Attachment B FP Core Elements.docx

Department of Mental Health – Division of Child, Youth, and Family Services Flexible Support Services Request For Response DMH Document Number: DMH #2019-FLEX-3066-02

Attachment B

DMH PARENT/CAREGIVER PEER SUPPORT (FAMILY PARTNER) SERVICE CORE ELEMENTS

This document outlines the service goals and core elements of the DMH Flexible Support Service called Parent/Caregiver Peer Support that is provided by Family Partner staff. This document is subject to changes throughout the life of the DMH Flexible Support Services procurement.

The DMH Flexible Support Services Family Partner may provide Parent/Caregiver Peer Support in 3 different ways: as a member of a Flexible Support Team, as a facilitator or co-facilitator of a Flexible Support Group, or as an Individual Practitioner (e.g., a “stand-alone” service). In all cases, the Family Partner (authorization permitting) obtains and reviews the: DMH referral information; youth’s most recent clinical assessment; and youth’s goals found in any active treatment plans, Community Service Plans, and Individual Education Program (IEP) plans in order to inform their work with the family. When Parent/Caregiver Peer Support is delivered in the context of a Flexible Support Team this information is sought and obtained in concert with the other Flexible Support Team members assigned to the youth/family. The Family Partner works closely with the family to explore progress, barriers and areas of needed support in achieving goals established with other providers. Additionally, the Family Partner works closely with the family to use information from these sources as well as the Strengths, Needs and Culture Discovery (described below) to identify and prioritize areas of need that will guide their work.

When providing Parent/Caregiver Peer Support as part of a Flexible Support Team, a Family Partner works in tandem with other Flexible Support Team members (Flexible Support Clinician, Therapeutic Support Specialist and/or a Young Adult Peer Mentor) assigned to the youth/family. A youth/family may be assigned two or more Flexible Support Team members in any combination.

When providing Parent/Caregiver Peer Support as part of a Flexible Support Group, a Family Partner either facilitates or co-facilitates the group as agreed upon with DMH. Completion of the Strengths, Needs and Culture Discovery is not required for Groups.

When providing Parent/Caregiver Peer Support as an Individual Practitioner, a Family Partner works outside of a Flexible Support Team or Flexible Support Group, but collaborates with any existing supports and providers in the family’s life as needed.

Vision:

The Department of Mental Health (DMH) is committed to maximizing caregiver engagement across the DMH service system. Parent/Caregiver Peer Support provided by Family Partners through DMH Flexible Support Services is a key way in which that vision is achieved. Family Partners are instrumental in achieving more sustainable, positive outcomes for children and families who utilize DMH services. DMH Parent/Caregiver Peer Support prepares families for successful parenting of their children at home, facilitates transitions between services, and helps to create an ongoing network of natural supports and resources.

Service Goals:

1. Coach and support the caregiver(s) to ensure family voice in DMH planning and service delivery.

2. Model for and coach the caregiver(s) to lead and coordinate their child’s care; and effectively partner with DMH, providers, schools and other family-serving systems in multiple settings. (The notion of “Do for, do with, cheer on”).

3. Coach and support the caregiver(s) to effectively navigate systems that serve youth and families.

4. Guide, support and assist the caregiver(s) to find, access, and utilize formal and informal community-based resources.

5. Model for and coach caregiver(s) to problem-solve and advocate for themselves and their children.

Core Elements of the DMH Flexible Support Services Parent/Caregiver Peer Support Service: The DMH Flexible Support Services Family Partner can provide Parent/Caregiver Peer Support as a member of a Flexible Support Team, Flexible Support Group or as an Individual Practitioner (e.g., a “stand-alone” service). In all cases, the Parent/Caregiver Peer Support service consists of the following core elements:

1. Initial and Ongoing Family Engagement. Initial Engagement is a critical time to establish common understanding and rapport, as well as to orient the family to the DMH Parent/Caregiver Peer Support Service. Talking about the purpose of the service and developing a mutual understanding about what the service will look like is a critical step in starting engagement with a family.

The primary function of the Family Partner in Ongoing Family Engagement is to find meaningful ways to engage families. It is how DMH Flexible Family Partners talk with, plan with, and collaborate with the families being served. It is the role of the Family Partner to meet the caregiver “where they are” and is intended to be strength-based and respectful of the perspectives, needs, and wishes of the family. A key component of engagement is for the Family Partner to effectively share their personal experiences with purpose and intent of supporting families in navigating through challenges.

2. Educate Caregivers Regarding the DMH System of Care that supports youth with mental health diagnoses, and/or with behavioral and emotional needs. It may include: 1) helping families cultivate their knowledge of the provider culture and structures while navigating and understanding their service options, 2) supporting families and youth in their central role in the treatment planning process as an equal and critical team member, 3) providing guidance on working effectively with providers, state agency staff, school systems, clinicians and other service providers, 4) supporting the family as the youth transitions between provider and community services, through different stages of need, and among various state systems.

3. Educate Caregivers Regarding Local Formal and Informal Community-based Resources to build a strong local network of natural supports for the family. This may include: 1) resources that support the youth and family in the community such as afterschool programs and respite, 2) resources for the family such as food assistance or housing, 3) resources that help the caregiver strengthen their parenting expertise such as medical, mental health or substance abuse services, and parenting skills or support groups, 4) other community resources such as faith groups, and supports that will assist the family to address the youth’s emotional and behavioral needs. It is critical that Family Partners are intimately connected with local community supports, including referral systems and agency wait lists.

4. Empowering Families in their Central Role on the Treatment Team. Families are the expert on their child, therefore their expertise should be held in the highest regard during treatment development, ongoing treatment and transition. The Family Partner supports this by: 1) helping families embrace their role and understand their rights in the ongoing treatment of their child, 2) assisting the family to maintain a central decision-making role regarding their child’s care, including bringing their own goals and/or proposing changes/additions to the treatment plan, 3) supporting and educating the family to strengthen their ability to advocate for themselves and their child, 4) educating the family in accessing, understanding and organizing documents related to their child’s treatment and services, 5) supporting families in the ongoing development of treatment plans and other relevant documents, 6) modeling/coaching the family in having conversations with providers if they feel disconnected and how to reach a common understanding of treatment goals and timelines, 7) upholding the integration of family traditions, functioning, and expectations into treatment, 8) modeling/coaching the family and team in developing effective partnerships, 9) supporting families and providers in transferring skills and strategies developed by both youth and family across environments for successful community tenure; and 10) when necessary, partnering with families to reinforce them as the primary caretaker of their child. It is important for the Family Partner to reinforce the understanding with the family and team that no one can represent the family’s voice better than the family themselves.

5. Modeling and Coaching Caregivers. An essential practice of Family Partners is “Do For, Do With and Cheer On" when working with families. Family Partners "meet families where they are" when they model and coach families. Family Partners demonstrate to caregivers, through preparation, action, and debriefing conversations, the methods used to strengthen the caregiver’s ability to problem-solve and advocate for themselves and their children. This often includes preparing parents before meetings with providers, demonstrating strategies during meetings, and then debriefing those strategies after meetings; all with the understanding that the parent will practice similar strategies at future meetings. Family Partners should possess advocacy skills, appropriate to the role, that allow them to connect with and/or educate providers and state agency staff about the role of the Parent/Caregiver Peer Support service and ways to best collaborate around supporting the family throughout the duration of the service.

Families receiving DMH services may benefit from specific coaching when engaging treatment providers, effectively relaying information and/or concerns so providers can understand their point of view. There will be times the Family Partner may relay information "for" the parent to model this skill. The Family Partner may pro-actively educate service providers to explain what modeling is and when they might see this practice in use. The practice of coaching and modeling should be explained to both families and providers alike by the Family Partner.

6. Culturally Relevant Practice. Family Partners must understand, identify and support culturally relevant services, which include respectful recognition of differing values and culture of the youth, family, school and other providers. This includes, but is not limited to, recognition of economic status, gender, sexual orientation, gender identity, ethnicity, race, language, religious practices, and the unique traditions, values and goals of each youth and family. Part of cultural sensitivity is supporting the family in talking about functioning and family norms in their home in order to help make their child’s treatment reflective of the culture in their home (i.e., access to electronics, exercise and nutrition habits, bed time, etc.). This approach of practice utilizes the strengths of all to provide comprehensive care to families. Culturally relevant practice is an ongoing learning process that should be viewed as a goal that Family Partners can strive toward, and there will always be room for growth. This practice accepts and respects differences, and emphasizes the dynamics and challenges arising from cultural and linguistic differences in planning and delivering services to diverse populations.

7. Strengths, Needs and Culture Discovery (SNCD). During the initial contact with a family, the Family Partner initiates the SNCD. The SNCD is a dynamic, on-going, family-driven process of inquiry and discovery between the Family Partner and the caregiver to ensure the full understanding of the caregiver’s strengths, needs, preferences, culture(s), beliefs, values, and life circumstances throughout the Parent/Caregiver Peer Support service delivery process. The Family Partner meets with the caregiver to explore and inquire about the caregiver, youth, and family’s strengths and experiences; and need for services, goals, and preferences relating to communications and accessing resources. This inquiry informs the completion of the Strengths, Needs and Culture Discovery form. This inquiry can integrate but is separate from any other information-gathering processes conducted by state agencies or other providers. The SNCD is updated as needed throughout the provision of the DMH Parent/Caregiver Peer Support service to reflect changes in the family’s journey as treatment and interventions progress, and will be updated at least every three months, or when there are significant changes to the family’s circumstances.

Additionally, the Family Partner obtains, reviews and keeps on file a copy of the youth’s most recent clinical assessment completed by a clinician.

8. Collaborative Goal Setting for DMH Services. The Family Partner obtains and reviews information regarding the current goals from DMH and the Youth’s school, clinician(s), and other relevant collaterals (authorization permitting) for the purpose of supporting the parent/caregiver in the achievement of their goals and/or and their child’s goals.

The Family Partner and parent/caregiver co-create an activities/intervention plan (Family Action Plan) that outlines activities/objectives and measurable progress/transition indicators that the family and Family Partner have prioritized to work on together in support of the Youth/family's needs and goals. These goals are documented in the Family Action Plan that is developed collaboratively between the family and Family Partner, and documents the family’s specific goals for the Family Partner service. The Family Partner and family use the Strengths Needs and Culture Discovery as well as the DMH referral and other collateral’s assessments, Community Service Plan(s), Treatment Plan(s), and Individualized Education Program plan to guide the development of the goals, action steps and activities of the Parent/Caregiver Peer Support service.

When any treatment team is in place for a youth, the Family Partner meets with the family prior to treatment planning meetings to identify/review the family’s goals. A key role of the Family Partner is to help the caregiver participate in the development of treatment plans with providers as well as understand any treatment plans that may have been written without the parent/caregiver so that they may determine if they agree with the goals or wish to propose changes or additions to their child’s goals. The Family Partner with authorization collaborates with other providers, supports and team members so that the goals the Family Partner is working on with the caregiver inform and are informed by any Community Service Plans or other treatment plans. The family, with the support of the Family Partner, shares their goals for the Parent/Caregiver Peer Support service with the treatment team. Youth/families receiving services from a Flexible Support Team have one Community Service Plan that includes the goals and objectives that each team member assigned to the family is working on (including the Family Partner when one is assigned to the family).

When functioning within a Flexible Team or Flexible Group, the Family Partner coordinates goals with other Flexible Team members assigned to the family or other Group facilitators working with the youth/family and consistently aligns the action steps to compliment and support goals with the family’s identified needs. When functioning as an Individual Practitioner, the Family Partner with authorization coordinates goals with other providers/supports (e.g. DMH, school, community providers) and consistently aligns the action steps to compliment and support clinical goals with the family’s identified needs.

It is also important that all treatment providers acknowledge the Family’s achievements that might not be on the action plan, but that can help the family and the team recognize milestones for the family. Senior Family Partners can support Family Partners to identify smaller achievements and encourage celebrations with families.

9. Conflict Resolution. Family Partners often must support families in situations where there is conflict between individuals, organizations and/or systems. Conflict is more than a disagreement; it's when involved parties are at an impasse (this can look like team members not returning calls or participating in meetings; or, having negative interactions with each other or "side conversations" outside of the team process which impacts the cohesion of the treatment team). Navigating and helping to resolve conflict is an essential function of the Parent/Caregiver Peer Support service.

In times of conflict, families may be faced with trying to understand complex systems, program protocols and procedures; how different systems work with each other; why conflicts arise; and what their rights as the family are through trying times. Family Partners can help families understand that these conflicts within a team are normal, and help them work through how to best respond, and what to say. There must be an opportunity for feedback, to practice boundaries with the family, to plan with families, and to help families see other’s perspectives. This is a vital component of helping families to achieve self-efficacy so, as their journey continues, they are educated and skilled in managing difficult situations and conversations.

10. Safety Planning. Safety is a concern all families face, and planning for the safety of children is the responsibility of the family and Flexible Support Services providers. A safety plan can address many different areas, as safety plans not only address potential unsafe situations but also help families plan for contingencies. Safety plans add another layer of family voice in which families can indicate how they’d like their youth supported when triggered, or identify the places their own expertise can be used when managing their child’s behavior and circumstances. Safety plans are living documents that should be adjusted as more information about the family becomes available. Safety plans should also be able to be implemented in any environment (e.g., the family's home, treatment program, and the community) to be useful and effective, and to encourage continuity of care.

It is the role of the Family Partner to work with the family, and to support them in conveying their needs, points of stress, and their family's position on what safety looks like in their home. Family Partners should have access to all existing safety plans. Family Partners work with the family in understanding and integrating this plan into their lives, day-to-day, visit-to-visit. The Family Partner collaborates with other service providers on anticipated triggers and/or safety concerns towards planning for and prevention of crises. Collaboration and development of safety planning is a critical role for Family Partners working with families in the DMH system.

11. Transition Planning. Transitions happen in every part of the DMH service system as they do for families in day to day life. Transition planning can be used to celebrate successes and milestones as well as anticipate any changes the child or youth will face throughout the time they are receiving services from DMH. Transition planning is a team-driven process that incorporates as many natural and informal supports as possible. It begins when any service starts, and should ensure the team is working together to transition the youth to the next step. The youth and family's overall wellbeing and functioning should align with the family and youth's goals and timelines, as clinically indicated. The Family Partner with authorization will likely have to work with all stakeholders (youth, families, programs, state agency staff, etc.) to ensure successful transition planning.

12. Collaboration with Family Support Staff in Provider Programs. If the youth is in out-of-home treatment, the Family Partner should create a common understanding with the out-of-home service treatment team about the role of the caregiver. Some out-of-home treatment providers have family support staff on staff in their program. For example, some group home provider programs have implemented a family support component to assist families with their residential experience. Family support staff at the provider program are critical partners in supportive, collaborative care for the family. In such cases, it is essential to clarify the role of the provider family support staff and the DMH Flexible Support Services Family Partner, to promote ongoing collaboration and clear expectations about the roles and responsibilities of the provider family support staff and the DMH Flexible Support Services Family Partner towards promotion of continuity of care. If possible, these roles and responsibilities should be described in the youth’s treatment plan, which is created in partnership with all treatment team members. The treatment plan should also describe how communication will occur between the caregiver, the DMH Family Partner, and the treatment program’s support staff. The youth and family's overall wellbeing and functioning should align with the family and youth's goals and timelines, as clinically indicated. The Family Partner will likely have to work with all stakeholders (youth, families, programs, state agency staff, etc.) to ensure successful transition planning. (For example, Family Partners should discuss with the treatment team the importance of planning for transition from the beginning, even during times of high stress and anxiety for all involved.) Family Partners may support providers in understanding processes and systems when services are transitioning, or may help current or new providers stay linked to a family’s supports or services when the youth is entering into treatment. Family Partners are critical for supporting transitions that are planned and effective, thereby helping to sustain the youth and family in successful outcomes.