I. OVERVIEW
The Holmes County Service Coordination Plan is a response to ASHB 117, HB 57 and most recently HB 66 which require Family and Children First Council members to work together to design and develop an improved procedure for responding to the strengths and concerns of multiple need children and their families. The plan must address the assessment and service needs of families with children who are abused, neglected, dependent, unruly, delinquent, or so adjudicated, and families who are voluntarily seeking services. The Holmes County Family and Children First Council will further define those voluntarily seeking services as families whose children are at risk--particularly of becoming abused, neglected, dependent, unruly or delinquent. This Service Coordination Plan is currently being implemented.

The county service coordination mechanism shall serve as the guiding document for coordination of services in the county. For children who also receive services under the Help Me Grow program, the service coordination mechanism shall be consistent with rules adopted by the Department of Health under ORC 3701.61. All family service coordination plans shall be developed in accordance with the county service coordination mechanism.

Council member organizations include schools, programs, agencies, juvenile court, county officials and service systems (such as the Mental Health and Recovery Board which represents both the mental health and substance abuse recovery systems). These member organizations have a long history of working closely together to provide appropriate, effective services to infants, children and adolescents and their families with a special emphasis on serving those at risk and those with multiple needs. Organizational members share a common philosophy of respect for the family and for the importance of the family, and/or the importance of the family and service provider partnership.

Holmes County Health Department
Holmes County Commissioners
Holmes County Department of Job & Family Services
Holmes County Juvenile Court
Mental Health & Recovery Board of Wayne-Holmes Counties
East Holmes Schools
West Holmes Schools
Tri-County Educational Services Center
Holmes County Board of MR/DD
Holmes County Head Start
The Counseling Center
Every Woman's House
Your Human Resource Center
OSU Extension
Big Brothers Big Sisters of East Central Ohio
Parents
Early Intervention/Help me Grow

All members of Holmes County Family & Children First Council are involved in development and/or review of the county Service Coordination Plan. Service Coordination is an objective of the Holmes County Family & Children First Council. Service coordination is herein addressed in a comprehensive outcome driven manner by the development of a Service Coordination Plan and process, which proceeds in three stages:

1. Identification of the strengths of present cooperative efforts among member organizations.
2. Identification of areas of service coordination in need of change and strengthening.
3. Development of agreed upon strategies for creating a coordinated, comprehensive continuum of family strengthening and child development enhancing services.

During the history of the Holmes County Service Coordination Plan development process, it has been clear that member organizations:

1.Have a commitment to making comprehensive coordination a reality.
2. Understand and expect that a number of issues will arise that could hinder the full implementation of the Holmes County Service Coordination Plan.
3. Are ready to use joint problem-solving to reach the service coordination goals.

The service coordination mechanism employed through this plan will create solutions based on Ohio’s Commitments to Child Well-Being, which are:

1. Expectant parents and newborns thrive
2. Infants and toddlers thrive
3. Children are ready for school
4. Children and youth succeed in school
5. Youth choose healthy behaviors
6. Youth successfully transition into adulthood

In addition, these underlying values of service coordination will be at the forefront of case planning and implementation:

1. Children have the right to live with their own family.
2. Children have the right to be nurtured and protected in a stable family environment.
3. When children are at risk of harm, the community has the responsibility to intervene.
4. Families are our community’s most important resource and must be respected, valued, and encouraged to build upon their strengths.
5. The racial, cultural and ethnic heritage of children and the neighborhoods where they live are respected and supported as strengths. Ethnic and racial child-rearing practices are valued.
6. Families have the right and responsibility to participate in identifying their concerns, priorities, and needed resources.
7. Families have a right to individualized service provision that addresses the multiple needs of their children.

II. TARGET POPULATION AND ENTRY INTO COORDINATED CARE
The total population of Holmes County is over 41,000 based on estimates from the Ohio Department of Development, of which over 14,000 are children and youth. About 40% of the families are Amish. Holmes County is designated as an Appalachian county. This creates unique service needs and opportunities for Holmes County. The Service Coordination Plan embraces a multi-cultural approach to serving the target population of families and children, and recognizes that strengths and needs must be assessed from a culture sensitive perspective.

HB 57 mandates that the Holmes County Family and Children First Council members work together to design and develop a better system of service delivery for children with multiple needs and their families. The plan must address the assessment and service needs of families with children who are abused, neglected, dependent, unruly, delinquent, or so adjudicated, and children whose parents are voluntarily seeking services. The Holmes County Family and Children First Council will further defines those voluntarily seeking services as families whose children who are at risk, particularly of becoming abused, neglected, dependent, unruly or delinquent. Long term Community Care is expected to result in a significant reduction in the number of adjudicated youth and high risk children and families in the target population. Passage of HB 57 requires counties to serve unruly youths, both alleged and adjudicated, in addition to those young people with multiple needs. Efforts will be made to divert any child alleged to be unruly to the Diversion Program through the Holmes County Juvenile Court system. Council member agencies and Project STAY (Services To At-Risk Youth) are engaged in such initiatives. Project STAY is an adjunct to Holmes County Family & Children First Council.

Each system has areas of responsibility, and the collaborative approach is not intended to replace or usurp the primary role of any one of those systems. Passage of HB 66 directs counties to provide a venue for families needing services where their needs may not have been adequately addressed in traditional agency setting.

Holmes County utilizes pooled dollars to fund service coordination. The Community Care funders have designated and appointed individuals to serve as members of the Service Funding Committee. The Holmes County Family & Children First Council Coordinator serves as Chair of this committee. The Service Funding Committee meets twice each month, with special meetings called as needed. Funding requests are submitted to the Council Coordinator, who sets the agenda for the Service Funding Committee. Services identified in a Family SC plan are addressed in this manner. School representatives and the Director of Project STAY are also invited to Service Funding Committee meetings.

III. SYSTEM ACCESS
There will be access through any member organization or the Family & Children First Council Coordinator by any family referred to or seeking services. Member organizations agree to serve as entry service providers and will share responsibility for forming a multi-discipline, multi-system service team to determine the most appropriate method of accessing services and addressing the needs of the youths or families with multiple needs. The Service Funding Committee FAST (Families and Systems Together) and the Access to Better Care initiative will be incorporated into this process. Member agencies who are not direct service providers will nonetheless support service coordination and give cooperative credit.

In addition, as service coordination is child-centered and family-focused, this mechanism will describe a plan of care for families identified by systems. It also allows for families to refer themselves into this level of service planning. Criteria for self-referral includes any multi-need child whose service and support needs may not be adequately met while working outside the Service Coordination Mechanism. It is not intended to override current agency systems, but to supplement and enhance what currently exists.

IV. FAMILY AND CHILD INFORMATION AND ASSESSMENT
Information and Application
It is expected that each member organization will provide staff that will assist in the application process, explain the service coordination mechanism to the family, provide a verbal explanation of the dispute resolution process, serve families in his/her own member organization and ensure the transition of multiple need families to a lead case manager. Written notices and explanation are provided as part of entry level services. Families voluntarily seeking services are referred to the Holmes County Family & Children First Council Coordinator, who facilitates the referral process for them.

All member organizations are required to protect client rights, and families will be encouraged to permit sharing of necessary information among member organizations, including the family service plan developed by a multi-disciplinary, multi-system service team. This authorization will facilitate the provision of coordinated, outcome based services to families including those with severe and/or multiple needs and includes use of the HIPAA Notice of Privacy Practices and Holmes County Family & Children First Release of Information form.

A county-wide referral procedure includes documentation of:
1. Referral receipt date
2. Referral source contact information
3. Contact information for referred family/child
4. Description of the issues
5. Response/outcome of referral
6. Timelines for each referral process step

It is the expectation of the Holmes County Family & Children First Council that a member=s intake process will focus on the child or youth in the context of the family unit and environment. In all instances the family is encouraged to express and define strengths and needs and to identify positive outcomes rather than to try to fit the child and themselves into existing services. The primary method of strengthening the family will be to wrap supportive services around the family unit in partnership with the parents/caretakers. The intent of the service coordination mechanism is to provide services in the least restrictive environment; ensure confidentiality, facilitate family input; review case plans and develop timelines for monitoring progress toward identified goals; develop plans for dealing with short-term crisis situations and safety concerns.

Family Strengths/Needs Based Assessment
The Holmes County Family and Children First Council has experience in implementing a family strengths/needs based model in working with the target population. The family strengths/needs based model will be integrated into all member organizations' service delivery. This improves service planning and delivery county-wide.

Every Council member organization and local systems of care has their own criteria for levels of intervention that Council will access and utilize. Member organization designees collect and contribute information as part of the procedure for assessing the needs and strengths of any child and family accessing the Service Coordination process. Information is collected from the child, family/caregiver, agencies/providers and others. A standardized tool or approach to guide assessment of needs and strengths in a culturally sensitive manner is utilized. The child and family are involved in all aspects of this process.

V. SERVICE RESPONSIBILITY AND SERVICE PROVISION
Member organizations provide entry services to families. This includes notifying the family that a service coordination meeting can be requested; setting a date, time and meeting location acceptable to the family; assuring that the meeting takes place before a non-emergency out-of-home placement occurs, or within ten days of an emergency placement. This does not over-ride or affect decisions of a juvenile court or children’s services regarding an out-of-home placement. Families are told that they may bring an advocate, mentor or support person to meetings. Written notice of a meeting, those invited, and the purpose of the meeting is distributed to all invited.

The schedule for Service Funding Committee meetings is utilized for scheduling service coordination planning meetings for families whenever possible. A family’s preference for scheduling the meeting is considered. The Family & Children First Council Coordinator serves as a contact person for scheduling and communication. A family may request a family Service Coordination plan meeting through an organization with which they are involved or by contacting the Holmes County Family & Children First Council Coordinator.

If the child-family unit only requires help which can be provided or arranged by one member organization, that member takes the responsibility for Case Care Coordination. In such cases the service coordination mechanism is not utilized, although the case may be referred in the future if circumstances warrant.

If the child-family unit has needs which can be met only through the assistance of multiple service providers, the staff designated to provide entry care coordination serves the family long enough (a) to secure agreement for a lead case manager from a fellow member organization and/or (b) to establish a Family Service Team which selects a lead case manager and develop a Family Service Plan. All multi-need families have a lead case manager and a team of helpers, referred to herein as a Family Service Team, who are likely to be able to help the child-family unit successfully complete their outcome based plan.

A Family Service Team approves or designates a lead case manager that is agreed upon by the family.

The lead case manager:
1. Tracks progress of the family SC plan
2. Assists in scheduling family SC plan reviews as necessary
3. Facilitates family SC plan meetings

It is understood that member organizations provide staff designated to provide entry care coordination and lead case managers who have up-to-date knowledge of the child-family strengthening services of every member organization and of other service providers which might be needed by families. It is expected that case managers are responsible for coordination of the family service plan and monitoring the outcomes. The lead case manager is responsible for:
1. Coordinating the arrangement of specialized assessments and the services identified as necessary as a result of those assessments.
2. Expediting the designation of a Family Service Team and the development of the family service plan.
3. Overseeing the measurement/observation of outcomes and evaluation of key indicators of progress.
4. Surveying service satisfaction of the child-family unit.
5. Arranging for transitional services when appropriate. 6. Coordinating the sharing of appropriate information among all service team members and families

Service Funding Committee meetings serve as the venue for setting timelines for service completion, reviewing family SC plans and monitoring progress toward identified goals. The Service Coordination plan for short-term crisis situations reverts to procedures utilized by the appropriate system of care for the particular crisis situation. If possible, a Family Service Team will develop a short-term crisis plan.

Family Service Plans
A family service plan is the individualized blueprint for addressing the needs/strengths of the child-family unit. Each Family Service Plan includes signature lines for providers of a service to formally acknowledge responsibility and agreement to meet that responsibility. Regular Team meetings are held with each child-family unit to assess progress mutually and to evaluate compliance of all parties with the terms of the Plan. Protocol is followed regarding informing families and other attendees of meeting date, location, purpose and other pertinent information. The Family Service team determines when, if ever, the family should be referred to the Service Funding Committee for services beyond the Team's ability to provide or secure.

When a Family Service Plan includes service needs not available through member organizations, Service Team Members are responsible for:
1. Searching for existing providers outside of the Holmes County Family & Children First Council network.
2. Presenting a request for services to the Service Funding Committee of the Community Care Board when unable to secure them by the above processes.

The Family Service Plan format is user friendly, both for the family and the service providers. Services identified in the Family Service Plan are provided in a timely manner. Throughout every stage of service planning family input is sought and services designed in a manner respectful of family strengths, needs and cultural issues.

VI. DISPUTE RESOLUTION
In some dispute situations which may arise involving implementation of this Service Coordination Plan, judicial processes already are in place. It is understood by all member organizations that judicial processes take precedence over those developed by Council for these disputes. Furthermore, it is understood that the Juvenile Court can only resolve cases for which it has been given legal jurisdiction and over which it has no inherent conflict of interest as a member of Council.

While it is acknowledged that disputes may interrupt aspects of service delivery, each agency represented on Council that is providing services or funding for services that are the subject of the dispute initiated by a parent shall continue to provide those services and the funding for those services during the dispute process, whenever possible. Given the primary goal of service coordination which is to strengthen families in the target population so that they are able to nurture the development of their children and their family unit.

Families will be informed about the dispute resolution process as well as client rights pertinent to each involved agency. The lead case manager will review the dispute resolution information with each family at the time of the initial team meeting and when the family service plan is developed. In order to access the dispute resolution process, either the family or their lead case manager on their behalf can submit a written petition to the Council Chair stating the facts of the dispute. Families may choose to have legal representation in the dispute process should a court become involved.

The dispute resolution process covers the following types of disputes: agency to agency, child/family to agency, child/family to their Service Coordination Plan.

Child/Family to Agency Case Disputes
Member organizations recognize that complaints, disagreements and disputes may arise involving children and families. Every effort will be made to develop such strong partnerships between families and service providers that virtually all disputes can be resolved informally. However, if the dispute cannot be resolved informally and it involves a specific member organization, the service coordination dispute resolution process may be used only after:
1. The member organization's dispute resolution process has been used but has failed to resolve the dispute, or
2. The member organization involved has waived its own process

The following Case Dispute Resolution Process will be used in the event a case dispute cannot be resolved by the member organization's process or the member organization has waived its own process:
1. A written petition stating the facts of the dispute will be presented to the Family and Children First Council Chair by (a) the family, (b) the lead case manager on behalf of the family, or (c) any other Council member who is involved in the provision of services to the family within five working days of the time it has been determined by them that the dispute cannot be resolved less formally.
2. The Council Chair will review the petition and contact a mediator within three working days of receipt of the written dispute petition. The mediator will make every effort to schedule mediation within one week of receipt of the petition. The date will be agreeable to all parties to the dispute. The mediator will submit a written summary of the mediation to the Council Chair. The Chair will provide copies of same to the family, the lead case manager and the Council Coordinator.
3. If the parties to the case reach an agreement the dispute will be considered resolved.
4. Should one or more of the parties disagree then the full Council membership will meet within five working days of notice of disagreement to the Chair. In a single meeting format, Council member organizations will attempt to resolve the dispute through discussion and negotiation. The parties to the dispute may be asked to agree to additional time for the resolution process. A two thirds (2/3) majority of the voting members will be required to achieve resolution. Such a resolution will be issued to the family and the lead case manager within three working days of the vote. Written determination of findings will be made within sixty days.
5. Any Council party affected by a decision of the Council pursuant to step #4 of this process may appeal to the Juvenile Court, which shall retain the authority granted to it in ORC Section 121.38 to issue an order to bring about a final disposition of the dispute. The appeal will be filed with Juvenile Court within seven days following a failed dispute resolution. An interagency assessment or treatment information will be submitted to the court.
6. Should Council members be unable to resolve the case dispute through the above process, the case together with all information relevant to it will be referred to the Juvenile Court (per ORC 121.38) for a binding resolution.

Member Organization Disputes
Disputes may arise involving the services provided through the service coordination process by a member organization or organizations. These disputes are likely to involve those areas in which a member organization's traditional way of doing business, fiscal constraints, job descriptions or service eligibility mandates conflict with a family's need and with a Family Service Team's service recommendations.

In the event of Family & Children First Council member organization disputes, the following processes will occur:
1. Disputes between or among organizational members may be referred by written petition to the Council Chair at anytime.
2. The Chair will notify all members of receipt of a dispute petition and appoint a neutral Council member to act as a mediator in the dispute.
3. The mediator will hold mediation sessions. The mediator will submit a written summary of the mediation to the Council within 60 working days. The dispute will be considered resolved if the parties to the dispute agree.
4. If the mediation process does not result in a resolution the Council may resolve the dispute through a two-thirds (2/3) vote of the voting members. Prior to any such resolution the Council may request that the parties participate in an arbitration process.
5. When arbitration is used, the arbitration panel shall consist of one Family & Children First Council member selected by each of the disputants and a third Family & Children First Council member chosen by these two panel members. The arbitration panel, may receive the best settlement offers from each of the disputants and recommend one or the other of these offers to the Council for its consideration. The arbitration panel may also hear the facts and arguments of each disputant and make a non-binding decision to be forwarded to the Council. This arbitration process and vote of the Council shall be completed within 30 days of the date the mediator issues his/her report to the Council. A two-thirds (2/3) vote of the voting Council members will be required to make a binding decision.
6. If any party to the dispute fails to abide by the decision of Council, the Council may access the State Cabinet Council appeal process following a majority vote of the voting Council member organizations. Cabinet Council decisions may result in a redirection of state funds to the county.

VII. QUALITY ASSURANCE, IMPROVEMENT AND EVALUATION
The Council Chair appoints a work group to develop an evaluation plan to evaluate how effectively and efficiently the service coordination process is being followed. The Family & Children First Council Coordinator will offer training to agencies, staff and direct care personnel about the county’s Service Coordination Plan. The work group reports its recommendations to the Council. Amendments may be made through the process described in Section X.  Holmes County Family & Children First Council places quality assurance as a high priority in its mission of promoting safe, healthy, and stable children and families.  The work group develops a plan and process for the regular annual evaluation of the Service Coordination Plan and reports its recommendations to the Council.  Agencies and direct care personnel inform families about the County’s Service Coordination Plan.

VIII. FISCAL IMPLICATIONS OF SERVICE COORDINATION
To ensure effective implementation of the Service Coordination Plan, the Holmes County Family & Children First Council and Community Care Board will each develop a budget designed to allocate resources and designate an equitable sharing of costs.

X. AMENDMENTS TO THE SERVICE COORDINATION PLAN, COMMUNITYCARE
The Council may amend this Service Coordination Plan at any of its regular meetings provided that written notice of the proposed amendment has been given to each member organization's Council representative not less than thirty days prior to the date of the meeting. Other than editorial changes, no change may be made in any proposed amendment after notice of the proposed change has been provided to Council members. Approval of any amendment to this plan shall require a two thirds (2/3) vote of all voting members.

APPENDIX

Implementation of the Service Coordination process is expected to focus in county-wide provision of services to infants, children and adolescents and their families in the target population. In order to maximize the positive impact on families and the member organizations serving them, the following nine (9) guidelines will be followed:
1. Families will help to determine their own strengths and needs.

2. Whether they are initially assessed as high need, resistant or at risk of system dependence or
overuse, all families will be engaged in the process of using their strengths to overcome risk
factors and meet their specific needs.

3. More families will be served with existing resources through reconfiguring, freeing up funds, and
expanding the number and kinds of services available.

4. The change from a disjointed, program eligibility approach to service delivery to a systematic,
family strengths/needs driven approach will maximize the positive impact of funding sources.

5. Families and service providers will work together to formulate clear, observable and/or
measurable outcomes.

6. Member organizations will assess their own service delivery processes to ensure that they are
outcome based.

7. System incentives will be put in place which produce the outcomes of:

1. Strengthening all families served and,
2. Improving the ways member organizations work to strengthen families.

8. Member organizations will share equitably in the cost of services to children and families
consistent with their statutory responsibilities and resources.

9. Cost savings should be prioritized for reinvestment in coordinated services to further benefit children and families
in the target population.

First Plan: December 10, 1998
Revised: November 9, 2000
Revised: August 14, 2002
Revised: February 6, 2004
Revised: December 2, 2005