Lawrence County Appalachian Family and Children First Council

Service Coordination Mechanism
Lawrence County

Overview and Purpose:
Appalachian Family and Children First Council (AFCFC) Service Coordination Mechanism’s purpose is to be a guiding document for coordination of services in Lawrence County. It gives guidance to implement a process of service planning that provides individualized services and supports to families. This mechanism is designed to pro

vide a complete, easy-to-access, collaborative, cross system team planning process, implemented to address the needs of families and children with multiple and complex needs within Lawrence County. This unified system makes the family a partner in the planning process, it is family-focused and strength-based, and is structured to enable families and children to achieve their fullest potential. Lawrence County’s Service Coordination Mechanism is responsive to the different cultural and ethnic diversities that make up our Appalachian community. We respect each individual child/family, their traditions, values, heritage, spiritual beliefs, and lifestyle choices. For non-English children/families an interpreter may be provided by Ohio University Southern to assist in any communication barriers in providing services. Target Population:
Appalachian Family and Children First Council Service Coordination Mechanism is open to all children ages 0 through 21 years of age who have multiple systemic needs that require services and supports that are not being adequately met while seeking assistance outside of the Service Coordination Mechanism. The criteria or standard norm of youth referred for service coordination services are children that are having behavioral issues within the traditional classroom setting or behavioral issues at home, family instability, needing or receiving mental health services, substance abuse issues, children that have experienced physical / emotional abuse, neglect, Developmental Disability clients, and children with severe health issues. A high percentage of the youth referred to service coordination may be at-risk of out-of-home placement. Children birth to 3 years of age who receive services through the Help Me Grow (HMG) program will be preliminarily served through HMG Early Intervention Service Coordination protocols. The AFCFC service coordination would likely be relinquished to the EI system upon completion of the developmental evaluation, determination of eligibility and need for service, and the development of the initial IFSP. The EI service Director may invite the AFCFC service Director to the initial IFSP meeting with the approval of the family. AFCFC services and supports could still be included on the child’s IFSP if determined by the family to be a priority. Awareness:
Appalachian Family and Children First Council’s Director collaborates with county child serving agencies to educate their staff in regards to AFCFC Service Coordination Mechanism. AFCFC Council Director provides a training on AFCFC Service Coordination Mechanism to council members. Council provides all child serving agencies with service coordination literature and service coordination referral forms/packets. The Council Director participates in local community events to educate the public about AFCFC Service Coordination Mechanism and Council’s role within the community. AFCFC works collaboratively with all Lawrence County’s School Districts in the education of staff on the Service Coordination Mechanism. Any agency or parent that wishes to have training or seeks information on AFCFC Service Coordination Services/Mechanism may contact: Karen Reed- Executive Director- 740-377-5612
OhioRISE Care Coordination:
On July 1, 2022, as a part of Ohio Medicaid’s effort to launch the next generation of Medicaid, ODM launched OhioRISE (Resilience through Integrated Systems and Excellence), a specialized managed care program for youth with complex behavioral health and multisystem needs. A Child and Adolescent Needs and Strengths (CANS) assessment is required to determine a child or youth's eligibility for OhioRISE. Regardless of youth/family enrollment with OhioRISE, FCFC Service Coordination can still be accessed for any youth with needs across multiple systems. Due to the restrictions of FCSS funding, county FCFCs are not permitted to utilize FCSS funding for service coordination activities for youth enrolled in OhioRISE that are receiving Care Coordination through a CME – Care Management Entity. If an FCFC provides Care Coordination for a youth enrolled in OhioRISE, the care coordinator must coordinate benefits with Aetna Care Coordination directly. Youth may also be referred to FCFC Service Coordination at any time at the request of the family. Procedures for referring a child or family:
There are several ways to refer a child/family for service coordination. A child/family can gain access through a parent/guardian referral, self-referral, school, medical/clinical therapy professional, juvenile court referral, or agency referral. Referrals for service coordination services are made to Appalachian Family and Children First Council. At first contact a brief child/family Informational Needs Assessment is completed. This short assessment identifies family/child strengths, needs, and any cultural barriers that could create problems with the delivery of services. The person, juvenile court, or agency making the referral will assist the family or if it is a child/family/self-referral the Service Director will assist the child/family in completing the form. Information will be gathered to complete the brief needs assessment from the parent / guardian, or from the person making the self-referral. The completed informational needs assessment form will be submitted along with the service coordination referral form. The referral form and the informational needs assessment form are included in the referral packet. These forms are to be submitted to the Service Director. Responding within a week to 10 days, the AFCFC Service Director will discuss the purpose of service coordination and the options available to the child/family. The Service Director gives the family information on the service coordination process. Service Director and the family decide if service coordination is appropriate. Some families or agencies making a referral may only need access to community resource information or a referral to appropriate services and the process may end here. Parent/Guardian/Self-Referral: The Service Director will review the referral process with the individual and assist them as needed. The parent/guardian or youth(age 18-21) will receive a referral form and an initial Information Needs Assessment; the Service Director will assist the family in completion (if needed) of the forms within the packet. The parent/guardian or youth will also need to complete a release of information form. A parent/guardian or youth making a referral for assistance does not need a referral from any agency or program. The parent/guardian or youth is encouraged to invite a support person to serve as an advocate. Parent advocate services or requesting a support person can be requested by the parent at any time during the service coordination process. Juvenile Court / Agency Referral: The juvenile court or any agency wishing to make a formal referral will be required to complete a Service Coordination Referral Form. This form is to be sent by email: [email protected], [email protected] or faxed: 740-353-5327 to the attention of the AFCFC Service Director. With each referral the following information needs to be received by the Service Director. (If an agency / juvenile court are making the referral no personal identifying information can be exchanged without a release of information).
• Signed Authorization of Release of Information
• Completed referral form (form must include contact information for person being referred, brief description of the reason child/family is being referred, name and contact information of agency making referral, name and contact information of agency staff making the referral, referral receipt date, and response/outcome of referral).
• A completed brief Informational Needs Assessment form.
• Non-emergency cases, a service coordination meeting must be scheduled within 15 days after making contact with child / family.
• Emergency cases for out-of-home placement shall have a service coordination plan meeting within ten (10) days of placement. Consultation and Referral: The Service Director will provide consultations with parents, schools, custodians, agencies, juvenile court, and/or community representatives regarding the referral. A consultation will assist the provider in identifying additional resources and whether or not additional systems need to be involved. In dealing with children alleged to be unruly, every effort will be made to divert the child from the juvenile court system and prevent out-of-home placement. Individual Assessment:
Once a referral and initial brief assessment are completed, there will be a CANS (Ohio Child and Adolescent Needs and Strengths). This will be completed by the Executive Director or Service Coordinator who will be subcontracted by the Appalachian Family and Children First Council. Intake: After receiving the referral, the Service Director will contact the family and schedule an intake meeting to:
1. Provide and explain the contents of the Service Coordination process:
• Initiate the Service Coordination Process
• CANS Assessment
• Parent and Custodial Rights
• Child/family will be given a written copy of County Council’s Dispute Resolution Process and informed of their rights to use this process
• Parent Advocacy that is available
• Release of Information

Child/family will be encouraged to identify their support person or anyone else they wish to bring to the meeting
2. Schedule a Service Coordination meeting date.
3. Establish a mode of communication between the child/family and the service coordination team members, (i.e. Once the preferred mode of communication is established the Service Director will explain to the child/family and service coordination team the procedure for notification of meeting dates, locations, and times. All mandated parties (child/family, mentor or advocate, involved agencies, and school district) are notified of meetings using the decided upon mode of communication. Arranging the first Service Coordination meeting:
1. The Service Director will schedule the meeting to take place no later than 10 days upon receipt of completed referral. And will be reviewed every 90 days
2. In the event of an emergency out-of-home placement the meeting may take place no later than 10 calendar days after receiving the parents signed information release forms.
3. The Service Coordinator will work with the family to help resolve any barriers that the family may have and every effort will be made to schedule the meeting, time and location that is convenient for the parents/guardian.
4. In the event that parents/guardians are unable to attend any subsequent meetings, the service coordination team members can still meet (with parent/guardian consent) to develop services around the identified needs of the child/family.
5. The Service Coordinator will notify each member of the service coordination team as to when the meetings will take place and request/encourage participation. (email)
6. The Service Coordinator will provide the family and each service coordination team member a copy of the referral form and the signed Consent for Release of Information form.
**If needed, a parent / guardian may initiate service coordination meetings at any time during the service coordination process. Consent for Release of Information/Protecting Confidentiality Procedures
Consent for Release of Information Form must be signed by the parent/guardian listing each agency or individual who will be represented on the service coordination team and each agency that child or family request to seek and share information with. This form will set the parameters for any information written or verbal that may be shared between the agencies or service coordination team members. Each agency represented on the service coordination team will follow confidentiality polices set forth by their agency/employer.
1. A separate release of information form must be completed for each child in the family who will be served by the coordination service.
2. A new Consent for Release of Information form must be filled out each time someone is added or deleted from the service coordination team or parent requests a specific time.
3. At the first service coordination meeting participants will receive instructions on the proper handling of confidential information. Parent/guardian and service coordination team participants will all sign a Statement of Confidentiality Form.
4. All forms, identifying information, paper work, and service coordination child/family plans are kept in individual file folders. These files are kept in a locked file cabinet within the Directors /Service Director’s office. After instruction on confidentiality the meeting will proceed as follows:
1. Other than the AFCFC, a lead agency may be selected by the parent/guardian
2. Review with the child/family council’s Dispute Resolution Policy and give them a copy.
3. A Service Coordination Child/Family plan will be written in a collaborative effort with the child present (if appropriate), family, and team members and will be submitted into OASCIS.
4. This plan will identify the child/family strengths, needs and cultural discovery of the family.
5. A designated individual, approved by the family, is selected to track the progress of the family service plan
6. Establish goals and set strategies to achieve these goals.
7. Set a timeline for strategies to begin and timeline for goals to be met.
8. Specify the services to be delivered (including further evaluation when needed), insuring assistance and services are provided in the least restrictive environment possible, and that services meet family or child’s cultural ethnicity.
9. Name the responsible participating agencies and team members that will be providing specific services, establishing dates and timelines that service will be delivered.
10. Document what funding will be used to provide services. (for example: FCSS, Medicaid etc)
11. Child/family and team members will develop and document an individualized crisis/safety plan.
12. Document parental/guardian agreement with the plans. (OASCIS)
13. Document service coordination team members and agencies’ agreement with the plans. (OASCIS)
14. Review Statement of Assurance form with parent/guardian and service coordination team members. Parent/guardian and team members will all sign Statement of Assurance form.
15. Copies of the Child/Family Service Plan will be made available to all team members at the conclusion of the meeting or within 5 working days thereafter.
16. Scheduling of follow-up meetings to monitor and evaluate the progress of the individual child/family service plan will be made by the Lead Agency or Service Director.
17. A Service Coordination Service Satisfaction Survey will be completed upon closure of services or 6 months after the initial Service Coordination meeting. Crisis / Safety Plan:
The crisis/safety plan is developed in a collaborative effort with the service coordination team members and child/family during the service coordination meeting. Members of the service coordination team will state their concerns regarding anticipated crisis. All team members have input on what the consequences (out-of-home placement, juvenile court involvement, harm to oneself or others, etc.) might occur if the crisis/safety plan is not followed. Proactive plans include supports that can be used to prevent the anticipated crisis. Reactive plans are noted in the plan in the event the anticipated crisis does occur. Each crisis/safety plan is individualized for the child/family. If the plan is not working for the family or additional supports need to be added, the plan can be modified at the request of child/ family or service coordination team members at any time. If plans are to be modified there will be a service coordination meeting and all members will work together to adjust the plan to prevent any anticipated crisis. Outcome, Monitoring, and Tracking (data collection): Individual service coordination plans are written using the AFCFC Service Coordination Child/Family Plan form. The form is set up to record child/family strengths and needs, it reflects goals, timelines, funding sources, and who or what agency is responsible for meeting these goals. This form reflects a respect for each individual family. The Service Coordinator will schedule meetings as needed to monitor the progress of the goals and objectives as stated in the child/family plan. The Service Coordinator/lead agency is responsible for making sure the child/family and all team members are informed of the follow-up meetings. The family or any members of the team may initiate a meeting at any time by contacting the Service Director or Service Coordinator and requesting a meeting. Progress and activity steps will be documented at each meeting. A case will be closed when the family and the team agree that the goals have been met or that no future progress can be achieved. A case can be reopened at any time at the request of the family, any member of the team, an agency, or community representative not currently represented on the team. Tracking service coordination for OFCFC purposes of use of FCSS funding is completed in a semi-annual report and at the end of the fiscal year and upon request from the state, service coordination data will be made available for review and evaluation. Out-of-Home Placement / Unruly / Delinquent Youth:
AFCFC works closely with Lawrence County Juvenile Court to be proactive in providing Service Coordination Services for children who may be or have been referred to Juvenile Court and could face out-of-home placement. These children require close monitoring of the service coordination plan and goals by the service coordination team members. These children/families are offered Respite Care (up to 12 hours per month for a period of no more than 3 months). Respite care helps the family reduce stress, and reduce conflict within the family unit. Respite care gives both parent and child a break from each other or situation, and helps reduce out-of-home placement. Respite services are an added support to decrease out-of-home placement. Respite care is provided through a provider (who is a friend or family member) that have completed a background check. If out-of-home placement is necessary at any time during the service coordination process, a service coordination meeting will occur prior to out-of-home placement. In the event of emergency out-of-home placement a service coordination meeting will take place within 10 days after placement is made. If the child is placed in or preparing for out-of-home placement, the parent/guardian, and service coordination team members will all work together on funding and placement issues. The team will ensure that safety nets are in place for the child’s return home. A service coordination meeting will take place prior to child coming back into the home and/or school setting. Quality Assurance:
Lawrence County Appalachian Family and Children First Council Service Coordination Mechanism and Service Coordination family plans forms are developed, up-dated, and revised with the participation of the Lawrence County Service Coordination Committee and the AFCFC Director. Appalachian Family and Children First Council consists of county entities that are outlined in ORC 121.37. The Service Coordination Committee meets on an as needed basis (annual at a minimum) to review the effectiveness of the service coordination plan in place; any revision or up-dates to the AFCFC Service Coordination Mechanism (SCM); developed and approved by the Service Coordination Committee. This committee presents any up-dates or revisions of the Service Coordination Mechanism to AFCFC for final approval before implementing the revised procedures. The committee reviews the Lawrence County’s Service Coordination Mechanism on a yearly basis or more frequently if deemed necessary by the state, council, or the service coordination committee to ensure that the mechanism is meeting the needs of children and families within Lawrence County, and is meeting the requirements of ORC 121.37. The implementation of the Service Coordination Mechanism is managed and monitored through the Service Coordination Committee and AFCFC. Service Coordination reports are given at each Service Coordination Committee meeting by the AFCFC Director who conducts Service Coordination. Service Coordination Reports are also presented to AFCFC at regular meetings. These reports give the total number of children / families receiving services for that month, how much Family Center Services and Support (FCSS) dollars have been expended, what services and supports were provided, did these services and supports meet FCSS guidelines, what agencies provided these services, and if there were any gaps in services or resources that still need to be addressed. Funding / Fiscal:
A coordinated network/ system of care, (Appalachian Family and Children First) integrates services/supports planning, coordination and management across multiple levels. AFCFC receives Family Centered Services and Supports (FCSS) as part of SOC funding. AFCFC works diligently to utilize FCSS funds. FCSS polices and guidelines for eligible expenditures for children ages 0-21. FCSS funds are used for children with multi-systemic needs and who are receiving service coordination services through the AFCFC service coordination mechanism. FCSS funds are used for non-clinical needs of children and their families. These needs are identified and documented on the Child / Family Service Coordination Plan. AFCFC service coordination is funded with FCSS dollars. Any FCSS funds spent, are to be approved through the Service Coordination Committee. Funding requests must only be made for expenses not otherwise covered by another payer source. AFCFC is the payor of last resort. Local funds as well as flexible grant funds that support service coordination are generally used to support service coordination or formal wraparound team facilitation. Each child and family team helps to locate community resources to fund strategies and fill gaps. AFCFC currently receives portions of Multi-System Youth (MSY) funds distributed by the local Public Children Service Agency (PCSA) which is Lawrence County’s Department of Job and Family Services (JFS). Use of these funds are restricted to providing services and supports needed to prevent the relinquishment of custody of children, 0-18, and to facilitate family reunification following a custodial episode. The AFCFC determines the broad use of the MSY/PSCA funds along with the oversight of the Council and Service Coordination Committee. These funds may be used in any of the following manners:
1. Service Coordination/Wraparound to prevent custody relinquishment or for a
relinquished youth.
2. In-home and/or community supports to prevent custody relinquishment.
3. Residential treatment and/or room and board for treatment to prevent custody
relinquishment
4. In-home and/or community supports needed to support family stability for a child
returning from agency custody. When a portion of a child’s plan requires funding for specific needs, the request will be referred to the AFCFC Council Director. As funds are available, the AFCFC Director makes a decision to help meet the needs of the child/family outlined in the service coordination plan and aligns with FCSS guidelines. AFCFC also has access to MSY funds through the Ohio Department of Medicaid. This State of Ohio program to prevent custody relinquishment for youth with multi-system needs, created in SFY20 pursuant to Section 333.95 of AM Sub H.B. No. 166, with the goal of preventing transfer of custody to the child protection system solely for obtaining funding to access treatment. The MSY Program is intended to assist caregivers when local resources and other payment sources have been exhausted. The State MSY Program is the funder of last resort and can only be accessed when local funds, health insurance, post-adoption assistance funds, and other sources of funding are used first. MSY Program funding cannot be used to supplant other funds. To access Ohio MSY funding, OhioRISE care coordinator or FCFC service coordinator will complete the MSY Grant application, assist with identifying placement facility, coordinate payments, monitor services, and plan for discharge. These funds are only to be used for those youth that require residential therapy/treatment and are child/youth specific. Once approved, the funds may only be used to pay for the Room and Board or other approved needs for the facility that the youth will be attending. If there are any funds not spent, it must be sent back to ODM. Local Cost Share Agreements -other agencies within the county, such as the Lawrence County Board of DD and Juvenile Court among others, may share costs for direct services to youth. Agreements are created on a case-by-case basis to address specific needs of youth being served by one or more of the agencies. These agreements are handled directly by the agency partners based on input from the team. PASSS- Youth who have been adopted and later need intensive behavioral health supports are eligible for PASSS (Post Adoption Support Services Subsidy) funds. Parent/guardian must apply for PASSS funds by contacting OhioKAN https://ohiokan.ohio.gov/ , PASSS funds must be approved and expended before MSY grant funds will be approved. OhioRISE Primary Flex Funds- These funds are used for services, equipment, or supplies that are not covered by Medicaid, but recommended by the team as something to benefit the OhioRISE member. The OhioRISE care coordinator will explain how to ask for funds, up to $1500 per calendar year. To be approved for primary flex funds, the family cannot have the ability to buy the service or item with other funds or resources.