What is Wrap Around?

One of the tools that can be utilized in “a systems of care” is the use of wraparound. The State of Kansas has identified this process as a way to strengthen the systems of care for youth and families.  Wraparound is a philosophy of care that includes a definable planning process involving the child and family that results in a unique set of community services and natural supports individualized for that child and family to achieve a positive set of outcomes. Wraparound is not something that you "get", it's something you "do"; it's a process, not a program.  These fundamental principles merge with a "never give up" philosophy that embodies an unconditional commitment to team development, family empowerment and outcome based interventions.

The goal of wraparound is to keep children in the home or bring them back home. The most challenging aspect of wraparound planning is to design plans that are comprehensive and therefore effective.  Team members strive to accomplish this by moving beyond conventional thinking to use their resources to support the child and family. Moreover, a Wraparound Plan is continually reviewed and modified based on the child and family's developing strengths and evolving needs. Referrals are made from various agencies and a placement team reviews the families individual needs to determine placement.

Wraparound could include any family member, neighbor, individual from the faith community, or any other person who gives support to the family. Together, these important individuals create a “family team”. The family team writes what is called a “wraparound plan” which develops an individualized plan. The family centered and strengths based plan integrates agency involvement and provides support for the family to meet the individualized goals. Every action requires discussion, consultation, and approval by the family team. The idea is that a team approach provides the family with one treatment plan, which meets the needs of the family as well as providing support. Families have a voice in what happens with their child while fulfilling the requirements of the different agencies involved with their child.

Wraparound Process

Services are community based, culturally competent and are created to meet the unique needs of the child and family. The following is additional information about the “wrap around” process:

• Key elements. Five basic mechanisms are used to accomplish this integration of effort:

• The local steering committee provides management oversight for the effort and includes representatives from all of the formal and informal groups who are regularly involved with helping families that have complex needs as well as representative members of these families. Together they develop a format for coordinating efforts and sharing resources across systems that take their community’s strengths, needs and preferences into account.

• The interagency agreement is the written document that records the design (often referred to as the "system of care") chosen by the community team and each participant’s commitment to assist in the implementation and operation of the system of care. It describes the process that will be used to enroll children and families, the roles of the agencies and individuals who participate in that process, the resources that will be available and the means for accessing them, and the criteria for measuring the effectiveness of the system of care and for improving it based on experience.
• A care coordinator is a person designated to guide a child and family and those who are helping them through the process of developing and implementing a unified plan of care. Care coordinators may work for public or private non-profit agencies and may do this work full or part time, depending on the type of system of care the community team develops.
• The child and family team is the group assembled by the care coordinator to work together to help a specific child and family that have been enrolled in the system of care. Because each child and family has different needs, each team will be different, although some people, like social workers and school special education directors, may be on several teams. The team usually consists of about 4 to 8 people about half of whom are paid service providers and half of whom are informal supports. Team membership will vary over time as the needs of a child and family change.
• The unified plan of care is the action plan developed by the child and family team. It outlines the child and family’s key strengths and needs across their various life domains, the specific goals the team will be helping the child and family achieve, the steps by which movement toward those goals will be accomplished, and the role each team member (including the child and family) will have in carrying out each of these steps.
• Rules of the road. A few guiding principles have come to be associated with improved outcomes when children and families have complex needs. They include: focus on building strengths rather than simply eliminating deficits, provide children and families with voice and choice in the process to insure buy-in and effectiveness, seek to blend perspectives rather than force consensus when team members disagree, don’t give up when initial strategies are ineffective, operate with cultural proficiency in engaging and supporting families, and seek to develop child and family competencies in the community environments in which they will be used after formal system involvement is completed.
• Planning stages. The child and family team process usually moves through four stages: a preparation stage as the coordinator brings the first members together, a stabilization stage where a foundation of safety is established, an implementation stage where the team helps the family begin to move toward its selected goals, and a resolution stage where formal system involvement recedes and is replaced by an informal network of support with the assistance of some maintenance services if they are needed.
• Facilitator’s role. The primary skill for the wraparound facilitator in a strengths discovery is the ability to have a conversation with another person. A strengths discovery is not done as a formal assessment. It is an interactive "chat" between a facilitator and a family or family member. In this chat, as in any conversation between two people, both parties share stories, laugh, and generally begin developing a relationship of trust and respect. The strengths discovery chat begins to break down the traditional "one up, one down" status of professional to client. The chat should be natural, informal, and reciprocal.
• Strengths discovery. It often is difficult to get children and parents to talk about their strengths. Some family members may be so focused on the negative information that they find it difficult to address strengths. Thus it may be necessary to let a person talk about their concerns and fears before they will talk about their strengths. However, it is important to be persistent and thorough about moving as quickly as possible into a discussion of the good news. Select a location to do the strengths discovery that is comfortable and reasonably private. Sometimes the family home is a good place, but some families may feel uncomfortable having you in their home. The following questions are ones commonly used when discovering family strengths, preferences, and cultures. They should be modified to fit the experiences and cultures of the family members with whom the facilitator is working.

With Children:

• If you could say one good thing about yourself, what would it be?
• I like your (hair, make-up, clothes, etc.). Did you come up with that yourself?
• What is your favorite color? Musician? Sport? Person? Friend? Subject in school?
• Who is the coolest person you know? What is cool about this person?
• Who do hang around with? Who would you like to hang around with?
• What do you value most in a friendship? (Loyalty? Fun? What?)
• What about your personality? Are you (quiet, boisterous, private, outgoing, loyal)?

With Parents:

The Dilemma

The systems of care for children’s mental health that many counties and states have established over the past decade are community-oriented, at present most do not incorporate an explicit prevention and primary care component. Their focus is on assisting families with children whose severe emotional disabilities place them at high risk for placement outside the home. Although the wraparound process that anchors many of these systems is designed to help child and family teams develop action plans that include natural and informal supports across life domains (which could be viewed as primary care resources) in most cases access to the formal wraparound process is limited to children with complex and enduring needs. Therefore, these systems function procedurally as tertiary or carve-out resources. It’s difficult to include front-end, label-free access to preventive options because funding is frequently driven by a recipient’s eligibility for medical assistance, or the redirection of high end costs, such as residential care, which in turn requires a specific diagnosis and level of severity. In essence, “you have to be sick to get help, even if the best help is the kind that keeps you from getting sick in the first place. “

Solution?

The resolution of this quandary is to have a balanced (“systems of care”) that connects people with resources and would provide the right intensity of options in the right proportions, with the minimum necessary procedural barriers, based on the needs of the community. This requires population-based planning, rather than a narrow focus on a particular cluster of symptoms. For example, after mapping children’s behavioral health needs and comparing them with the existing distribution of resources, planners in Monterey County, California, established a goal of assigning approximately 65% of their resources to front end options with low entry barriers, 25-30% to targeted secondary services such as intensive in-home, therapeutic foster care, etc. that would require a diagnostic finding and 5-10% to wraparound, which would require special enrollment. (Figure 3 demonstrates their arrangement for resource distribution.) They also developed longitudinal connections that would allow people working in front-end services in a variety of sites to make effective and accurate referrals for secondary and tertiary care. An important element to the linkage across options was the use of a consistent model of strength-based planning at every level. To help support the systems of care philosophy, communities must establish collaborative partnerships that focus on strengths assessment, action planning, family involvement, team facilitation and similar topics. Staff from the county department of social services, community supports and services, and local non-profit agencies, as well as, family members and advocates should come together to establish a common framework and vocabulary for their community.

Because the wraparound approach is a cluster of innovations that are implemented at the practice, program, inter-agency and community levels, the stages of growth that wraparound follows will vary in each community, based on the strengths and needs of the community, the partnerships from which the impetus to adopt wraparound first arises and the broader patterns of climate and culture among the county or state’s human service organizations.

Example of existing structure of local systems of care

WHAT DOES THE LOCAL LEVEL LOOK LIKE FOR GREAT PLAINS SYSTEMS OF CARE ? ?

The local level is where SOC comes alive. For the Great Plains Counties, Red Rock

Behavioral Health Services is the host agency. Every county has a host agency which serves as the fiscal agent. However, the actual day-to-day operations of the SOC program is the responsibility of the community team. Great Plains System of Care has over 100 members on their support roster. Although not all of these individuals are available to meet on a regular basis, they still support the concept of SOC and can be contacted if needed. Each site maintains their own community team, which addresses local barriers and needs. Both Beckham/Mills and Custer/Washita Systems of Care sites have review and executive committees. Each site meets monthly, except for every third month, when the Great Plains System of Care area meeting replaces the local meeting. These groups come together to set a common goal for the community, and to strive for a common vision of what services for children and families should look like. The working team consists of dedicated individuals who have spent time and energy helping build each local SOC. Some of these people are, most importantly parents, but also individuals from DHS/Child Welfare, law enforcement, education, law, faith community and many others. A smaller subgroup comprises the local review team, which is responsible for reviewing referrals and wraparound plans, and determining eligibility for the program. Review teams ensure each family’s individual needs are met while staying true to the model. An executive committee for each site oversees the SOC budget and deals with other day-to-day issues. The larger group stays busy working on items such as eligibility criteria, goal setting, and strategic planning. The teams have also been instrumental in helping develop a website, raising money for the program and many other things which will benefit the community. The local level has the option of working with the State SOC team to help remove state policy or funding barriers, which are limiting local integration of services.