Free Collaborative Systems of Care (CSOC) Plan of Care - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Mental Health and Substance Abuse Services F-22687 (Rev. 07/2008)

STATE OF WISCONSIN Completion of this form meets the requirements of Chapter 46.56, Section 14(c) of the Wis. Stats.

COLLABORATIVE SYSTEMS OF CARE (CSOC) PLAN OF CARE
Personally identifiable information is collected for monitoring the development of CSOC projects. All information gathered is confidential

Name ­ Child (Last, First, Middle Initial) Address ­ Home

Instructions: Complete the Plan of Care within 60 days of enrollment Telephone Number Date of Birth

Social Security Number County of Residence

CHILD AND FAMILY TEAM MEMBERS
Team Member Role SIGNATURE*

* I agree with the Plan of Care and have participated in the planning process. Name ­ Service Coordinator (Case Manager) Date of Enrollment Date Plan of Care Completed Dates Updated

Adapted from "Collaborative Team Planning Form" by Lucille Eber, 8/99

F-22687

Page 2

TEAM GOAL / MISSION STATEMENT

CHILD, FAMILY, AND TEAM MEMBER STRENGTHS
Instructions: List all strengths identified during the Summary of Strengths & Needs Assessment process. These strengths should then be used to address identified needs in this Plan of Care.

Strengths, Interests, and Successful Strategies

Adapted from "Collaborative Team Planning Form" by Lucille Eber, 8/99

F-22687

Page 3

"Greatest Needs" as Identified in the Summary of Strengths and Needs Assessment
Instructions: Identify Life Domain Areas from the Summary of Strengths and Needs Assessment containing needs that scored Likert ratings of "4" and "5" (in addition to Crisis/Safety Domain). Then, as a team, prioritize the top needs; these Life Domains and corresponding needs will be the focus of the team's planning. Update as needed.

Domain (See key below)

Needs Rated "4" or "5"

Planning Priority (1, 2, 3, etc.)

DOMAIN KEY:

CS = Crisis/Safety MH = Mental Health CU = Cultural

MD = Medical LS = Living Situation AODA = Alcohol & Other Drug Abuse

SP = Spiritual FA = Family ED = Educational

BNF = Basic Needs/Financial SR = Social & Recreational LE = Legal

Adapted from "Collaborative Team Planning Form" by Lucille Eber, 8/99

F-22687

Page 4

GOALS AND ACTIVITIES
Instructions: Complete a "Goals and Activities" page for each of the top three or four Life Domain Areas prioritized by the family team on page three.

Domain to be Addressed: Identified Need (from page 3) · · · · · · · · · · · · · · · · · · PROGRESS KEY NA = No longer a need or goal 1 = Unresolved or worse; not attained 2 = Unchanged; still a need or goal 3 = Progress made but still a need Strengths Related to Need (from page 2) Outcome/Goal Activities (Include who, what, by when, and how paid for) Progress Toward Goal (Use key below)
Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress

4 = Unresolved or partially attained, but improved 5 = Resolved or attained satisfaction

Taken from: Dunst, C.J.; Trivette, C.M.; & Deal, A.G. (1988). Enabling and Empowering Families: Principles and Guidelines for Practice. Cambridge, MA: Brookline

Adapted from "Collaborative Team Planning Form" by Lucille Eber, 8/99

F-22687

Page 5

GOALS AND ACTIVITIES
Instructions: Complete a "Goals and Activities" page for each of the top three or four Life Domain Areas prioritized by the family team on page three.

Domain to be Addressed: Identified Need (from page 3) · · · · · · · · · · · · · · · · · · PROGRESS KEY NA = No longer a need or goal 1 = Unresolved or worse; not attained 2 = Unchanged; still a need or goal 3 = Progress made but still a need Strengths Related to Need (from page 2) Outcome/Goal Activities (Include who, what, by when, and how paid for) Progress Toward Goal (Use key below)
Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress

4 = Unresolved or partially attained, but improved 5 = Resolved or attained satisfaction

Taken from: Dunst, C.J.; Trivette, C.M.; & Deal, A.G. (1988). Enabling and Empowering Families: Principles and Guidelines for Practice. Cambridge, MA: Brookline

Adapted from "Collaborative Team Planning Form" by Lucille Eber, 8/99

F-22687

Page 6

GOALS AND ACTIVITIES
Instructions: Complete a "Goals and Activities" page for each of the top three or four Life Domain Areas prioritized by the family team on page three.

Domain to be Addressed: Identified Need (from page 3) · · · · · · · · · · · · · · · · · · PROGRESS KEY NA = No longer a need or goal 1 = Unresolved or worse; not attained 2 = Unchanged; still a need or goal 3 = Progress made but still a need Strengths Related to Need (from page 2) Outcome/Goal Activities (Include who, what, by when, and how paid for) Progress Toward Goal (Use key below)
Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Date Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress Progress

4 = Unresolved or partially attained, but improved 5 = Resolved or attained satisfaction

Taken from: Dunst, C.J.; Trivette, C.M.; & Deal, A.G. (1988). Enabling and Empowering Families: Principles and Guidelines for Practice. Cambridge, MA: Brookline

Adapted from "Collaborative Team Planning Form" by Lucille Eber, 8/99

F-22687

Page 7

CRISIS RESPONSE PLANNING
"A crisis occurs when adults don't know what to do." ­ Carl Shick

Each child and family team should develop safety plans to address possible safety/crisis situations at home and in school. Teams may choose to create additional plans if needed (e.g., bus crisis response plan, community crisis response safety plan). Consider the following when developing your safety plans... · Expect that a child with multiple needs living in the community will experience crisis · Consider the most challenging act(s) that could happen and create the intervention · Review historical strength-based information regarding strategies that have worked · Pre-plan the interventions with people and/or agencies who may be involved in the safety issue resolution. Include an outline of responsibilities and communication procedures. · Develop a protocol of who will be notified, and in what time frames. · Develop a process for evaluating the safety plan use/effectiveness
Name ­Child (Last, First MI) Past Behaviors/Situations Considered Crises or Safety Concerns Crisis Response Plan for (home, school, etc.): Date Plan Prepared

Progressive List of Interventions to Respond to a Crisis/Safety Situation (include description of the intervention, who is involved, contact information & responsibilities)

Service Costs
Instructions: Record all costs associated with maintaining the child in the community for a one-month period. Adapted from "Collaborative Team Planning Form" by Lucille Eber, 8/99

F-22687 Service Code * Service Description Vendor (Service Provider) Units Projected Unit Description ** Unit Cost Total Cost

Page 8 Paid for By ***

Total: * Service Codes
MEDICAL SERVICES
5000 Assessments Outpatient 5010 Assessments Inpatient 5020 Medication Trial Inpatient 5030 Medication Trial Outpatient 5050 Psychiatric Reviews/Medication Checks 5099 Other Medical Services

MENTAL HEALTH SERVICES
5100 Individual Therapy 5101 Individual AODA Therapy 5110 Family Therapy 5120 Group Therapy 5121 Group AODA Therapy 5130 Special Therapy 5140 Crisis Intervention 5050 Crisis Counseling 5160 In-Home Treatment 5170 Day Treatment 5180 Evaluation Services 5200 Therapeutic Community Support Services 5201 Reintegration Treatment Services 5210 Reintegration Treatment Services 5220 Consultation with Other Professionals 5221 Child and Family Team Meeting/Planning 5230 Crisis Case Planning 5240 Behavior Management Services 5229 Other Mental Health Services

PLACEMENT SERVICES
5300 Crisis Home/Beds 5310 Treatment Foster Care 5320 Therapeutic Group Home 5330 Partial Hospitalization 5340 Residential Treatment/Child Caring Institutional Placement 5350 Psychiatric Hospitalization 5360 Assessment Home 5370 Foster Day Care 5380 Shelter Care 5390 Foster Home Care 5400 Group Home Care 5499 Other Placement Services

SOCIAL/RECREATIONAL COSTS
5527 Membership Costs 5528 Recreational Equipment Costs 5529 Social Activities Cost 5520 Recreational Reimbursement Costs 5550 Supported Independent Living 5560 Supported Work Environments 5570 Transportation 5580 Discretionary Funds 5590 Other Case Aide Services 9999 Non-Covered Services

SUPERVISION SERVICES
5530 Community Supervision 5540 Intensive Supervision 5541 Education Costs

CASE AIDE SERVICES
5521 Teacher's Aide 5522 Parent Aide 5523 Supervision 5524 Mentoring 5525 Recreation 5526 Life Coach

OTHER SERVICES
5410 Respite Services 5500 Case Management 5501Case Management-Treatment Foster Care 5502 Training Expenses

CORRECTIONAL PLACEMENTS
5420 Detention 5430 Corrections Per Month Total Amount CY = County PR = Program FA = Family (1st Party)

** Unit Descriptions
Per Hour Per Day Per Week

***Paid for By Codes
PS = Public School System FR = Free MC = Medicaid ST = State PI = Private Insurance NA = Not Applicable

Adapted from "Collaborative Team Planning Form" by Lucille Eber, 8/99