BRANT COMMUNITY PROTOCOLS

AND PROCESSES

Welcome to the Brant community electronic orientation package

on community Protocols and processes.

Revised April 2013

Background

The Children’s Services Committee, represented by numerous sectors, has approved these community protocols

This electronic orientation was developed by the Children’s Services Committee

Communication, Coordination, CollaborationThe Brant community Protocols guide

our daily practice in serving people -Communication, coordination &

collaboration help us: Best meet the needs of the people

we serve Address services for ‘Most in Need’ Avoid duplication and contradiction

Guiding Community Principles

Person/Family-centered service Work collaboratively Address ‘Most in Need’ Least intrusive services Utilize best practice Confidentiality Maximizing available resources

Service Collaboration Protocol

Ensures staff are working together when multiple agencies involved:

Supports a single plan of care Supports coordinated &

complementary services Avoids duplication and contradiction

Every staff has a role in establishing and maintaining communication with other

service providers

Collaboration Protocol cont’d

Staff aware of more than 1 agency involved will communicate (with Consent):

All staff are responsible to initiate communication within 2 weeks with other providers

Document* the coordinated planning

Identify clients that are ‘stressing’ services as “Emergent” or “Urgent”

Most in Need Tool

Tool describes: Priority, Situation, & Timing of Request Action required for those prioritized as

Emergent or Urgent Emergent = Stressing service system; support needs not easily met

Urgent = At risk; services exhausted

CASE CONFERENCES

Meeting together ensures: Seamless system for families Planning for individual’s outcomes Communication between services Coordination & collaboration of

supports

Case Conference Agenda

Prepare: Have a clear purpose for the meeting Briefly review current situation Identify strengths, as well as needs &

barriers *Explore support options &

coordination of services Set an action plan - define who is doing

what and when

CASE CONFERENCE ROLES

“Case Manager” Role: Identify and invite participants Identify prior who will Chair meeting Identify prior who will take Minutes Prepare/present brief summary Follow-up on your role after

meeting

CASE RESOLUTION Protocol

A community response to children/youth at risk: Urgent and complex needs Community services exhausted Barriers include resources Preceded by a case conference

Facilitated by Contact Brant

CASE RESOLUTION AGENDA (At Risk)

Has a clear plan based on clinical goals Case Manager prepares a Case

Resolution Summary Report prior to meeting

Case Res. Team, family & case manager discuss the plan, barriers, options

Case Resolution Team only meets to address resources and how the support plan will be implemented

CASE RES AGENDA Transitional Aged Youth

At age 16: Identify the developing plan & supports for a youth with a developmental disability; inform adult DS services

At age 17: Identify the discharge plan at age 18 from children’s services for supports and activities

Case Manager submits the Transition Plan Case Res. Team discuss the plan, barriers,

options; ensures a realistic plan is in place

CASE RESOLUTION ROLES

‘Case Manager’: Requests Case

Resolution Invites family & staff Submits Case Res.

package 4 days prior to meeting

Clarifies any questions Supports

individual/family Follows-up Updates Contact

Brant re outcomesof the plan

Contact Brant: Confirms eligibility/date Assists Case Manager Invites Case Res. Team Sends package to Team to

review prior to meeting Chairs meeting Follows-up Prepares Case Res.

Report for MCYS & Team Reports updates to Team Identifies gaps & pressures

for system planning

Transition Planning Protocol (DS)

Provincially mandated Regional Protocol for youth with a developmental disability: Start planning at age 14 by referring to Contact

Brant Develop a written transition plan; it should be

realistic, evolving, and updated annually Identify personal goals and community

services, as well as desired adult service supports

Plan with: youth & family, school, children’s and adult community services

What will really happen at age 18?

TAY Planning Checklist

Use the Checklist template! Transition Planning should identify:

what the youth wants what they need now and in the future how they want to do things who they want to help them Involve youth, family, service providers & school;

ensure transition plans are meaningful and seamless at age 18

The plan is about community involvement and quality of life - not just about services

Brant Community Crisis Protocol

Crisis Plan template: Complete for individuals likely to have police or ER involvement

Coordinated response for children and adults with special needs in crisis

Cross-sectoral protocol & response

Crisis Protocol - cont’d

Crisis PlanningUse the Crisis Plan form

Crisis Response – follow plan Post Crisis Follow-up – improve

response

Transitioning from Children’s Mental Health

Services ProtocolTransitioning Youth from Children’s

Mental Health to Adult Mental Health and Addictions Services Community Protocol

Ensures a coordinated transition plan for youth with acute mental health needs/longer-term service users at highest risk and require on-going mental health and addictions supports

Transitioning from Children’s Mental Health cont’d Provides definitions to understand the

differences between children’s mental health services and adult mental health & addictions services

Start at age 14 to identify these youth By age 16, provide information about

services, expectations once 18, and support connections to adult mental health & addictions services

Assist youth/families to develop a proactive, coordinated, and seamless transition plan

Transitioning from CMH Protocol cont’d Collaboration between Children’s

Mental Health Services and Adult Mental Health and Addictions Services is key

Support the need for increased independence Provide choices and involve youth in the

transition process to promote and support self-advocacy

By age 18, the youth has a coordinated transition plan between children's mental health services and adult mental health &

addictions services

Telepsychiatry Protocol

Access to child psychiatrists with various expertise through Woodview Children’s Mental Health and Autism Services’ videoconferencing equipment

One-time Psychiatric consultation, available in our community

Telepsychiatry Protocol cont’d

Must have a ‘case manager’ for follow-up: Completes referral form and mental

health assessment specific to the consultation requested – send to Woodview

Participates in meeting (60 – 90 minutes) with child and family

Follows-up on recommendations

Note: Other child psychiatry services are available through CPRI, McMaster, and St. Leonard’s Clinic

Residential Placement Advisory Committee

Child and Family Services Act legislates an RPAC review:

For children/youth placed in a residential facility of 10+ beds, and will be staying over 90 days

To advise, inform, assist re the residential service and alternatives; recommend appropriateness

Within 45 days of placement & every 9 months after

RPAC Team includes: An Informed Citizen, a Children’s Service provider, an Aboriginal representative (when appropriate)

Contact Brant coordinates for Brant

RPAC Agenda

Case Manager: Prepares a summary report and submits 48

hours prior to Contact Brant Makes a brief presentation; child/family &

residence may also present

RPAC Team reviews the reason for residential placement, the goals of placement, and appropriateness of the residential placement

RPAC is chaired by Contact Brant

RPAC ROLES

Case Manager: Notifies Contact Brant

within 7 days of residential placement

Prepares package 48 hours prior to RPAC

Invites participants Supports child/family Presents briefly Follows-up with residential

provider and community services

Notifies Contact Brant when discharged

Contact Brant: Assists Case Manager Sets date of RPAC

meeting Invites RPAC Team Ensures package

copied for RPAC Team Chairs meeting Submits RPAC Report

to MCYS Identifies future review

dates when needed

A community publication of free workshops, courses, groups,and events provided by local organizations for families, children & teens

Watch for publications 3 times per year

Available at your agency, or electronically at:

www. contactbrant.net/yourguide

.

Community Information Database

A web-based Community Services Database:

Make sure your programs are listed and updated! Check it out –

www.info-bhn.ca This database is used by 211 Ontario to

provide their information for Brant, Haldimand & Norfolk: call 211 24/7 or visit 211ontario.ca

Managed locally by Contact Brant

Community Collaboration around supporting people…

Communicate

Coordinate

Collaborate

Together we can make things happen!

For information & help with

Community Protocols/Processes:

Call:

(519) 758-8228