound 201 (Strengthening Practice), Wraparound 202 (Beyond Behavior), and Wraparound 203 (Supportive Planning) for Care Coordinators to enhance their skills and learn more in depth techniques around supportive planning and strengthening their practice. (See HFW Training Plan pages 1, 6-9, and NWIC Training Catalog pages 1-2). 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. (See River oak Training Catalog pages 6-10). In the first 60-90 days of hire, River Oak staff are also required to attend four or more shadowing opportunities. (See new employee 90 day program orientation checklist). 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 Coaching Log, HFW Training Plan page 12, NWIC Coaching Tools Descriptions, item 3).
c) All Wraparound Care Coordinators are required to attend the following training s annually: Wraparound 201 (Strengthening Practice), Wraparound 202 (Beyond Behavior), and Wraparound 203 (Supportive Planning) for Care Coordinators to enhance their skills and learn more in depth techniques around supportive planning and strengthening their practice. These trainings are delivered by NWIC certified trainers. (See HFW Training Plan pages 1, 6-9, and NWIC Training Catalog pages 1-2).1, All Wraparound staff are required to attend monthly booster trainings that address HFW 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 enhance their skills. (See Booster training template, HFW Training Plan page 11; River Oak Training Catalog pages 5-10)
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 and HFW Training Plan pages 1-7). Wraparound trainer/coach attend NWIC led, quarterly Wraparound Virtual Coaching Collaboration (WVCC) where coaching and supervision best practices are presented from NWIC trained coaches nationwide. (see HFW Training Plan, WVCC forum description)
e) River Oak Wraparound is building a partnership with the Tribal Affairs office, Central ICWA 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. (see HFW Training Plan pages 10-11 and Child and Family Teams – Tribal Engagement Guide)
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) The Wraparound Training manager/HFW coach and one rotating WRAP staff member develop a monthly booster training curriculum that reflects youth and family responses to previously administered surveys and direct feedback from quarterly advisory dinners. In addition, Wraparound Youth and Family advocates provide ongoing feedback on meaningful and applicable training topics and curriculum development based on their lived experience. The Advocates are an integral part of the family and become a crucial source of support to youth and families who sometimes are unsure about the HFW components or unwilling to participate. (See HFW Training Plan page 11; Booster Training template-ppt)
b) River Oak Wraparound managers work closely with the Sacramento County Contract Monitor in our effort to implement HFW effectively. The contract monitor and Sacramento County Wraparound providers conduct One Stop delivery at Child Protective Services and Probation offices to introduce them to the Wraparound process. During this one-hour presentation to each of their facilities, the probation officers, social workers, and their supervisors are oriented in HFW components, eligibility for the Wraparound process and the importance of their role and participation in WTM/CFTMs. They are provided with Wrapround Process user’s Handbook to learn more and/or share with youth and families. River Oak Wraparound will continue to reflect the community partners’ feedback on the development of booster training and invite them to attend our monthly booster training. In addition, Wraparound team members strive to have consistent contact with the community partners to continue educating them about the Wraparound process and answering their questions. In the beginning of services, when a Care coordinator receives a referral, the Care Coordinator and an Advocate are conducting a one-on-one session with the referring partner to explain the process, their role on the team, their strengths, agenda, and perspectives of the family to inform the Family Story and the promote effective teaming during the Wrap process. This connection is continued across all phases of Wraparound. (See HFW Training Plan page 11, WTM agenda within HFW Phase 2 and phase 3 Expectations, Explaining HFW components page 10, Wraparound Process User Handbook)
9.8 Coaching and Supervision
River Oak Wraparound onboarding process ensures that all staff are introduced to HFW within one week of hire by meeting with HFW coach and learn about HFW components, their role on the team, required onboarding trainings with National Wraparound Implementation center (NWIC) and a brief description of Integrated Core Practice model (ICPM).
a) HFW Coach meets with new staff via Microsoft Teams to provide an overview of the high-fidelity Wraparound process covering Wraparound phases, 10 principles, key elements and role specific Wraparound activities they are expected to perform in their job duties. The HFW Coach invites new staff to create a profile in the NWIC portal to start HFW online, prerequisite courses and then sign up for 3 live training taught by NWIC trainers. Staff are provided with a copy of Wraparound Process User’s Handbook for their reference and share with youth, families, and community partners. All staff are required to attend Flex Funding / BHSA training upon hire to learn ways of meeting families’ needs with support of Flex funds as needed. They learn that this process is discussed and decided upon in WTM settings. The HFW coach schedules a follow up session with the new hire to answer questions or support in completion of prerequisite courses, etc., to ensure their onboarding process continues successfully. (See HFW Training Plan pages 3, 4, 5; Wraparound Process User’s Handbook, BHSA training ppt pages 21-23)
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 follows the agency’s Open Agency policy and offers additional ‘open office hour, 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. After hours and over the weekend, staff can connect with an assigned on-call manager by direct phone call, email and Microsoft Teams messaging, as needed (See HFW Training Plan page 12, NWIC Coaching Tools Description items 3 & 9 for CREST, CCRSR, Care Coordinator HFW coaching log, On call Crisis Response System)
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) Wraparound training manager/coach utilizes a data driven approach when training and coaching staff based on observation, document review (utilization review) and data aggregated from the Quality management team on a 6–12-month basis. The coach reviews the data with Care Coordinators and other River Oak HFW team members in their weekly individual and monthly group coaching. The data reviewed includes the presence or absence of natural support or relevant formal support on HFW Teams, number of days that elapse before the next Wrap Team Meeting, and percentage of successful discharges. This information is used to improve the quality of care provided to the families by ensuring staff are using skillful approaches to meet individual youth and family needs. The data and interpretations are shared by the Quality Management team with River Oak WRAP supervisors to use as training, supervision, and coaching tools. The Quality Management team also administers WFI-EZ (quarterly), TOMS (quarterly), and annual Client Satisfaction Survey (Consumer Perception Survey) results to provide the team with feedback on WRAP fidelity and youth/family reports. Enclosed 2025 report card for Client Satisfaction Survey details samples of Wrap specific youth and caregiver’s satisfaction in areas of Access to Services, Participation in Treatment Planning, Appropriateness of Services, Outcome of Services and Social Connectedness in comparison to previous two years (pages 5, 21-22 Client Satisfaction Survey results 2025, HFW raining Plan page 12, Care Coordinator HFW coaching log). This report is meaningful feedback for the management team to review with staff and use as coaching and training tools on an ongoing basis. 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 procedure pages 1-2, Utilization Review policy pages 1-2, Client Satisfaction Survey Results document for 2025 as an example of aggregated Wrap data Pages 5, 7, 21-22; Timely Access to Services policy
b) The HFW team is provided with data at 6 to 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 managers conduct 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. (See Outcome Methods page 1-2; UR Tools, Utilization Review Policy, TOM, WFI-EZ, and Consumer Perception /Client Satisfaction survey tools; Implementation Group Meeting Agenda template)
c) Data gathered from the Quality Management team is shared with the River Oak program and organization leadership to identify and address system barriers. At River Oak Wraparound, based on the natural support tracking, the identification and/or involvement of natural support people in the Wraparound process and in Wraparound Team Meetings (WTM) appear to be an area barriers. The Community Leadership Team is advised of such barriers and share the trend with the rest of the team to share ideas and provide staff and managers with feedback. Though the Community Leadership Team is established recently, River Oak is represented by three members, Amy Fierro, Chief Operations Officer: Rene Oliver, Intensive Community-Based Services (ICS) Division Director, and Noelani Villasenor, 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. (See Outcome Methods, Natural, Formal, & Community Support Tracking)
Fidelity Indicators
1.1 Timely Engagement and Planning
a. County of San Diego (CoSD) operates two Wraparound programs that are managed through two distinct contracts. One contract is primarily focused on serving system involved youth with high level of expertise and collaboration with the local Child Welfare Services Department (locally referred to as Child and Family Well Being – CFWB) and the Probation Department. The second contract is primarily focused on serving children, youth and families that are community based with an emphasis on other child serving systems such as schools. Both contracts have overall expertise in wraparound and are not limited to the primary focus. Both contracted providers offer aftercare services and have been utilizing the Wrap Fidelity Index Short Version WFI-EZ since October 2022.
CoSD High Fidelity Wraparound (HFW) providers are expected to adhere to the Department of Health Care Services (DHCS) access time standards as outlined in the CoSD, Behavioral Health System of Care Organizational Provider Operations Handbook (OPOH), where routine appointments are required to be offered within 10 days of request for services. (Attachment 1: OPOH section C16). This requirement is also outlined in the Statement of Work (SOW) item 3.2.1.1 and 6.11.2 (Attachment 2: Statement of Work,). Contracted providers document adherence to access timelines in the CoSD Timely Access Data Tool Report which is included in the Quarterly Status Report (QSR) (Attachment 3: QSR Template, Access Time tab pages 7-8). Additionally, the infrastructure and expectation for urgent requests is outlined in the OPOH (Attachment 1: OPOH C16) which indicated that urgent appointments are offered within 48 hours of the request. The CoSD Contracting Officers Representative (COR) team meets with the contracted HFW provider monthly for Technical Assistance (TA) to review access time, and to identify and problem solve any access to care barriers. Requests may be sent for urgent “Barrier Buster” referrals for youth that have acute complex needs and involvement with various parts of the system of care (hospitals, intensive outpatient services, partial hospitalization, etc.), and HFW providers prioritize these urgent referrals. The system follows the same process for AAP eligible children, with the overall philosophy of making contact with families as soon as possible.
b. HFW providers complete the Child and Family Team Meeting (CFTM) Summary and Action Plan (Attachment 4) hereafter referred to as the HFW Plan of Care (HFW-POC) within timelines established in the HFW Aftercare BHIN 25-027, as required in 6.2 and 6.11.2. of the SOW (Attachment 2: SOW). The SOW requires that the contractor have a Quality Assurance Process (QAP) in place (Attachment 2: SOW items 5.6.1. and 5.9.1.1., and Attachment 1: OPOH, G1) that includes internal quality improvement controls to ensure alignment and adherence to SOW requirements. The HFW-POC is a locally established document in partnership with the Child Welfare and Probation Departments as well as contracted HFW providers who bring in the input of the youth, family and those with lived experience. The HFW-POC has gone through various phases of quality improvement, and the local Wraparound Oversight / Community Leadership Team is currently reviewing and considering adjustments to several HFW documents to ensure alignment with State guidance as it is made available.
c. CoSD HFW providers are required to review the HFW-POC at each HFW Team Meeting, or at a minimum of every 30 days (Attachment 2: SOW items 6.11.2.2.). Adherence to the requirements is monitored through the HFW provider’s QAP as stated in the OPOH (Attachment 1: OPOH G1). The HFW-POC (Attachment 4: CFTM Summary and Action Plan) is dated with a copy offered to each of the HFW Team Meeting participants. Current review and dialog pertaining to the HFW-POC document includes adding a notation that the Plan of Care was offered to the youth/family. Contracted HFW providers have an established QAP to ensure that documentation requirements outlined in the SOW are adhered to, and each contracted HFW provider staffs a HFW Supervisor who reviews documentation to reinforce adherence to expectations (Attachment 2: SOW 6.21.4.2.).
For system involved youth, the placing agency manages the CFT meetings where the CFTM Summary and Action Plan is completed. Since the CDSS mandated CFT meeting timeline is on a 90 day vs. 30/45-day rotation, there are typically additional HFW Team Meetings (HFW CFT meetings) which may not be identified as the mandated CFT meetings by the placing agency (CFWB and/or Probation). The goal is to have all the child/youth team members participate in CFT and HFW CFT meetings. The CFTM Summary and Action Plan is utilized as the HFW-POC and any updates made within the context of a HFW CFT are brought forward and reviewed at the 90 (or triggering event) CFT meeting.
d. CoSD contracted HFW providers adhere to the State Medi-Cal Manual (3rd Edition 2018) when serving children or youth who are receiving ICC, IHBS, or TFC, which states that a CFT meeting must occur at least every 90 days. Adherence to these requirements are outlined in section 6 of the SOW (Attachment 2: SOW item 6.11.3.1. and 6.43) in which the County calls for contractors to adhere to the State Medi-Cal Manual for Intensive Care Coordination (ICC), Intensive Home-Based Services (IHBS), and Therapeutic Foster Care (TFC) Services for Medi-Cal beneficiaries. Providers document HFW-POC and HFW-POC updates in the CoSD BHS Electronic Health Record (hereafter referred to as the “medical record”), SmartCare, and adherence to the requirements are monitored through the program’s Quality Assurance Process (Attachment 1: OPOH G1 and Attachment 2: SOW 5.6.1.), and in the Quality Assurance Program Review (QAPR) (Attachment 5: QAPR item QC6). Currently the ‘HFW-POC’ document is maintained by the HFW provider as a hybrid record, with intent to update the process to require uploading of the HFW-POC document into SmartCare. The HFW-POC document specifically outlines an expectation that it is ‘shared with all members of the CFT.’ Partnering agencies are collaborating to update the HFW-POC form to include a checkbox that denotes when the document was offered to all participants, including the child/youth/family. It is anticipated that the finalized form will be approved and available for use prior to the start of the 26-27 fiscal year.
e. Feedback related to expected timelines is provided to HFW staff as outlined in the SOW (Attachment 2: SOW 6.25.2.) by HFW Supervisor and/or Fidelity Coach. Documentation timelines are reviewed in the QAPR (Attachment 5), which is reviewed with providers in an exit interview. If there are deficits to meeting expected timelines, program is directed to complete a mitigation plan. The QAPR is currently under review to ensure alignment with forthcoming DHCS guidance related to HFW, with a goal of completing updates by 7.1.26 for utilization in fiscal year 2026-27.
f. The CoSD Full-Service Partnership model calls for a “whatever it takes” philosophy (Attachment 2: SOW 2.10.1.) to meet client needs, by providing intensive services and supports. Contracted HFW providers are required to implement this “anything necessary” approach outlined in the SOW (Attachment 2: SOW 6.1). Contracted HFW providers report all referrals received each quarter and must provide explanations for any referrals that do not result in program enrollment (Attachment 3: QSR, Access Time tab pages 7-8). HFW providers utilize the 10 principles of Wrapround as a guide to services, which includes ‘unconditional care’ and ‘persisting’ despite challenges. HFW staff are trained in Foundational Wraparound, which includes timely engagement and alternative strategies (Attachment 2: SOW 6.24.). Training is monitored in training logs submitted by the HFW provider with the submission of the QSR (Attachment 2: SOW 6.26).
1.2 Led by Youth and Families
a. CoSD requires that contracted HFW providers offer coordinated services that are child, youth, and family driven, where family voice, choice, and lived experience are elicited during the Strengths, Needs, Culture and Vision Discovery and Team Mission Statement. These activities occur during the Engagement and Plan Development Phases with expectations outlined in the SOW (Attachment 2: SOW 6.11.1.4. and 6.11.2.1.), monitored by the program through supervision and coaching for Continuous Quality Improvement (CQI) (Attachment 2: SOW 6.25.1) and through the providers QAP (Attachment 1: OPOH G1 and Attachment 2: SOW 5.6.1.). HFW Supervisors are expected to routinely review chart documentation to provide feedback to HFW staff on HFW practices, including Family Vision and Team Mission statements (Attachment 2: SOW 6.21.4.2.). For Indian children, CoSD emphasizes the inclusion of tribal perspectives. The Wraparound Oversight Team and Community Leadership Team have identified tribal engagement as a priority. A designated representative from the Southern Indian Health Council participates in these bodies to ensure tribal considerations are incorporated, as described in the Community Leadership Team Charter Agreement (Attachment 10).
b. Family values, culture, expertise, capabilities, interests and skills are elicited from each client and family during the engagement phase of wraparound (Attachment 2: SOW 6.11.1.) and documented in the client’s medical record CalAIM Assessment (Attachment 6, Domain 5 and 6), which are reviewed and monitored in the QAPR (Attachment 5: QAPR A2). This practice reflects core HFW principles, which emphasize family voice and choice, cultural humility, and a strengths-based approach. Clear documentation of the family’s values and cultural context ensures that the HFW team can consistently ground planning, decision-making, and service strategies in what is most important to the family. This information is revisited throughout all phases of the wraparound process to support individualized, culturally responsive care and maintain fidelity to HFW practice standards.
c. CoSD contracted HFW providers are required to staff a HFW Supervisor and Fidelity Coach (Attachment 2: SOW 6.21.4. and 6.21.5., respectively). These roles observe HFW team meetings and review documentation to gather and provide feedback to staff to reinforce practice expectations, build skills, and increase staff confidence (Attachment 2: SOW 6.21.4.2.). Positions are monitored via the QSR S&P tab (Attachment 3: pages 9-10), with monthly staffing updates provided by the contracted HFW provider to the Contracting Officers Representative (COR) team in monthly Technical Assistance meetings.
d. CoSD requires contracted HFW providers to complete annual Wraparound Fidelity Index – Short Form, Version EZ (WFI-EZ) surveys (Attachment 2: SOW 6.44), with outcomes monitored in the QSR (Attachment 3: QSR, Outcomes Tab pages 3-5, rows 74-116). CoSD partners with the University of California, San Diego (UCSD) Child and Adolescent Services Research Center (CASRC) to support data collection and outcomes monitoring for High Fidelity Wraparound. CASRC gathers WFI EZ data directly from contracted HFW providers, analyzes and synthesizes the information, and produces an annual outcomes report (Attachment 8). This report includes key findings and recommendations that CoSD uses to guide program improvement and ensure ongoing fidelity to the Wraparound model. As the State releases further guidance, the contracted providers are expected to make any necessary adjustments to fidelity tool utilization and direct coordination with the identified Center of Excellence (COE) (Attachment 2: SOW 6.2.). In addition to information and feedback gathered specific to wrap fidelity, contracted HFW providers are required to elicit feedback from families at a minimum two times per year through the administration of a Program Advisory Group (PAG) (Attachment 2: SOW 6.32) (monitored in QSR, Attachment 3, Outcomes tab pages 3-5, item 4), once a year through the administration of the Youth Services Survey (YSS) (administered to youth and caregivers), and through outcome measures including the IP-CANS and the Pediatric Symptom Checklist (PSC). Outcome measure expectations are outlined in the OPOH (Attachment 1: OPOH G14 and N6-N12). IP CANS and PSC Assessments are integral measures that are used to monitor outcomes for each client. These various measures to gather input are expected to be used by the HFW providers to inform and improve practice.
1.3 Strength-Based
a. CoSD contracted HFW providers facilitate activities to gather strengths for each team member beginning in the engagement phase of wraparound (Attachment 2: SOW 6.11.1.4.). The Strengths, Needs, Culture, and Vision Discovery form is currently in development through the Wraparound Oversight Team and will be expected to be uploaded to the client’s medical record with plans to monitor as a part of the QAPR process, and will be included in the QAPR tool.
b. The IP-CANS assessment is administered for each client (Attachment 1: OPOH N7), and the outcomes provide a comprehensive understanding of the child’s strengths and needs. The identification of strengths is not limited to information gathered from the IP-CANS, as the HFW team identifies strengths through various activities throughout the phases of wraparound (such as the Strengths, Needs, Vision, and Culture Discovery) (Attachment 2: SOW 6.10.2.). Additionally, information about client, family, and team member strengths are gathered at HFW CFTs and documented on the HFW POC, which is included in the chart documentation with copies distributed to attendees (Attachment 4: CFT Summary and Action Plan).
c. HFW Supervisor and/or Fidelity Coach provide ongoing coaching and training to HFW staff in alignment with HFW requirements, to support reinforcement of HFW practice expectations, build staff skills in strengths-based and solution focused services, and to increase staff confidence (Attachment 2: SOW item 6.3.2., 6.4.3., 6.21.4.2., 6.25., and 6.26.). Staffing and training logs are monitored in the HFW providers training log submission with QSR (Attachment 2: SOW 6.26).
d. CoSD requires contracted HFW providers to complete annual WFI-EZ surveys, as outlined in the SOW (Attachment 2: SOW 6.44.) and monitored in the QSR (Attachment 3: QSR, Outcomes tab pages 3-5, rows 74-116). One of the WFI-EZ Key Element gathered from caregivers includes their perspectives on strengths-based and family-driven services (Attachment 2: SOW 6.44.7.5.). These caregiver perspectives support CoSD’s ongoing assessment of fidelity to HFW principles and help inform continuous quality improvement efforts and are summarized in the WFI-EZ Annual Report (Attachment 8: WFI-EZ Annual Report). In addition to information and feedback gathered specific to HFW, providers are required to elicit feedback from families two times per year through the administration of a Program Advisory Group (Attachment 2: SOW 632) (monitored in QSR, Attachment 3: Outcomes tab pages 3-5, item 4), and once a year through the administration of the Youth Services Survey (YSS) (administered to youth and caregivers). Outcome measure expectations are outlined in the OPOH (Attachment 1: OPOH, G14 and N6-N12).
1.4 Needs Driven
a. CoSD contracted HFW providers adhere to the 10 principles and 4 phases of wraparound. During the Engagement Phase, the HFW team works with the youth and family to identify needs and strengths (Attachment 2: SOW 6.11.1. and 6.11.1.4.), which are documented as a part of the CalAIM assessment (Attachment 6) and documented in the medical record. Contracted HFW providers have an established QAP to ensure that documentation requirements outlined in the SOW are adhered to, as outlined in the OPOH (Attachment 1: OPOH G1 and Attachment 2: SOW 5.6.1.). HFW providers prioritize the underlying needs to develop the HFW-POC. San Diego aligns with the State policy by embracing a single, unified CANS assessment upon admission to HFW, ensuring consistency with both DHCS and CDSS. The IP-CANS serves as an essential tool for identifying priority areas and guiding individualized planning. Its use ensures that the team has a clear, structured understanding of the child’s strengths and needs, forming the foundation for effective decision-making and service coordination. In support of consistent practice across the system, the CoSD Wraparound Oversight Team (consisting of BHS, Probation, CFWB, and contracted providers) has also begun exploring the development of a “Strengths, Needs, Culture and Vision Discovery” form used by both community- and system-serving HFW providers to support a consistent, systematic approach grounded in HFW principles.
b. CoSD contracted HFW providers are required to ensure that their staff training aligns with California Wraparound Standards (Attachment 2: SOW 6.21.4.3 and 6.25), which specifies that contractor provides ongoing training and coaching of team members in alignment with COE guidance to support consistent, high-fidelity youth and family-driven HFW services, and CQI. Training is monitored through training logs submitted by the HFW provider with the submission of the QSR (Attachment 2: SOW 6.26).
c. CoSD contracted HFW providers follow state guidance by using an IP-CANS assessment at the time of admission to HFW, ensuring alignment with both DHCS and CDSS requirements (Attachment 1: OPOH N7). Information gathered through the IP CANS directly informs individualized planning and helps the team clearly understand the areas that must be addressed to support effective decision making and coordinated service delivery. This is a foundational assessment measure, but not the only method that HFW providers use to identify needs; other methods and activities are implemented, and each is individualized based on the unique youth and family. The IP-CANS data is entered into the medical record and monitored through the HFW POC (Attachment 4) and outcomes monitoring. Data collected from the IP-CANS is used as one of the guides for the HFW POC (Attachment 4: Child and Family Team Meeting Summary and Action Plan, section 3). The CoSD Wraparound Oversight Team is actively working to align with CDSS and DHCS HFW standards by expanding strategies-beyond the IP-CANS- that deepen family engagement and foster the trust necessary for families to comfortably share their needs with the HFW team. This includes the development of a Strengths, Needs, Culture & Vision Discovery form and incorporating practices such as guided conversational storytelling, life-domain mapping, eco-mapping, exploration of cultural rituals and identities, and review of past service experiences. Together, these approaches support a structured and individualized process for identifying youth and family needs and strengthen fidelity to California’s HFW model.
d. Transitions are planned within the context of the HFW Child and Family Team Meetings (CFTM), where goals are reviewed and any additional needs are reviewed through the HFW POC (Attachment 4: Child and Family Team Meeting Summary and Action Plan, section 4). CoSD contracted HFW providers support the youth and family in transitioning out of HFW, ensuring that benchmarks and indicators mark sufficient progress towards goals and that youth and family are ready for transition (Attachment 2: SOW 6.11.4.1.). Transitions are documented in the Discharge Summary (Attachment 7) and monitored in the QAPR (Attachment 5: QAPR C3).
1.5 Individualized
a. CoSD contracted HFW providers implement various strategies to support individualized plan development, including the completion of the Strengths, Needs, Culture, and Vision Discovery (Attachment 2: SOW 6.11.1.4.). The HFW POC (Attachment 4: Child and Family Team Meeting Summary and Action Plan) is a living document, updated at CFTMs to allow for flexibility as new needs arise; the HFW POC will be included in the medical record and monitored through the providers QAP (Attachment 1: OPOH G1 and Attachment 2: SOW 5.6.1.). HFW forms that will be monitored in the QAPR are currently in development with providers and system partners. This is part of an ongoing workgroup aligning documentation and monitoring of HFW activities in accordance with the forthcoming HFW Policy Manual and will be launched in FY 26-27.
b. CoSD contracted HFW providers are required to ensure that their staff training aligns with California Wraparound Standards (Attachment 2: SOW 6.25), which specifies that the HFW contractor provides ongoing training and coaching of team members in alignment with COE guidance to support consistent, high-fidelity youth and family-driven HFW services, and CQI. Training is monitored in training logs submitted by the HFW provider with the submission of the QSR (Attachment 2: SOW 6.26).
c. CoSD contracted HFW providers are required to ensure that their HFW Facilitators complete the Statewide Standardized CFT Facilitation Training and the Foundational Wraparound Training (Attachment 2: SOW 6.23 and 6.24) and have ongoing training that aligns with California Wraparound Standards (Attachment 2: SOW 6.25). The Statewide Standardized CFT Facilitation Training is grounded in the Integrated Core Practice Model, which centers on the youth and family voice, and emphasizes creating a culturally responsive space; the Foundational Wraparound Training similarly ensures facilitators have the tools to engage youth and families to develop culturally responsive and strengths-based plans of care guided by the youth and families values, cultures, and preferences. HFW Facilitators Training and ongoing training is monitored in training logs submitted by the HFW provider with the submission of the QSR (Attachment 2: SOW 6.26). HFW Supervisor and Fidelity Coach routinely observe and provide field coaching, training, and/or feedback to increase staff (including Facilitator) skill set and confidence in their role and function (Attachment 2: SOW 6.21.4. and 6.21.4.3.).
d. CoSD contracted HFW provider Supervisor shall review documentation (Attachment 2: SOW 6.21.4.2.), which includes the HFW POC. Additionally, HFW providers conduct ongoing Quality Assurance monitoring through their QAP (Attachment 1: OPOH G1 and Attachment 2: SOW 5.6.1.) to ensure adherence to requirements.
e. CoSD requires contracted HFW providers to gather family feedback on their experience receiving individualized and customized services through multiple mechanisms, including the WFI-EZ survey which provides critical insight into how well providers are delivering strengths-based, family-driven and need-focused services. Contracted HFW providers are required to meet specific Key Element WFI EZ score thresholds, including family-driven practices as noted in the SOW (Attachment 2: SOW 6.44.7.5), and monitored in the QSR (Attachment 3: QSR, Outcomes tab pages 3-5, rows 74-116). A comprehensive outline of WFI-EZ findings is shared with CoSD and providers in the WFI-EZ Agency Report (Attachment 8). In addition to information and feedback gathered specific to HFW, providers are required to elicit feedback from families two times per year through the administration of a Program Advisory Group (Attachment 2: SOW 6.32) (monitored in QSR, Attachment 3: QSR, Outcomes tab pages 3-5, item 4), and annually through the administration of the Youth Services Survey (YSS) (administered to youth and caregivers). Outcome measure expectations are outlined in the OPOH (Attachment 1: OPOH G14 and N6-N12).
1.6 Use of Natural and Community Based Supports
a. CoSD requires contracted HFW providers to maximize the identification and inclusion of natural supports as part of the HFW CFT as described in the SOW (Attachment 2: SOW 6.11.1.1). In addition to youth and family identified support individuals, the HFW team intentionally explores community-based supports and relationships-such as faith communities, cultural or religious groups, sports teams-as potential natural supports that can strengthen long-term gains for the youth and family. Following forthcoming DHCS and CDSS guidance, Activity Funds will be leveraged, as appropriate, to cover the costs of physical wellness activities and other healthy-lifestyle or strengths-based activities for child welfare involved youth to access community support activities. Natural supports are incorporated into the HFW POC and listed as CFT members (Attachment 4: page 1), and the team works to ensure that they are actively engaged in planning and can support with action steps as appropriate. Natural and community supports inventories are documented in the shared medical record and monitored through the HFW providers ongoing Quality Assurance monitoring through their required QAP (Attachment 1: OPOH G1 and Attachment 2: SOW 5.6.1.).
b. Contracted HFW providers are expected to implement ongoing training and coaching for staff, inclusive of identification, engagement, and integration of natural supports, and in efforts to decrease reliance on formal supports (Attachment 2: SOW 6.21.4.2.). Training is monitored in training logs submitted by the HFW provider with the submission of the QSR (Attachment 2: SOW 6.26).
c. County contracted HFW providers are required to have HFW Supervisors and Fidelity Coaches on staff who routinely review documentation (Attachment 2: SOW 6.21.4.2. and 6.21.4.3.) to ensure alignment with HFW principles, which includes ensuring a team-based approach that actively seeks to incorporate natural supports. HFW team members consistently revisit the topic of natural supports in each HFW CFT meeting, helping the youth and family identify individuals who can be part of their support system. As new natural supports are added, they are included and documented in the HFW POC (Attachment 4).
d. Natural supports are an important part of the HFW team and it is a priority that the HFW team supports youth and families in identifying natural supports to join the team. The WFI-EZ is one of the tools used (Attachment 2: SOW 6.44) to gather feedback from the family about their experience with the HFW team engaging their identified natural supports, with WFI-EZ questions such as “My family and I had a major role in choosing the people on our Wraparound team” and “Our Wraparound team includes people who are not paid to be there (e.g., friends, family, faith).” WFI-EZ outcomes are monitored in the QSR (Attachment 3: QSR, Outcomes tab pages 3-5, rows 74-116). In addition to information and feedback gathered specific to HFW, providers are required to elicit feedback from families two times per year through the administration of a Program Advisory Group (Attachment 2: SOW 6.32) and monitored in QSR (Attachment 3: QSR, Outcomes tab pages 3-5, item 4).
1.7 Culturally Respectful and Relevant
a. CoSD contracted HFW providers are required to address Strengths, Needs, Culture, and Vision Discovery (Attachment 2: SOW 6.10.2.), which informs development of the HFW POC. To support the culturally responsive completion of this process, particularly in the case of an Indian child, providers submit an annual Promoting Cultural Diversity Self-Assessment (Attachment 18) and may elicit support from additional county resources such as the San Diego Tribal Justice Collaborative, the ICWA-trained CFWB Indian Specialty Unit. Countywide expectations for working with Indian families includes collaborating with tribes, respecting tribal sovereignty, and incorporating tribal perspectives into the culture discovery process. The Strengths, Needs, Culture, and Vision Discovery form is in development with system partners and providers with plans to monitor as a part of the QAPR process, and will be included in the QAPR tool. The form is planned to explicitly identifies Native American status and Tribal Membership to ensure that this critical information is incorporated into the plan. The Strengths, Needs, Culture, and Vision Discovery form is expected to be documented in the client’s medical record through an upload of a form.
b. CoSD requires contracted HFW providers to provide staff with ongoing training and coaching that emphasizes values, principles, and essential elements of wrapround (Attachment 2: SOW 6.25). Additionally, all direct and indirect HFW staff are required to take the Foundational Wraparound Training, which includes components that support elicitation and use of family and culture in planning and services delivery, through tools such as the Strengths, Needs, Culture, and Vision Discovery (Attachment 2: SOW 6.24). Lastly, as County contracted providers, all staff are required to complete a minimum of four (4) hours of cultural competency (Attachment 2: SOW 5.9.1.7.4.) training annually, which continues to reinforce the expectation that providers implement culturally respectful and relevant strategies. Training is monitored in training logs submitted by the HFW provider with the submission of the QSR (Attachment 2: SOW 6.26).
c. The Youth Services Survey (YSS) (Attachment 21) is an outcomes measure which gathers information annually from youth and their caregiver and includes a set of questions grouped under the “Perception of Cultural Sensitivity”. Outcome measure expectations are outlined in the OPOH (Attachment 1: OPOH G14 and N6-N12). In addition to information and feedback gathered specific to HFW, providers are required to elicit feedback from families two times per year through the administration of a Program Advisory Group (Attachment 2: SOW 6.32) and monitored in the QSR (Attachment 3: QSR, Outcomes tab pages 3-5, item 4). Information elicited from the PAG will be reviewed with the Community Leadership Team (Attachment 10: Community Leadership Team Charter Agreement, Responsibilities & Function) for the purpose of CQI.
1.8 High-Quality Team Planning and Problem Solving
a. Team agreements are included in the HFW POC (Attachment 4: CFTM Summary and Action Plan, page 2). The HFW POC is reviewed at each HFW CFT (Attachment 2: SOW 6.113.2.2.) which offers repeated opportunities to review, adjust, and expand on the group agreements and commitments. The HFW POC is uploaded into the youth’s file – SmartCare. CoSD team has an ongoing workgroup to align documentation and monitoring of HFW activities in accordance with the forthcoming HFW Policy Manual and will be launched in FY 26-27.
b. CoSD requires contracted HFW providers to complete annual WFI-EZ surveys (Attachment 2: SOW 6.44), which elicits feedback from youth and caregiver about their experiences with team engagement and collaboration. WFI-EZ outcomes are monitored in the QSR (Attachment 3: QSR, Outcomes tab pages 3-5, rows 74-116). In addition to information and feedback gathered specific to HFW, providers are required to elicit feedback from families two times per year through the administration of a Program Advisory Group (Attachment 2: SOW 6.32), which may result in feedback related to team engagement and collaboration; this is monitored in QSR (Attachment 3: Outcomes tab pages 3-5, item 4), once a year through the administration of the Youth Services Survey (YSS) (administered to youth and caregivers). Outcome measure expectations are outlined in the Organizational Provider Operations Handbook, G 14 and N 6-N 12 (Attachment 1: OPOH).
c. CoSD requires contracted HFW providers to complete WFI-EZ surveys (Attachment 2: SOW 6.44). The HFW provider uses the outcomes for CQI purposes and outlines action plans for underperforming WFI-EZ outcomes domains, which are documented and monitored in the QSR (Attachment 3: QSR, Outcomes tab pages 3-5, rows 74-116). HFW providers are tasked with training and coaching staff to support high-fidelity youth and family-driven HFW services and CQI (Attachment 2: SOW 6.25). Training is monitored in training logs submitted by the HFW provider with the submission of the QSR (Attachment 2: SOW 6.26).
d. CoSD contracted HFW providers review the HFW POC at each HFW CFT meeting (Attachment 2: SOW 6.11.2.2. and 6.11.3.) to monitor identified needs and progress. In alignment with the HFW POC, the Action Plan section (Attachment 4: section 5) ensures that needs, strategies, and action items are clearly identified, including who is responsible, the specific action steps and rationale, and the expected timeline for completion, allowing the team to track progress and adjust supports as needed. HFW Supervisor and Fidelity Coach review documentation in the client’s medical record to ensure that HFW services are provided in accordance with CA Wrap Standards and the HFW POC is included (Attachment 2: SOW 6.21.4.2. and 6.21.5.1.). CoSD team has an ongoing workgroup to align documentation and monitoring of HFW activities in accordance with the forthcoming HFW Policy Manual and will be launched in FY 26-27.
1.9 Outcomes Based Process
a. The HFW POC outlines an action plan including who will be responsible for specific action steps, to be completed by a specific date (Attachment 4: CFTM Summary and Action Plan, page 3). The HFW Facilitator leads the HFW team in monitoring benchmarks and indicators marking sufficient progress towards goals (Attachment 2: SOW 6.11.4.1). Adherence is monitored through the HFW providers ongoing Quality Assurance monitoring through their required QAP (Attachment 1: OPOH G1 and Attachment 2: SOW 5.6.1.).
b. HFW POC is reviewed at HFW team meetings, and HFW Facilitator guides the team through the four phases of wraparound, including monitoring HFW POC outcomes (Attachment 2: SOW 6.21.1.2.). Action item completion is monitored through the HFW providers ongoing Quality Assurance monitoring through their required QAP (Attachment 1: OPOH G1 and Attachment 2: SOW 5.6.1.).
c. The HFW POC is a document that is regularly reviewed and updated. Updates to the HFW POC are distributed to all team members (Attachment 2: SOW 6.11.3.1.); changes are discussed in the context of a HFW CFT (Attachment 2: SOW 7.13.3) and documented in the client’s medical record as monitored in the QAPR (Attachment 5: QAPR item C1).
d. The IP-CANS is a required assessment completed for each client (Attachment 1: OPOH N7). Completion of the IP-CANS is a team priority, and staff work collaboratively within the CFT to ensure timely and accurate administration. Consistent with the countywide philosophy of “one CANS per child,” the IP-CANS is shared with all team members to support transparent, collaborative planning. The completion of one CANS reduces redundancy and supports unified treatment and care planning. CANS may be administered by staff who have completed the Certification process (Attachment 1: OPOH N8), typically be the HFW Facilitator. Adherence to IP-CANS completion is monitored in the QAPR (Attachment 5: QAPR A6) and monitoring of individuals certified to administer the CANS is tracked in the QSR, S&P tab (Attachment 3: QSR, S&P tab page 9-10).
e. The IP-CANS is required for all children and youth served in CoSD (Attachment 1: OPOH N7). HFW relies on individualized, family-driven planning and the IP CANS offers the shared language and objective framework that teams need to develop meaningful, actionable, and culturally relevant plans of care. The IP CANS supports fidelity by ensuring that planning is not driven by services, but by clearly identified underlying needs. It helps teams move beyond surface-level behaviors to understand what driving challenges, allowing supports and strategies to be tailored to each youth’s unique context. In addition, the assessment highlights strengths across domains, which HFW teams use as the building blocks for engagement, visioning, and intervention design. CANS progress is monitored at a system level through outcomes reports compiled by CASRC, and at an individual level in the client’s medical record and in the QAPR (Attachment 5: QAPR item A6).
1.10 Persistence
a. The HFW model emphasizes persistence, unconditional care, and shared team responsibility, ensuring that youth and families continue to receive support even when faced with setbacks, crises, or periods of limited progress. HFW teams are equipped and supported to maintain engagement through ongoing supervision, coaching, fidelity monitoring, and clear expectations outlined in training and the SOW (Attachment 2: SOW 6.25.2). Facilitators, Parent Partners, and Specialists are coached to adopt a “whatever it takes” approach (Attachment 2: SOW 2.10.1), using alternative engagement strategies, flexible scheduling, crisis/safety planning, and culturally responsive practices to rebuild momentum whenever challenges arise. Transitions out of wraparound are planned with the CFT to ensure that benchmarks and indicators of sufficient progress have been achieved (Attachment 2: SOW 6.11.4.1).
b. CoSD contracted HFW providers must maintain staffing that includes a HFW Supervisor and Fidelity Coaches. These roles support teams through coaching and training to build staff skills and confidence in HFW practices (Attachment 2: SOW 6.21.4.2. and 6.21.5.1). Staffing for these roles is monitored in the QSR (Attachment 3: QSR, S&P tab pages 9-10).
c. CoSD contracted HFW providers are to be trained in the Foundational Wraparound Training (Attachment 2: SOW 6.24.), and HFW Facilitators are required to complete the Statewide Standardized CFT Facilitation Training (Attachment 2: SOW 6.23.). HFW providers Supervisor and Fidelity Coach provide ongoing staff training to support HFW services (Attachment 2: SOW 6.25.). Training is monitored in training logs submitted by the HFW provider with the submission of the QSR (Attachment 2: SOW 6.26). HFW Supervisor and Fidelity Coach roles are monitored in the QSR (Attachment 3: QSR, S&P tab pages 9-10).
1.11 Transitions as a part of the Fourth Phase of HFW
a. Transitions of care are planned within the context of HFW CFT meetings (Attachment 2: SOW 6.11.4.), and transition sessions held for closure (Attachment 2: SOW 6.11.4.3.). Transitions are planned using benchmarks and indicators marking sufficient progress towards goals and readiness for transition (Attachment 2: SOW 6.11.4.1.). Documentation of case closure is documented in the Discharge Plan/Summary, included in the client’s medical record and monitored in the QAPR (Attachment 5: QAPR C3).
b. Transitions out of HFW are celebrated, to facilitate a positive transition in a meaningful way (Attachment 2: SOW .11.4.3.). HFW providers have a flex fund allocation, which they can leverage to support the client’s treatment goals, which may include goal achievement (Attachment 2: SOW 6.33.); flex fund expenditures are monitored on a monthly basis through submission of the Flex Fund Expenditure Report, which is submitted with the HFW providers invoice (Attachment 9: Flex Fund Expenditure Report).
Expected Outcomes
2.1 Youth and Family Satisfaction
Youth and family satisfaction with their HFW experience is assessed through WFI-EZ administration (Attachment 2: SOW item 6.44, Attachment 3: QSR, pages 4 & 5, and Attachment 8: WFI EZ Agency Report, page 8) and the Program Advisory Group (PAG) (Attachment 2: SOW item 6.32 and Attachment 3: QSR, page 4).
2.2 Improved School Functioning
Improvement in educational and vocation functioning as a result of HFW is assessed through the IP-CANS administration (Attachment 1: OPOH N7 and Attachment 2: SOW item 7.1), and the WFI-EZ administration (Attachment 2: SOW item 6.44 and Attachment 3: QSR, pages 4 & 5, and Attachment 8: WFI EZ Agency Report, pages 9 & 10).
2.3 Improved Functioning in the Community
Improvement in community functioning is assessed through WFI-EZ administration (Attachment 2: SOW item 6.44, Attachment 3: QSR, pages 4 & 5, and Attachment 8: WFI EZ Agency Report, pages 5, 6, and 10), IP-CANS administration (Attachment 1: OPOH N7 and Attachment 2: SOW item 7.1), and the Youth Services Survey (Attachment 21: Youth Services Survey Report, page 6).
2.4 Improved Interpersonal Functioning
Improvement in interpersonal functioning as a result of HFW involvement is assessed through WFI-EZ administration (Attachment 2: SOW item 6.44, Attachment 3: QSR, pages 4 & 5, and Attachment 8: WFI EZ Agency Report, page 10), Youth Services Survey (Attachment 21, pages 5 & 6), and IP-CANS administration (Attachment 1: OPOH N7 and Attachment 2: SOW item 7.1).
2.5 Increased Caregiver Confidence
Families have access to effective services and supports and caregivers feel increased confidence to manage future problems, how to access services and address crises are assessed through the IP-CANS administration (Attachment 1: OPOH N7 and Attachment 2: SOW item 7.1), and WFI-EZ administration (Attachment 2: SOW item 6.44, Attachment 3: QSR, pages 4 & 5, and Attachment 8: WFI EZ Agency Report, page 6).
2.6 Stable and Least Restrictive Living Environment
Youth do not experience a new placement as outlined in the Statement of Work (Attachment 2: SOW item 6.27, 6.28, 6.29, 6.30, and 6.31), and reported in the QSR (Attachment 3: QSR, page 3).
2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits
Youth experience behavioral health stability, necessitating fewer or no hospital visits as outlined in the Statement of Work (Attachment 2: SOW item 6.27), OPOH (Attachment 1: OPOH N12), and reported in the QSR (Attachment 3: QSR, page 3).
2.8 Reduction in Crisis Visits
Youth and natural supports are able to avert most crisis and manage most impending crises Statement of Work (Attachment 2: SOW 6.11.2.4 and 6.11.2.5), reported in the QSR (Attachment 3: QSR, page 3), and assessed through WFI-EZ administration (Attachment 2: SOW item 6.44, Attachment 3: QSR, pages 4 & 5, and Attachment 8: WFI EZ Agency Report, page 6 and page 9).
2.9 Positive Exit from HFW
Youth and their families exit HFW based on stabilization and adequate progress in meeting needs as outlined in the Statement of Work (Attachment 2: SOW item 6.11.4.1) and the Discharge Summary (Attachment 7: Discharge Summary).
Engagement
3.1 Orientation
Procedures Ensure:
a. CoSD contracted HFW providers are expected to orient clients and their families, and Tribes in the case of an Indian child, to HFW services (Attachment 2: SOW 6.11.1.). In the case of an Indian child, this would include information about the role and rights of the Tribe. Adherence to the overview is documented in an intake progress note in the client’s medical record and monitored through the HFW providers ongoing Quality Assurance monitoring through their required QAP (Attachment 1: OPOH G1 and Attachment 2: SOW 5.6.1.).
At a minimum the explanation provided to the family includes:
a. CoSD contracted HFW providers are required to provide new clients and families with a comprehensive overview of the 10 principles and 4 phases of HFW as outlined in the SOW (Attachment 2: SOW 6.11.1.3.). The HFW overview is documented in progress notes in the client’s medical record and monitored through the HFW providers ongoing Quality Assurance monitoring through their required QAP (Attachment 1: OPOH G1 and Attachment 2: SOW 5.6.1.).
b. CoSD contracted HFW providers outline legal and ethical considerations as a part of the Phase 1 Engagement process as outlined in the SOW (Attachment 2: SOW 6.11.1.3.). Adherence to Phase 1 requirements outlined in the SOW are monitored by the HFW Supervisor, who routinely observes HFW team meetings and reviews documentation to reinforce HFW practice expectations (Attachment 2: SOW 6.21.4.2).
c. CoSD contracted HFW providers explain the roles of each member and work to maximize the identification and inclusion of natural supports (Attachment 2: SOW items 6.131.1.3. and 6.11.1.1.). Roles are documented in the HFW POC and included in the client’s medical record and monitored through the HFW providers ongoing Quality Assurance monitoring through their required QAP (Attachment 1: OPOH G1 and Attachment 2: SOW 5.6.1.).
3.2 Safety and Crisis stabilization
a. CoSD requires contracted HFW providers to conduct individualized care planning, and identification of immediate needs including safety and crisis stabilization (Attachment 2: SOW 6.11.1.). Adherence to this requirement is monitored through the HFW providers ongoing Quality Assurance monitoring through their required QAP (Attachment 1: OPOH G1 and Attachment 2: SOW 5.6.1.).
b. CoSD requires contracted HFW providers to identify and address immediate needs, including safety and crisis needs (Attachment 2: SOW 6.11.1.). During the engagement phase, if a crisis or safety concern is brought forward, the team develops an immediate crisis plan to provide stabilization and identify intervention needs. Immediate interventions may include implementing coordinated stabilization supports among team members, ensuring families know the steps to request assistance from local supports including the San Diego Mobile Crisis Response Team (https://www.sandiegocounty.gov/content/sdc/mcrt.html), Crisis Stabilization Unit, and access to the HFW team 24/7. The development and periodic revision of various care plans, including safety and crisis planning are a comprehensive part of the HFW process (Attachment 2: SOW 6.6.1.2.), and do not replace the Crisis and Safety Plan developed in the Plan Development Phase, but will be used to help inform the development of the Crisis and Safety Plan. The Crisis and Safety Plan is in development with the Wraparound Oversight Team as a standardized form. Risk and safety factors are documented as a part of the CalAIM Assessment (Attachment 6: Domain 6) and monitored in the QAPR (Attachment 5: QAPR A1).
c. CoSD requires HFW providers to ensure that 24-hour, 7 day a week coverage is available for the youth and family directly through the HFW program. Providers maintain a written defined mechanism for crisis response available to all HFW clients and caregivers (Attachment 2: SOW 6.11.2.5.). HFW policy on 24/7 availability for crisis response is reviewed as a part of the desk review (Attachment 11).
3.3 Strengths, Needs, Culture and Vision Discovery
a. CoSD requires that contracted HFW providers engage families in activities such as the Family Vision, which is elicited as a part of the Strengths, Needs, Culture and Vision Discovery (Attachment 2: SOW 6.11.1.4.). The Strengths, Needs, Culture and Vision Discovery form is currently being developed in collaboration with the Wraparound Oversight Team and will be formalized as a form for use across programs. The form will be expected to be documented in the client’s medical record; CoSD team has an ongoing workgroup to align documentation and monitoring of HFW activities in accordance with the forthcoming HFW Policy Manual and will be launched in FY 26-27.
b. A Strengths, Needs, Culture and Vision Discovery form is currently being created in collaboration with the Wraparound Oversight Team and will be formalized as a form for use across programs. The form will be reviewed, updated, and documented in the client’s medical record and shared with new team members at a minimum every 90 days as expected in the SOW (Attachment 2: 6.11.1.4). CoSD team has an ongoing workgroup to align documentation and monitoring of HFW activities in accordance with the forthcoming HFW Policy Manual and will be launched in FY 26-27. CoSD contracted HFW providers will standardize these activities through a completion of the forthcoming Strengths, Needs, Culture and Vision Discovery form.
3.4 Engage All Team Members
a. CoSD requires contracted HFW providers to maximize the identification and inclusion of natural supports as a part of the HFW CFT as described in the SOW (Attachment 2: SOW 6.11.1.1.), and these supports are included in the HFW POC with notation of their name, relationship to the youth or family, best contact, and whether they were present at the meeting. The HFW POC is documented in the client’s medical record. CoSD team has an ongoing workgroup to align documentation and monitoring of HFW activities in accordance with the forthcoming HFW Policy Manual and will be launched in FY 26-27.
b. CoSD requires HFW providers to include and engage system of care partners (e.g. CFWB, Probation, SMHS providers, and/or schools) as outlined in the SOW (Attachment 2: SOW 6.11.1.2.). Inclusion of these partners as a part of the HFW team is monitored in chart documentation in the client’s medical record, in the HFW POC and the QAPR (Attachment 5: QAPR QC5).
c. CoSD contracted HFW providers staff Peer Supports who, among other tasks, support the HFW team and work directly with the family on development of natural supports (Attachment 2: SOW 6.6.2.); the HFW team consistently works to engage Tribes in the case of an Indian child (Attachment 2: SOW 6.11.1.3), and formal system partners (Attachment 2: SOW 6.11.1.2.). Staffing for the Peer Support role is monitored in the QSR (Attachment 3: QSR, S&P tab pages 9-10), and HFW Supervisors are tasked with documentation review to ensure that team members are operating in the scope of their role, while the Fidelity Coach supports HFW staff in their understanding of HFW roles and interventions (Attachment 2: SOW 6.21.4.2. and 6.21.5.).
d. CoSD contracted HFW providers are expected to facilitate activities with youth and family to support completion of the Strengths, Needs, Culture and Vision Discovery (Attachment 2: SOW 6.11.2.4 and Attachment 19: Strengths, Needs, Culture and Vision Discovery DRAFT). The Strengths, Needs, Culture, and Vision Discovery form is currently in development through the Wraparound Oversight Team and will be expected to be uploaded to the client’s medical record with plans to monitor as a part of the QAPR process and will be included in the QAPR tool.
3.5 Arrange Meeting Logistics
a. The Statement Of Work calls for HFW contracted provider to have service hours available in the evening and weekends to accommodate family and HFW team needs (Attachment 2: SOW 6.18); services are provided countywide and predominantly offered in the community (Attachment 2: SOW 4.4.). CoSD COR team conducts site visits and confirms that flexible service hours and locations are in place that are convenient and accessible for client and family (Attachment 12: Site Visit Tool).
b. CoSD requires contracted HFW providers to train staff in alignment with California Wraparound Standards (Attachment 2: SOW 6.21.4.3.), which includes overview of the provision of individualized services. Training is monitored in training logs submitted by the HFW provider with the submission of the QSR (Attachment 2: SOW 6.26).
Plan Development
4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission
a. CoSD contracted HFW providers are expected to engage the team in the planning process by identifying the Strengths, Needs, Culture and Vision Discovery during the engagement phase. This discovery process forms the foundation for the development of the elements of the HFW POC, ensuring that goals, strategies, and the family’s mission and vision are guided by the youth and family’s identified strengths, cultural identity, needs, and priorities. To standardize this process the Strengths, Needs, Culture and Vision Discovery form (Attachment 19: Strengths, Needs, Culture and Vision Discovery DRAFT) is in development with the Wraparound Oversight Team and will be expected to be documented in the client’s medical record. CoSD team has an ongoing workgroup to align documentation and monitoring of HFW activities in accordance with the forthcoming HFW Policy Manual and will be launched in FY 26-27.
b. The Strengths, Needs, Culture and Vision Discovery form is currently in development with the Wraparound Oversight Team (Attachment 19: Strengths, Needs, Culture and Vision Discovery DRAFT). As strengths are identified during engagement, they will be documented in the youth’s file by uploading the Strengths, Needs, Culture and Vision Discovery form to their medical record. The form is designed to be a living document and updated at least every 90 days (Attachment 2: SOW 6.11.1.4), as well as whenever new information emerges or new team members join, ensuring that additional strengths discovered throughout the HFW process are continuously incorporated. CoSD team has an ongoing workgroup to align documentation and monitoring of HFW activities in accordance with the forthcoming HFW Policy Manual and will be launched in FY 26-27.
4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies
a. CoSD contracted HFW providers are required to gather and prioritize client and family underlying needs as a part of the activities related to the Strengths, Needs, Culture and Vision Discovery (Attachment 2: SOW 6.11.1.4.). Additionally, the IP-CANS is leveraged to help inform the HFW POC and documented in the client’s file (Attachment 2: SOW 6.11.2.1.).
b. CoSD contracted HFW providers utilize the HFW POC as a CFT meeting guide to ensure that the team identifies current needs/goals that must be addressed, including action plans to address needs/goals. As a part of the HFW planning process, HFW providers will work with team members to complete the Strengths, Needs, Culture and Vision Discovery form, which includes dedicated sections to document strengths of the family and individual team members (Attachment 19: Strengths, Needs, Culture and Vision Discovery DRAFT). Identified strengths are used to support goal development as resources that can assist the youth and family in meeting their identified needs; individual and team strengths function as practical, leverageable tools within the planning process, not just descriptive information. The HFW Facilitator monitors HFW POC outcomes (Attachment 2: SOW 6.21.1.). In addition to action items targeted to address client and family identified needs, HFW provider also monitors outcomes associated with avoiding hospitalization (Attachment 2: SOW 6.27.), avoiding placement into a higher level of care (Attachment 2: SOW 6.28.), and have monitored key event tracking (KET) pertaining to education, living arrangements, legal issues, and emergency intervention, and quarterly assessment (3M) which gather follow-up information on the client’s areas of strength, need, and treatment focus, all part of the Full Service Partnership (FSP) Data Collection and Reporting (DCR).The DCR will be sunset beginning FY 26-27, however it is anticipated that the HFW Policy Manual will have guidance on outcome measure to be implemented for HFW FSP. All outcomes align with the expectation that the HFW program will empower the child or youth and family in developing sustainable strategies that allow the youth to remain in school and in the community (Attachment 2: SOW 6.10.3.), and needs associated with these domains are monitored in the IP-CANS. HFW POC outcomes are monitored by the provider as a required part of their internal quality improvement controls (Attachment 1: OPOH G1), with additional outcomes monitored in the QSR (Attachment 3: QSR, Outcomes tab pages 3-5).
c. HFW POC is reviewed at each HFW CFT meeting to ensure needs have a goal/action plan identified, along with a target date of when the item will be completed (Attachment 4: CFTM Summary and Action Plan, section 5). Youth, caregivers, and their formal and natural supports work collaboratively to identify needs and develop culturally responsive strategies to address them. The WFI-EZ tool reinforces this collaborative approach by asking youth and caregivers to indicate whether progress toward meeting needs is monitored at each meeting, whether the team develops creative and individualized plans to address those needs, and whether the decision-making and planning occurs through a shared, collaborative process. Completion of the HFW POC is monitored by the provider as a part of their internal quality improvement process (Attachment 1: OPOH G1) and documented in the client’s medical record. CoSD team has an ongoing workgroup to align documentation and monitoring of HFW activities in accordance with the forthcoming HFW Policy Manual and will be launched in FY 26-27.
d. CoSD contracted HFW providers are required to offer a HFW program that includes the development of a HFW POC through structured, creative, and individualized strategies that are effective and relevant to the youth and their family (Attachment 2: SOW 6.102.2.). The HFW team facilitates activities with the youth and family to identify needs, strengths, culture, vision (Attachment 2: SOW 6.11.1.4.), Team Mission Statement (Attachment 2: SOW 6.11.2.3.), and other strategies chosen by the youth and family, including natural supports (Attachment 2: SOW 6.11.2.4.). Activities are documented in dedicated forms such as the HFW POC and progress notes. Interventions are monitored through the providers internal quality improvement process (Attachment 1: OPOH G1). CoSD team has an ongoing workgroup to align documentation and monitoring of HFW activities in accordance with the forthcoming HFW Policy Manual and will be launched in FY 26-27.
e. CoSD contracted HFW providers are required to have all HFW Facilitators complete the CFT meeting facilitation training (Attachment 2: SOW 6.23.). The HFW Facilitator is tasked with guiding the HFW team through the four phases of wraparound (Attachment 2: SOW 6.21.1.). Training is monitored in training logs submitted by the HFW provider with the submission of the QSR (Attachment 2: SOW 6.26).
f. The HFW POC is developed in a team-based, collaborative environment, and through activities such as the Strengths, Needs, Culture and Vision Discovery, that are used to formulate and/or update the HFW POC (Attachment 2: SOW 6.11.2.1.). The interventions used to develop the HFW POC are monitored through the providers internal quality improvement process (Attachment 1: OPOH G1) and documented in the client’s medical record. CoSD team has an ongoing workgroup to align documentation and monitoring of HFW activities in accordance with the forthcoming HFW Policy Manual and will be launched in FY 26-27.
4.3 Develop an Individualized Child or Youth and Family Plan
a. CoSD contracted HFW providers are required to provide HFW staff with ongoing training and coaching in alignment with COE guidance to support consistent, high-fidelity youth and family-driven HFW services (Attachment 2: SOW 6.25). Contracted HFW provider is required to keep a staff training log that is submitted with the QSR (Attachment 2: SOW 6.26.).
b. CoSD contracted HFW providers utilize the IP-CANS, the Strengths, Needs, Vision, and Culture Discovery, and other HFW team led activities to comprehensively identify needs, goals, and action plans as a part of the HFW CFT (Attachment 2: SOW 6.11.1.2.) to develop the HFW POC goals and objectives. Pertinent Tribal information gathered through the completion of the Strengths, Needs, Vision and Culture Discovery, in the case of an Indian child, is shared with the CFT and incorporated into the HFW POC and used to guide culturally responsive planning. This includes inviting Tribal representatives to participate in the CFT; integrating Tribal cultural values, traditions, or supports into strengths and action plans, and ensuring that HFW POC goals honor the child’s cultural identity and Tribal community. Collaboration between team members, including system of care partners is outlined in the HFW POC (Attachment 4: CFTM Summary and Action Plan, page 1), documented in the client’s medical record, and monitored through the providers internal quality improvement process (Attachment 1: OPOH G1). CoSD team has an ongoing workgroup to align documentation and monitoring of HFW activities in accordance with the forthcoming HFW Policy Manual and will be launched in FY 26-27.
c. The HFW POC is documented in the client’s medical record, which is a shared health record between CoSD and the HFW contracted provider. Documentation in the medical record is monitored through the providers’ internal quality improvement process (Attachment 1: OPOH G1). CoSD team has an ongoing workgroup to align documentation and monitoring of HFW activities in accordance with the forthcoming HFW Policy Manual and will be launched in FY 26-27. The HFW POC is shared with all members of the CFT (Attachment 4: CFTM Summary and Action Plan, page 1). The HFW POC meets all 6 criteria: it is created based on the strengths, needs, culture, and vision of the youth and family (Attachment 2: SOW 6.11.2.1.), integrating the IP-CANS to address needs across multiple life domains (Attachment 4: CFTM Summary and Action Plan, section 3), strategies and action items are clearly documented (Attachment 4: CFTM Summary and Action Plan, section 5), the HFW POC takes youth and family needs into account when developing array of services and supports, coordinated across system of care partners (Attachment 4: CFTM Summary and Action Plan, comprehensive document), inclusion of natural supports and sustainable community resources are included in the plan (Attachment 2: SOW 6.10.3., 6.11.1.1., 6.1.1.3., 6.113.2.4., 6.11.3., and 6.11.4.), and transition from formal services is a graduated process (Attachment 2: SOW 6.11.4.).
d. CoSD contracted HFW Supervisors and Fidelity Coaches routinely review HFW documentation and provide staff with feedback, coaching, and training to reinforce HFW practice expectations and documentation standards (Attachment 2: SOW 6.21.4.2. and 6.21.4.3.). Team member roles and identification of HFW Supervisors and Fidelity Coaches who fulfil this requirement are noted in the QSR (Attachment 3: QSR, S&P tab pages 9-10).
4.4 Develop a Crisis and Safety Plan
a. CoSD contracted HFW providers are required to develop various care plans, including Safety and Crisis plans (Attachment 2: SOW 6.6.1.2.). A Crisis and Safety Plan specific form will be developed and shared with HFW CFT team members, including prioritization of safety needs, potential risk and crisis situations, and individualized strategies for the youth, family, and team members to respond effectively (Attachment 2: SOW 6.11.2.4.). Strategies are expected to be chosen by youth and family, be culturally relevant, and maximize the use of natural supports (Attachment 2: SOW 6.11.2.4.). The HFW provider is required to have a defined mechanism for 24/7 crisis response for HFW clients (Attachment 2: SOW 6.11.2.5). The Crisis and Safety Plan is in development with the Wraparound Oversight Team as a standardized form and will be expected to be documented in the clients medical record, which is monitored through the providers internal quality improvement process (OPOH G1, attachment 1) and the QAPR. CoSD team has an ongoing workgroup to align documentation and monitoring of HFW activities in accordance with the forthcoming HFW Policy Manual and will be launched in FY 26-27.
b. HFW Crisis and Safety Plan are developed as a team, with strategies chosen by youth and family, are culturally relevant, and maximize the use of natural supports when possible (Attachment 2: SOW 6.11.2.). The HFW Supervisor is tasked with coaching and training HFW staff in alignment with the California Wraparound Standards (Attachment 2: SOW .21.4.3.). All HFW staff complete the Foundational Wraparound Training (Attachment 2: SOW 6.24.), and ongoing training to support consistent, high-fidelity youth and family-driven HFW services (Attachment 2: SOW 6.25). Training completion is monitored in the completion of a staff training log that is submitted with the QSR (Attachment 2: SOW 6.26.).
c. CoSD contracted HFW providers employ HFW Supervisors (Attachment 2: SOW 6.21.4) and Fidelity Coaches (Attachment 2: SOW 6.21.5) who review Crisis and Safety Plans to ensure they include individualized strategies, culturally relevant approaches, with both proactive and reactive responses, as well as integration of natural supports. HFW Supervisors and Fidelity Coaches provide ongoing training, coaching, and feedback to staff to support adherence to these standards and strengthen overall HFW practice (Attachment 2: SOW 6.25.2.). HFW staffed roles are monitored in the QSR (Attachment 3: QSR, S&P tab pages 9-10), and trainings are monitored through a training log submitted with the QSR (Attachment 2: SOW 6.26).
Implementation
5.1 Implement The Plan of Care
a. CoSD contracted HFW Facilitator guides the HFW team through the four phases of wraparound at HFW CFT meetings, including monitoring the HFW POC for progress towards outcomes (Attachment 2: SOW 6.21.1.2.). The HFW POC is used to guide the meeting, with team members proving updates on outstanding action step assignments, including timeline for completion on action step assignment, and making necessary updates to action items or strategies to address current action items (Attachment 4: CFTM Summary and Action Plan). The HFW POC is documented in the client’s medical record and will be monitored in the QAPR. This is part of an ongoing workgroup aligning documentation and monitoring of HFW activities and will be launched in FY 26-27.
b. CoSD contracted HFW provider staff (direct and indirect) are required to complete Foundational Wraparound Training (Attachment 2: SOW 6.24.) and receive ongoing staff training and coaching in alignment with California Wraparound Standards and in alignment with COE guidance (Attachment 2: SOW 6.25.) to ensure that staff are facilitating activities that are aligned with HFW standards. The Foundational Wraparound Training emphasizes the importance of celebrating successes as they occur, as an essential component of the wraparound process. The curriculum teaches that recognizing accomplishments is a key part of strengths-based engagement and contributes to team cohesion, family motivation, and positive reinforcement. The curriculum instructs HFW Facilitators to begin HFW CFT meetings in discussing accomplishments since the last meeting. Training completion is monitored through training logs submitted with the QSR (Attachment: SOW 6.26.).
5.2 Review and Update The Plan of Care
a. The HFW POC is reviewed in each HFW CFT in order to monitor progress on action items, identify new strategies to be employed as needed, or to assess next steps (Attachment: SOW 6.11.3.). The HFW POC is provided to team members and is documented in the client’s medical record. CoSD team has an ongoing workgroup to align documentation and monitoring of HFW activities in accordance with the forthcoming HFW Policy Manual and will be launched in FY 26-27.
b. CoSD contracted HFW Facilitators guide the HFW team through the four phases of wraparound (Attachment 2: SOW 6.21.1.2.). As a part of this process, the HFW CFT meets regularly to review the HFW POC, and make updates as new needs develop, or as action items are completed, taking time to acknowledge and celebrate successes (Attachment 2: SOW 6.11.3.). Team members document their interventions in the client’s medical record, and documentation is monitored through the providers internal quality improvement process (Attachment 1: OPOH G1).
c. The team uses HFW CFT meetings guided through the HFW POC to note changes, including completion of tasks, new assignments, team attendance, changes in team members (formal and natural supports), all of which are documented in the HFW POC (Attachment 4: CFTM Summary and Action Plan) which is offered to all team members at least every 90 days (Attachment 2: SOW 6.11.3.1.) HFW Supervisor and Fidelity Coaches review documentation and provide coaching and training to the HFW Facilitator to provide reinforcement of HFW practice expectations, ensure documentation meets standards, and that the HFW Facilitator understands the HFW roles and interventions (Attachment 2: SOW 6.21.4.3. and 6.21.5.1.). These interventions are documented in the client’s medical record and monitored through the providers internal quality improvement process (Attachment 1: OPOH G1).
d. The HFW POC is a living document, that is updated when there are changes to team members, youth and family needs, or progress is made (Attachment 2: SOW 6.11.2.2.). While the document is standardized, there is opportunity on the form to individualize any changing needs, which are noted on the document. The HFW team facilitates activities to identify new strengths, needs, culture and vision, updated as new team members are identified and at least every 90 days (Attachment 2: SOW 6.11.1.4.). The activities are documented in the client’s medical record and monitored through the providers’ internal quality improvement process (Attachment 1: OPOH G1).
5.3 Build Supports While Maintaining Team Cohesiveness and Trust
a. The HFW POC is reviewed at each HFW CFT (Attachment 2: SOW 6.11.2.2.), which includes the review of team agreements (Attachment 4: CFTM Summary and Action Plan, section 2). Team agreement review is documented in the client’s medical record and monitored through the providers internal quality improvement process (Attachment 1: OPOH G1).
b. CoSD contracted HFW providers are required to train HFW Facilitators in CFT Facilitation Training (Attachment 2: SOW 6.23.) and Foundational Wraparound Training (Attachment 2: SOW 6.24.). Additionally, HFW providers offer ongoing staff training and coaching in alignment with COE guidance to support consistent, high-fidelity youth and family-driven HFW services (Attachment 2: SOW 6.25.). Training is monitored through the completion of training logs that are submitted with the QSR (Attachment 2: SOW 6.26).
c. HFW teams ensure that natural supports are included in the HFW CFT (Attachment 2: SOW 6.9., 6.10.3., 6.11.1.1.). HFW team maximize the identification and inclusion of natural supports, and Peer Support Services are provided to support the development of natural supports (Attachment 2: SOW 6.6.2.). Team members, including natural support, are documented in the HFW POC. HFW team members receive structured feedback supported by coaching, supervision, and documentation review from the HFW Supervisor and Fidelity Coach (Attachment 2: SOW 6.21.4.2., 6.21.5.1.). This process includes observation of team meetings, documentation audits, and the use of fidelity tools such as the WFI-EZ to monitor engagement of natural supports and adherence to practice standards (Attachment 2: SOW 6.44.). Continuous Quality Improvement (CQI) activities are implemented to reinforce strengths-based strategies and ensure that natural support remains central to the team’s approach, with coaching focused on building staff confidence and skill in leveraging these supports effectively (Attachment 2: SOW 6.25.1.). Staff for the HFW Supervisor and Fidelity Coach are monitored in the QSR (Attachment 3: QSR, S&P tab pages 9-10).
d. CoSD contracted HFW providers have established comprehensive processes for orienting new team members, including both formal and natural supports, to ensure alignment with the HFW model. Upon joining, team members receive a detailed explanation of the HFW process, including the ten principles and four phases of wraparound, as required by DHCS guidance and the National Wraparound Initiative (Attachment 2: SOW 61. and 6.11.1.3.). Orientation also includes a review of current individualized plans and strategies, such as the HFW POC, Strengths, Needs, Culture and Vision Discovery, and Crisis and Safety Plan, to ensure new members understand the youth and family’s goals and strategies (Attachment 2: SOW 6.11.1., 6.11.2., and 6.11.3.). Additionally, team building exercises and structured activities are incorporated to foster collaboration and trust among team members, supporting the family-driven, strengths-based approach central to HFW (Attachment 2: SOW 6.11.1.4.). These processes collectively promote shared understanding, effective teamwork, and fidelity to the HFW model. Team agreement review is documented in the HFW POC and documented in the client’s medical record. CoSD team has an ongoing workgroup to align documentation and monitoring of HFW activities in accordance with the forthcoming HFW Policy Manual and will be launched in FY 26-27.
Transition
6.1 Develop a Transition Plan
a. The HFW Facilitator leads the HFW CFT in identifying when the youth and family are ready for transition, based on benchmarks and indicators monitored throughout the wraparound process. This includes reviewing progress toward goals outlined in the HFW POC and adapting strategies as needed to ensure readiness for transition (Attachment 2: SOW 6.11.4.1.). The HFW Facilitator guides the team in monitoring these benchmarks during regular HFW CFT meetings and ensures that responsibility is gradually shifted to the family and natural supports as part of the transition phase (Attachment 2: SOW 6.11.4.). This structured approach promotes sustainability and successful discharge from HFW services. As part of transition planning, the HFW team also explores ongoing resources and supports that may benefit the family. When adoptive families are receiving HFW, the Facilitator and team may explore resources available through the Adoption Assistance Program (AAP) funding and collaborate with the AAP worker to leverage their expertise and identify supports that can assist the family beyond HFW services. The HFW Facilitator completes a Discharge Summary, that includes documentation of the duration of treatment, summary of treatment, care coordination and aftercare referrals, any medications prescribed at time of discharge, and progress towards treatment goals within the client record (Attachment 7: Discharge Summary). Discharge Summary is monitored through the providers internal quality improvement process (Attachment 1: OPOH G1) and the QAPR (Attachment 5: QAPR, C3).
b. Once the determination has been made that the youth and family are ready for transition, the HFW Facilitator leads the HFW CFT in creating an individualized transition plan that identifies needs, services, and supports. This requirement is outlined under Phase 4 – Transition, which specifies that the HFW Facilitator ensures the development of a transition plan to prepare the youth and family for discharge from HFW services (Attachment 2: SOW 6.11.4.,). The steps for transition promote sustainability and successful transition to natural supports and community-based resources. Plans and summary of services are documented in the client’s medical record in progress notes and the Discharge Plan/Summary (Attachment 7: Discharge Summary) and monitored through the providers internal quality improvement process (Attachment 1: OPOH G1) and the QAPR (Attachment 5: QAPR, C3). The Wraparound Oversight Team is reviewing the need to create a Transition Crisis & Safety Plan form that will formalize the process and build in a process to offer the plan to all team members.
c. The development of the individualized transition plan occurs in a team-based, collaborative environment, as required under Phase 4 – Transition, which specifies that the HFW CFT works together to prepare the youth and family for discharge from services (Attachment 2: SOW 6.11.4.). The HFW Facilitator ensures that this process is guided by collaboration among formal and natural supports, aligning with the family-driven approach central to HFW. Additionally, HFW Facilitators receive training and coaching to support this process, as outlined in the SOW under requirements for ongoing staff training and coaching in alignment with Centers of Excellence (COE) guidance (Attachment 2: SOW 6.25.). These provisions ensure that transition planning is both collaborative and conducted with fidelity to the HFW model. Training completion is monitored through training logs submitted with the QSR (Attachment 2: SOW 6.26.).
d. The HFW CFT meets to collaboratively develop a transition plan that shifts responsibilities to the family and natural supports. This expectation is outlined under Phase 4 – Transition, which requires that transitions are planned within the context of HFW CFT and include strategies to ensure continuity of care and sustainability of supports (Attachment 2: SOW 6.11.4.). The HFW Facilitator leads the team in developing a formal individualized transition plan, including a crisis and safety plan, that identifies needs, services, and supports that will persist after HFW concludes (Attachment 2: SOW 6.11.4.2.). These requirements ensure that families are equipped with resources and connections to maintain stability and success beyond the HFW program. Transition plans are documented in the client’s medical record and monitored through the providers internal quality improvement process (Attachment 1: OPOH G1) and the QAPR (Attachment 5: QAPR, C3), and in the discharge summary (Attachment 7). The process is being updated, and work is being done by the Wraparound Oversight Team to standardize the process through the creation of the Transition Crisis & Safety Plan form.
6.2 Develop a Post-Transition Safety Plan
a. CoSD contracted HFW providers are required to ensure that a HFW Transition Crisis & Safety Plan is developed to support the youth as a part of the transition from HFW services (Attachment 2: SOW 6.11.4.2.). This clause requires the team to prepare the youth and family for transition, identify anticipated crisis situations post transition, and shift responsibility to the family and natural supports. It also ensures that proactive and reactive crisis management strategies are selected by the youth and caregiver, aligning directly with the HFW principle of family-driven planning. Transition Crisis & Safety Plan form will be expected to be documented in the client’s medical record, and completion will be monitored through the providers internal quality improvement process (Attachment 1: OPOH G1) and monitored in the QAPR. CoSD team has an ongoing workgroup to align documentation and monitoring of HFW activities in accordance with the forthcoming HFW Policy Manual and will be launched in FY 26-27.
b. CoSD contracted HFW providers are required to ensure that all HFW services, inclusive of the HFW Crisis & Safety Transition Plan, are developed in a team-based environment (Attachment 2: SOW 6.1.). All HFW teams include a HFW Supervisor and a Fidelity Coach, who review documentation to gather and provide feedback, offer coaching and training for staff to reinforce HFW practice expectations, build staff skills, increase staff confidence, and provide feedback to staff to support understanding and development of HFW roles and interventions (Attachment 2: SOW 6.21.4.2. and 6.21.5.1.). Documentation review is monitored through the providers internal quality improvement process (Attachment 1: OPOH G1), and training is monitored through training logs which are submitted to the COR team for review with the QSR (Attachment 2: SOW 6.26).
c. CoSD contracted HFW providers are required to provide training and coaching, including documentation review (inclusive of the Crisis & Safety Plan), to ensure that staff are implementing consistent, high-fidelity youth and family-driven HFW services, and CQI which will be used to improve teams’ HFW skills (Attachment 2: SOW 6.25., 6.25.1., and 6.25.2.). Documentation review is monitored through the providers internal quality improvement process (Attachment 1: OPOH G1), and training is monitored through training logs which are submitted to the COR team for review with the QSR (Attachment 2: SOW 6.26).
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, outlined in the SOW, which call for the HFW CFT to facilitate a celebratory closing service to acknowledge and celebrate successes throughout services (Attachment 2: SOW 6.11.4.3.). The SOW emphasizes that the HFW services must be led by the voice of the youth and their caregiver (Attachment 2: SOW 6.10.1.), and the HFW team ensures that the transition celebration is guided by the family’s culture, values, and preferences. These provisions align with the core principles of HFW, which prioritize honoring family voice and choice in all phases of service delivery. The celebratory transition is documented in the client’s medical record and monitored through the providers internal quality improvement process (Attachment 1: OPOH G1), the QAPR (Attachment 5: QAPR, C3), and in the Discharge Summary (Attachment 7).
b. CoSD contracted HFW providers are expected to adhere to HFW principles and four phases of wraparound (Attachment 2: SOW 6.1.), which includes a celebration to acknowledge and celebrate successes in the transition phase (Attachment 2: SOW 6.11.4.3.). These celebrations are for HFW CFT members, including formal and natural supports, and there are no administrative barriers to these activities. HFW providers may access flex funds as a part of the celebration, and documentation of funds expended for celebratory activities are submitted for review as a part of the monthly invoicing process (Attachment 9: Flex Fund Expenditure Report).
Wraparound Program and Community Leadership
7.1 Youth and Family as Key Decision-Makers
a. CoSD contracted HFW providers are expected to gather information from current and past clients to advise the HFW program on program design, practice and policies, at least twice annually in a Program Advisory Group (PAG) (Attachment 2: SOW 6.32) which is documented and monitored through the QSR (Attachment 3: QSR, Outcomes tab pages 3-5, lines 67-73). PAG feedback is reviewed and discussed with the Community Leadership Team (CLT) (Attachment 10: CLT Charter Agreement, Responsibilities and Functions). In addition, feedback is gathered from HFW clients and caregivers through the administration of the WFI-EZ (Attachment 2: SOW 6.44.). HFW providers utilize their programs WFI-EZ outcomes to develop action plans for CQI. WFI-EZ outcomes are monitored in the QSR Outcomes Tab and utilized to inform CoSD administration (Attachment 3: QSR, Outcomes tab pages 3-5, rows 74-116).
b. Family feedback provided via the PAG and WFI-EZ outcomes are reviewed with the Community Leadership Team. This venue provides an opportunity for HFW Provider Family Specialists (Attachment 2: SOW 6.21.2.1.), Caregiver/Parent Peer Partner (Attachment 2: SOW 6.21.3.), and other team members to bring the family voice forward for ongoing discussion and planning for service provision, policy and procedure development, workforce development and CQI (Attachment 10: CLT Charter Agreement).
7.2 Community Leadership Team
a. CoSD has developed a Community Leadership Team with representatives including Behavioral Health Services, Child and Family Well-Being (Child Welfare), Probation, contracted HFW providers, Tribal Partners and other stakeholders inclusive of family and youth partners, school representatives, and other child/family focused supporters. CoSD contracted HFW providers are required to participate (Attachment 2: SOW 6.38.) to support the decision-making process and ensure that CA HFW standards are being implemented across HFW programs (Attachment 10: Community Leadership Team Charter Agreement, Authority and Scope).
b. The Community Leadership Team includes contracted HFW system serving and community-based providers (Attachment 2: SOW 6.38.) and has dedicated representation from the Southern Indian Health Council (Attachment 10: Community Leadership Team Charter Agreement, Roles and Membership).
c. The Community Leadership Team maintains a formal reporting relationship to the Interagency Leadership Team, providing at least annual updates (Attachment 10: Community Leadership Team Charter Agreement, Authority and Scope).
d. The Community Leadership Team (CLT) meets quarterly (Attachment 10: Community Leadership Team Charter Agreement, Roles and Membership), with additional meetings scheduled as needed. Items 1-6 above, also identified in ACL 25-47, are attended to at each CLT meeting and outlined in the CLT Charter Agreement (Attachment 10: Community Leadership Team Charter Agreement, Responsibilities and Functions).
7.3 Eligibility and Equal Access
a. CoSD contracts for two HFW providers, to include a HFW program for system involved children and youth (probation and/or child welfare), and a HFW program for community-based referrals. All children or youth referred to one of the CoSD contracted HFW providers will be assessed for services, in alignment with the “No Wrong Door” policy (Attachment 1: OPOH C1) in alignment with BHIN 22-011 (Attachment 13). CoSD contracted HFW providers adhere to service provision for their identified primary population” (system involved or community-based children or youth) but may be flexible based on the specific needs of the child, youth, and family as identified in Target Population section of the SOW (Attachment 2: SOW, Section 4: Target Population and Geographic Area). Referrals received are monitored in the HFW providers submission of the QSR (Attachment 3: QSR, Access Time tab pages 7-8). DHCS forthcoming decision support tools will be incorporated upon release of the HFW Policy Manual anticipated in 2026.
b. CoSD HFW contractors adhere to Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) provisions (Attachment 2: SOW 2.1). CoSD contracted HFW services are available for BHSA priority populations, inclusive of children and youth who are chronically homeless or experiencing homelessness or at risk of homelessness, in, or at risk of being in the juvenile justice system, are reentering the community from a youth correctional facility, are in the child welfare system, or are at risk of institutionalization (Attachment 2: SOW item 4.3., 4.1.2., and 4.1.7.). In addition, HFW services are provided to youth stepping down from STRTPs, Children’s Crisis Residential Programs, Psychiatric Residential Treatment Facility, or Community Treatment Facilities (Attachment 2: SOW 4.1.7.). Children and youth that are assessed for services that present with significant needs are not limited to HFW services, and may be linked to other services and supports (Attachment 2: SOW 5.15), such as a Partial Hospitalization Program/Intensive Outpatient Program (PHP/IOP), or the treatment team may call for a BHS “Barrier Buster” meeting to brainstorm ideas for support.
c. Timely access to services is a priority for the CoSD and contracted HFW providers (Attachment 2: SOW 3.2. and 5.9.1.3.). Access times are reviewed monthly in Technical Assistance meetings with the CoSD contracted HFW providers and the County BHS COR team, in monthly Wraparound Oversight Meetings (Attachment 2: SOW 6.37.) and monitored in the QSR (Attachment 3: QSR, Access Time tab pages 7-8).
d. Funding is allocated based on the unduplicated number of clients that the program is expected to see on an annual basis. During the competitive procurement process, potential HFW providers (Offerors) review the SOW (Attachment 2) and Pricing Summary (Attachment 14: Exhibit C – Payment Schedule) to propose the funding their legal entity is projected to need to operate a functional program serving the unduplicated clients, while maintaining staffing ratios, office space, and other funds necessary to operate the program (including 24/7 staff availability to support families in crisis as required in attached SOW 6.11.2.5.). The awarded contractor will then enter negotiations to finalize an annual contract allocation. The contracts are designed as fixed price and connected to service provisions. If service provision begins to outpace the annual allocation, the County COR evaluates the need for a contract amendment to infuse sufficient funding to align with service level need.
e. HFW services are reflected in the CoSD forward facing website, which offers a brief description of Wraparound and how to access services (Wraparound). Additionally, CoSD contracted HFW providers are expected to maintain regular contact with STRTP, CCRP/PRTF, and CTF administrators to ensure youth are referred for HFW Aftercare services (Attachment 2: SOW 6.15.). The CoSD Children, Youth, and Families Services Directory offers information for the two contracted HFW providers (Attachment 15: pages 29 and 30). The CoSD Quality Assurance department is in the process of updating the 2026 member handbook in alignment with the required information regarding HFW as outlined in BHIN 26-XXX (Attachment 16: page 17).
Fiscal
8.1 Funding Supports the CA High Fidelity Wraparound Model
a. CoSD Behavioral Health Services Department contracts for HFW services through two distinct providers, one that primarily serves system involved youth and families, and one that primarily serves community-based referred youth and families. Each contract outlines HFW service provision aligned with DHCS and CDSS roles and responsibilities, and zero-based budgeting is utilized to plan for contracting allocations that support the contractor in staffing and providing the designated services. CoSD contracted HFW providers are on fixed price budgets with services reimbursed based on services provided. COR team reviews service provision and run rates at monthly TA meetings with the HFW provider.
b. State mandated staffing ratios are considered when CoSD completes zero-based budget forecasting to propose total budget allocations. CoSD uses state mandates to determine how many staff would be necessary for each contract to serve the identified number of annual unduplicated clients. CoSD requires minimum required staffing to be met in accordance with the Statement of Work, with contractors able to increase staffing above the minimum requirements if the contractor chooses to do so, for example, if referral trends increase beyond what has been projected for.
c. CoSD contracts with UCSD CASRC to support data collection and management systems. These costs are not the responsibility of contracted HFW providers; they are funded by the CoSD Behavioral Health Services department. UCSD CASRC collects data from HFW providers for the WFI EZ, CANS, YSS, and PSC, and generates outcomes reports for both CoSD and contracted providers.
8.2 Equitable Funding Across System Partners
a. In BHS, multiple teams carry out essential functions that strengthen overall effectiveness and efficiency, working collaboratively to achieve shared goals:
The BHS Budget/Fiscal team oversees the system’s financial landscape, which includes mapping funding sources, aligning resources, managing the budget cycle, tracking expenditures, and analyzing gaps or redundancies. They also forecast financial needs, evaluate cost-effectiveness, and ensure compliance with fiscal and regulatory requirements.
The Strategy & Finance team leads long-term financial planning, focusing on multi-year financing strategies, leveraging diverse funding streams, addressing resource gaps, creating sustainability plans, and monitoring state and federal funding opportunities.
The Billing team plays a critical role in optimizing fund usage by determining federal match eligibility, monitoring service utilization, resolving billing issues, auditing practices, and coordinating with providers. They also track reimbursement trends to ensure proper financial management.
The Grants Team identifies and researches new funding opportunities, facilitates effective communication and collaboration among management, program teams, and other key personnel, prepares and submits grant applications, oversees all phases of the grant lifecycle, and ensures ongoing compliance with grant requirements.
As an active participant in the California Behavioral Health Directors Association (CBHDA) Financial Services/IT Joint Committee, the County contributes to discussions around budgeting, implementation, vendor selection, financial reporting, system integration, and the impact of these factors on service delivery. This involvement ensures that counties can properly bill, claim, and track services, which is essential for maintaining funding, compliance, and service provision.
Together, these collaborative teams and processes ensure the systematic identification, access, and alignment of all potential funding sources, maximizing the resources available to support the Children’s System of Care.
b. The County follows a structured procedure to analyze available resources and funding streams. During regular program and fiscal meetings, representatives from BHS, CFWB, and Probation review updates from BHIN, CFL, and other funding sources. These discussions are used to evaluate current allocations, identify new or emerging resources, and determine opportunities for maximizing funding. The information gathered informs the development of coordinated plans and budgets that ensure resources are leveraged efficiently across System.
Throughout the year, the County gathers input from multiple sources, including public feedback and Board recommendations, to inform the development of its Strategic Plan, which sets the long-term direction for the BHS. This is supported by the Five-Year Financial Forecast, which anticipates significant needs, challenges, risks, and opportunities. From these, the two-year Operational Plan is developed to allocate resources over the next two fiscal years in alignment with strategic goals.
Although the budget is formally adopted annually, the planning cycle is continuous and directly linked to both the Strategic Plan and the five-year financial forecast. As part of the General Management System (GMS), departments perform quarterly fund balance projections to ensure that actual expenditures and revenues remain on target throughout the fiscal year.
c. Under the current County process, internal agreements and Memoranda of Understanding (MOUs) are in place or established as needed between Child Welfare, Probation, and Behavioral Health to define fiscal responsibilities for shared services, joint programs, and cross-system initiatives. As appropriate, each department contributes funding based on established formulas or programmatic needs. These agreements are regularly reviewed during joint fiscal meetings to ensure compliance, transparency, and appropriate use of resources. At present, there is no MOU/Cost Sharing Agreement between BHS and either Probation or Child and Family Well-Being due to the nature of current structure of the two HFW contracts. However, an MOU/Agreement will be developed when cost-sharing arrangements is required.
d. COSD leverages Medi-Cal and BHSA (formerly MHSA) as the primary funding sources for the two contracted HFW programs. In addition, BHS and CFWB conduct monthly joint fiscal meetings to plan for and coordinate the use of Aftercare Funds and Immediate Needs Funding, ensuring that available resources are utilized effectively and in alignment with program goals. As part of ongoing efforts to expand access and support for HFW services, CFWB is currently evaluating the potential inclusion of respite services and family finding activities under the Aftercare Funds umbrella. These efforts reflect the County’s commitment to exploring and maximizing all feasible funding avenues to enhance service capacity and better meet the needs of youth and families.
8.3 Cost Savings are Reinvested
a. The County of San Diego BHS manages fiscal resources by covering costs as they are incurred, in alignment with the rate‑based reimbursement model used for contracted programs. The County continues to closely monitor program budgets throughout the year and adjusts as needed to ensure that funding remains aligned with program requirements and is sufficient to meet the needs of the community. At this time, there are no savings available for reinvestment.
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 to the CoSD contracted HFW provider and are included in their annual budget (Attachment 14: Exhibit C-Payment Schedule). Flex fund use is managed by the CoSD contracted HFW provider, with flex funds spending reviewed and monitored by the CoSD Contract Oversight Team through monthly submissions that accompany the HFW provider invoice (Attachment 9: Flex Fund Expenditure Report).
b.1. Flex funds can be used by the HFW team for anything determined necessary in alignment with California Wraparound Standards and CoSD policy. The funding is available to support and address the urgent and individualized needs of children, youth and their families (Attachment 2: SOW 6.20). Flex fund expenditures are monitored through the provider submission of the Flex Fund Expenditure Report (Attachment 9) and the submission of the monthly invoice, which are reviewed and approved by the CoSD BHS COR team.
b.2. CoSD contracted HFW providers are expected to develop an internal Flex Fund Expenditure Policy which the program uses to guide HFW teams in expenditures (Attachment 17: SDCC Flex Fund Expenditure Policy). CoSD BHS COR team reviews and retains a copy to ensure alignment with requirements, and policy may be subject to review as a part of the Desk Review (Attachment 11).
b.3. CoSD reviews contracted HFW providers flex fund expenditures monthly, to ensure alignment with CoSD policies. For atypical spending that exceeds $350 for one youth for one expenditure, the HFW provider consults with the COR team for approval prior to expenditure (Attachment 17: SDCC Flex Fund Expenditure Policy, page 2).
8.5 Collaborative Oversight of Flex Funds
a. CoSD provides contracted HFW providers with access to flex funds as part of their annual budget allocation. HFW providers implement internal processes to manage the funds (Attachment 17: SDCC Flex Fund Expenditure Policy). Flex fund expenditures are currently monitored through monthly flex fund submissions to the CoSD BHS COR team for review and approval and are intended to support the client’s treatment goals on an individual basis (Attachment 2: SOW 7.31). Monthly report submission includes amount, purpose and a brief reason of how this will benefit the client or client’s family, as related to youth or family needs (Attachment 9: Flex Fund Expenditure Report).
b. CoSD provides program an annual budget for flex funds as noted on Exhibit C – Payment Schedule (Attachment 14, item 6). These funds are made available to the contractor in alignment with California Wraparound Standards, to meet urgent and individualized client needs (Attachment 2: SOW 6.20), as contracted HFW provider deems appropriate. The Flex Fund Expenditure Report is reviewed by CoSD COR team monthly to ensure that funds are used in alignment with HFW (Attachment 9: Flex Funds Expenditure Report).
8.6 Funding Sources and Program Requirements do not Limit Flex Funds
a. Flex funds are annually allocated for the CoSD contracted HFW provider, as noted in the Exhibit C – Pricing Summary (Attachment 14). CoSD does not currently braid funding for HFW services, but this does not limit the availability of Flex Funds for HFW. Children and youth may be additionally eligible for other supports and those are discussed at CFT meetings with other system representatives who hold different expertise.
b. CoSD currently leverages Mental Health Services Act (transitioning to Behavioral Health Services Act 7/1/26), Medi-Cal, and Federal Financial Partnerships for funding HFW. CoSD fiscal department reviews opportunities for additional funding streams and conducts operational planning to confirm funding for established programs. HFW contracts are awarded for an initial 1-year term, with 4 additional option years, and Flex Fund allocations are available for the duration of each contract award. Placing agencies may identify other funding sources through direct work with the family and/or part of the CFT Team (for example, FFPSA). Forthcoming Activity Funds may also be a resource to leverage as well as the Immediate Needs Program.
c. The current CoSD HFW funding sources do not prohibit families from accessing flexible funds to meet their needs. Flex funds are allocated to each CoSD contracted HFW provider and are allocated specifically for the urgent and individualized needs of the children, youth and families served in the HFW programs (Attachment 2: SOW 6.20 and 7.31).
Workforce Development and Human Resource
9.1 Culturally Responsive Workforce
a. CoSD requires that all contracted HFW providers ensure that program staff are representative of, and knowledgeable about, the client’s culturally diverse backgrounds and that programs are reflective of the specific cultural patterns of the service region (Attachment 1: OPOH H2). HFW providers must submit a Cultural Competence Plan to the CoSD COR team, that includes a comparison of staff to diversity in community. HFW providers include information on staff race/ethnicity, and languages spoken on the QSR (Attachment 3: QSR, S&P tab pages 9-10), which is monitored by the CoSD COR team.
b. CoSD contracted HFW providers are expected to maintain minimum staffing levels to serve the minimum unduplicated clients as required in the Statement of Work (Attachment 2: SOW 6.19.). Staffing and recruitment efforts are reviewed and monitored in monthly Technical Assistance meetings between the HFW provider and the CoSD COR team. The HFW CFT maximizes the identification and inclusion of natural supports (Attachment 2: SOW 6.11.1.3.) and may leverage natural supports more at times to meet family needs as appropriate.
c. CoSD requires that contracted HFW providers offer culturally responsive and linguistically appropriate interventions (Attachment 2: SOW 5.13). CoSD BHS policy prohibits the expectation that family members, including minor children will provide interpreter services; however, if clients choose to use family or friends, this choice should be documented (Attachment 1: OPOH C21). CoSD contracted HFW providers unable to meet the language needs of a clients can use the contracted interpreter service “Interpreters Unlimited” (Attachment 1: OPOH C22).
9.2 Tribally Responsive Workforce
a. CoSD contracted HFW provider staff (direct and indirect) are required to take the Foundational Wraparound Training (externally through UC Davis Resource Center for Family-Focused Practice or internally utilizing the Statewide Standardized Foundational Wraparound curriculum or UC Davis RCFFP approved internal contractor curriculum (Attachment 2: SOW 6.24). The training infuses learning components regarding the Indian Child Welfare Act (ICWA), Tribal sovereignty, and Tribal jurisdiction. This continues to be reinforced with staff as HFW Supervisors and Fidelity Coaches provide them with training and coaching to support their understanding and development of HFW interventions, and to reinforce HFW practice expectations (Attachment 2: SOW 6.21.5.1. and 6.21.4.2.). Training completion is monitored through training logs submitted with the QSR (Attachment 2: SOW 6.26.).
b. CoSD contracted HFW providers are expected to engage system partners (Attachment 2: SOW 6.113.1.2.) and maximize the identification and inclusion of natural supports as a part of the HFW CFT (Attachment 2: SOW 6.11.1.1.), which in the case of an Indian child includes members of the Tribe. The HFW team is always expected to explain HFW and outline team member roles to family, natural supports, and Tribes in the case of an Indian child (Attachment 2: SOW 6.11.1.3.). Through the completion of the Strengths, Needs, Culture and Vision Discovery (shifting to require a form that is currently in development with the Wraparound Oversight Team), the HFW team gathers information about the youth and family’s Tribal affiliation, cultural practices, and any traditions or ceremonies that are meaningful to them. This information is used to support culturally grounded planning to ensure Tribal perspectives are honored throughout the HFW process. In addition, the Community Leadership Team includes dedicated representation from the Southern Indian Health Council, whose participation helps inform system-level cultural responsiveness and may provide guidance or recommendations regarding culturally appropriate services and supports for an Indian child. The HFW Supervisor and/or Fidelity Coach monitor the HFW teams’ ability to build partnerships with tribal representatives and cultural engagement through field coaching, training, and feedback for staff (Attachment 2: SOW 6.21.4.2., and 6.21.5.).
9.3 Flexible and Creative Work Environment
a. CoSD contracted HFW providers are required to have a Quality Assurance Process (QAP) in place (Attachment 2: SOW 5.6.1. and 5.9.1.1.) that includes internal quality improvement controls to ensure alignment and adherence to SOW requirements. As part of the QAP, each member of the HFW team shares responsibility for contributing to program quality and continuous improvement, and may include participation in internal documentation peer review, Program Manager, HFW Supervisor and/or Fidelity Coach monitoring charts and billing activity, and/or a formal Quality Assurance department (Attachment 1: OPOH G1). HFW providers complete an annual attestation that there is a policy and procedure in place to conduct internal documentation reviews as a part of their program quality and improvement process and is monitored in the QAPR (Attachment 5: QAPR, Provider Compliance tab).
b. CoSD fosters cohesive team environments with contracted HFW providers through regular communication, an open-door approach, and structured meetings. These interactions create opportunities for CoSD and the HFW provider to model and reinforce wraparound principles. In turn, the HFW provider promotes team cohesion within their own organization through consistent team meetings, staff development activities, and intentional relationship building. The provider shares updates on these efforts during monthly technical assistance meetings with the CoSD COR. Strong team cohesion within the HFW provider organization often serves as a key support strategy for staff retention.
c. CoSD COR team has open lines of communication with contracted HFW providers, implemented through Technical Assistance, Program Manager meetings, Wraparound Oversight collaboratives, and the Community Leadership Team. CoSD Children, Youth & Families System of Care Principles and Values are modeled after the 10 principles of Wraparound, which prioritizes collaboration (Attachment 1: OPOH A5). It is expected that CoSD contracted HFW providers will integrate these values and principles into their work environment.
d. CoSD embraces the Wraparound philosophy, which is extended to contracted HFW providers (Attachment 1: OPOH A5). The contracted HFW provider demonstrates internal alignment with wraparound values by operationalizing the same principles, practices, and expectations within its organizational culture and staff development process which is facilitated through ongoing training, coaching, and strengths-based approaches (Attachment 2: SOW 6.21.4.).
9.4 Hiring, Performance Evaluation, and Job Descriptions
a. CoSD has clearly outlined the required roles and responsibilities for the contracted HFW providers to be in alignment with DHCS requirements (Attachment 2: SOW 6.21.). Staffed positions are reviewed and monitored by the COR team in monthly Technical Assistance meetings, and in the QSR (Attachment 3: QSR, S&P tab pages 9-10).
b. CoSD requires the contracted HFW providers staff their HFW positions in alignment with the DHCS requirements, and UC Davis’ role descriptions (linked descriptions for each role in the SOW), as outlined in the SOW (Attachment 2: SOW 6.21). Staffed positions are reviewed and monitored by the COR team in monthly Technical Assistance meetings, and in the QSR (Attachment 3: QSP, S&P tab pages 9-10).
c. CoSD requires contracted HFW providers to align Wraparound roles with DHCS and CDSS Wraparound Role Descriptions as outlined in the SOW (Attachment 2: SOW 6.21), which includes links to each complete role description. Staffing for each position is monitored in the QSR (Attachment 3: QSR, S&P tab pages 9-10).
d. CoSD contracted HFW providers are required to staff their programs in alignment with roles outlined in the Statement of Work (Attachment 2: SOW 6.21) and maintain staffing levels and composition that comply with regulatory requirements governing the levels and service types provided and aligned with any DHCS and CDSS fidelity requirements (Attachment 2: SOW 5.4.). During the competitive procurement process, Offeror’s submit outlines of the required positions and ideal candidates to staff the positions.
e. The HFW Supervisor and Fidelity Coach provide HFW staff with oversight and feedback that includes coaching and training for staff to reinforce HFW practice expectations, build staff skills in strengths-based and solution-focused services, increase staff confidence, and support the understanding and development of HFW roles and interventions (Attachment 2: SOW 6.21.4.2. and 6.21.5.1.). Staffing is monitored by the COR team in the program’s submission of the QSR (Attachment 3: QSR, S&P tab pages 9-10).
9.5 Workforce Stability
a. CoSD contracted providers are reimbursed under a fixed price contract; therefore, CoSD no longer has oversight of providers’ internal budgeting for staffed positions. CoSD uses zero based budgeting to project system wide funding needs based on the unduplicated clients required in the SOW and the staffing levels necessary to serve that population. This approach allows the HFW contractor to allocate salaries in a way that aligns with local cost of living requirements for their employees.
b. CoSD requires staffed positions to align with DHCS identified staff to client ratios (Attachment 2: SOW 6.21.). Adherence to ratios is monitored by the COR team in the submission of the QSR (Attachment 3: QSR, Data tab page 6 and S&P tab pages 9-10).
c. CoSD has integrated current roles and responsibilities outlined by DHCS and CDSS for HFW positions (Attachment 2: SOW 6.21.). These positions offer flexibility for promotion or advancement through the contracted HFW providers as they determine appropriate. Staffed positions are monitored by the COR team in QSR (Attachment 3: QSR, S&P tab pages 9-10).
d. CoSD contracted providers are reimbursed under a fixed price contract; therefore, CoSD no longer has oversight of providers’ internal budgeting for staffed positions. CoSD outlines the required positions in alignment with DHCS and CDSS requirements, and the contracted HFW provider has flexibility within those roles. This allows the provider to offer wage increases or expanded leadership opportunities to staff without needing to change position titles or classifications.
9.6 High Fidelity Training Plan
a. Option 3: CoSD contracted HFW providers report that they utilize internal curriculum that aligns with the Statewide Standardized Foundational HFW curriculum and that they have submitted their internal curriculum as a part of their Portal Certification submission.
b. CoSD contracted HFW providers are required to train direct and indirect staff in the Foundational Wraparound Training, and to provide ongoing staff training and coaching in alignment with Center of Excellence guidance to support consistent high-fidelity youth and family-driven HFW services and CQI (Attachment 2: SOW 6.24 and 6.25). Training completion is monitored through training logs submitted with the QSR (Attachment 2: SOW 6.26.).
c. Training is required to be provided in alignment with the Centers of Excellence (Attachment 2: SOW 6.25.). Training completion is monitored through training logs submitted with the QSR (Attachment 2: SOW 6.26.).
d. CoSD contracted HFW providers are required to adhere to support, training, technical assistance, and fidelity monitoring offered by the Centers of Excellence (Attachment 2: SOW 6.3.2.). HFW staff (including Supervisors and Managers) will participate in ongoing staff training (Attachment 2: SOW 6.25.). Training completion is monitored through training logs submitted with the QSR (Attachment 2: SOW 6.26.).
e. CoSD requires contracted HFW providers to train all staff in cultural competence, which may include ICWA and Tribal sovereignty (Attachment 1: OPOH H6). In addition, all direct and indirect staff are required to be trained in Foundational Wraparound which includes training components specific to ICWA and Tribal sovereignty. For ongoing training beyond Foundational Wraparound, contracted HFW providers may leverage UC Davis RCFFP training offerings such as ICWA Overview & Tribal Engagement in Team Best Practices, ECHO: ICWA & Tribal Engagement, or other local ICWA and Tribal sovereignty trainings. Current system serving HFW provider will have a local ICWA professional train their staff on 5/1/26 (Attachment 20: SDCC ICWA presentation-training). Training completion is monitored through training logs submitted with the QSR (Attachment 2: SOW 6.26.).
9.7 Community-based Training Program
a. CoSD contracted HFW providers are required train direct and indirect staff members in Foundational Wraparound Training, using either a CDSS approved curriculum, through the UC Davis Resource Center for Family-Focused Practice (RCFFP), or internally using a UC Davis RCFFP approved curriculum. The current contracted HFW providers train using internal curriculum (these have been submitted with their Portal Application for Certification) which integrates youth, families and peer partners with Wraparound experience incorporated into the delivery of the trainings (Attachment 2: SOW 6.24. and 6.25.2.1.). Training completion is monitored through training logs submitted with the QSR (Attachment 2: SOW 6.26.).
b. One of the responsibilities and functions of the Community Leadership Team is to 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 (Attachment 10: Community Leadership Team Charter Agreement, Responsibilities & Functions). As such, training offerings will be reviewed and discussed so that stakeholders may have the opportunity to attend training courses to gain understanding of HFW.
9.8 Coaching and Supervision
a. CoSD requires contracted providers to ensure staff training align with California Wraparound Standards including ongoing coaching of team members and training that empathizes values, principles, and essential elements of wraparound per (Attachment 2: SOW 6.25.). HFW staff receive ongoing training and coaching from identified HFW Supervisor and Fidelity Coach, whose roles are to support and reinforce staff knowledge of roles, responsibilities, and increase skills and staff confidence (Attachment 2: SOW 6.21.4.2 and 6.21.5.). CoSD COR team monitors staffed positions in the QSR to ensure that there are HFW Supervisors and Fidelity Coaches to provide staff with apprenticeships, coaching and training (Attachment 3: QSR, S&P tab pages 9-10).
b. CoSD contracted HFW providers are required to have defined mechanisms to provide 24 hour a day, 7 day a week coverage for HFW clients (Attachment 2: SOW 6.11.2.5.), with HFW Supervisor and Fidelity Coaches staffed to support the HFW staff (Attachment 2: SOW 6.21.4. and 6.21.5.).
Utility-Focused Data and Outcomes Processes
10.1 Continuous Quality Improvement
a. CoSD uses multiple tools to support CQI and fidelity monitoring, including the WFI EZ, IP CANS, Youth Services Survey (YSS), and the Pediatric Symptoms Checklist (PSC). These tools collectively capture the required demographic information, wraparound fidelity indicators, and program outcomes. For HFW specific WFI EZ data collection, the county engages in a collaborative planning process with the Wraparound Oversight Team to determine timing, support accurate data collection, and jointly review findings. Outcomes and fidelity data are reviewed with both the Wraparound Oversight Team and the Community Leadership Team to promote shared decision making and continuous quality improvement (Attachment 2: SOW 6.37 and 6.38 and Attachment 10: Community Leadership Team Charter Agreement, Responsibilities & Functions).
b. Relevant child serving entities, including CFWB, Probation, BHS, and contracted providers, participate in established information sharing processes that support implementation of the local CQI evaluation plan. These collaborative processes are implemented through regular monthly Wraparound Oversight meetings and Community Leadership Team meetings (Attachment 2: SOW 6.37 and 6.38 and Attachment 10: Community Leadership Team Charter Agreement, Responsibilities & Functions) to ensure that information and outcome data are shared in a timely and accurate manner. Shared information is used to support continuous quality improvement activities, reinforce fidelity to the HFW model, and promote coordinated accountability across the system of care.
c. Collected data is maintained in a current and accurate manner through established CQI procedures, regular monitoring, and coordinated data collection schedules, facilitated through UCSD CASRCs established protocols. CoSD and contracted HFW providers jointly review outcome data through the Wraparound Oversight Team and the Community Leadership Team (Attachment 2: SOW 6.37 and 6.38) to ensure shared understanding of trends and needs. The data is used to inform practice improvement, guide decision making, and monitor progress toward desired outcomes. Findings from tools such as the WFI EZ, IP CANS, YSS, and PSC are integrated into supervision, training, at the HFW provider program level, ensuring ongoing accountability and alignment with HFW principles and expected outcomes.
d. Data is collected at the level closest to the individual and is subsequently uploaded in the appropriate format for analysis at the next level. For HFW services, data is collected directly from participants or through a team-based approach, as appropriate. For the WFI EZ assessment, information is gathered from the HFW youth, caregiver, Wraparound Facilitator, and an additional team member. All outcome measures are compiled and analyzed by UCSD CASRC and then shared with Behavioral Health and made available to contracted HFW providers (Attachment 8: WFI-EZ Agency Report).
10.2 Evaluation Metrics & Outcomes
a. HFW Supervisors and Fidelity Coaches observe meetings, review documentation, and provide feedback on engagement, strengths discovery, timelines, and fidelity (Attachment 2: SOW 6.21.4.2 and 6.21.5.1). The WFI-EZ is the Wrap specific outcome measure used by CoSD to assess progress towards fidelity with the contracted HFW providers. Following data collection periods, comprehensive reports are drafted by UCSD CASRC (Attachment 8: WFI EZ Agency Report), then shared with the HFW providers administrators, who review and share at a program level with staff. HFW provider administrators draft action plans to address areas of growth from the WFI-EZ and to implement trainings that will address these areas, which they outline in the Action Plan narrative of the QSR (Attachment 3: QSR, Outcomes tab pages 3-5, rows 74-116).
b. WFI-EZ data is used to highlight areas of success in wrap fidelity, and to uncover areas of growth. CoSD contracted HFW providers use the WFI-EZ outcomes to identify and address program needs to better serve families and improve overall program effectiveness. This is done through Action Planning based on outcomes, which is done at the HFW program level and reported back to CoSD in the QSR (Attachment 3: Outcomes tab pages 3-5, rows 74-116).
c. The WFI-EZ outcomes, the Program Advisory Group Feedback, and IP-CANS outcomes are the primary outcomes reviewed with the Community Leadership Team (Attachment 10: Community Leadership Team Charter Agreement, Purpose, and Authority & Scope), for the purpose of addressing and removing system barriers, and promoting and monitoring effective HFW and Aftercare service delivery.
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).