Planning for a Better Tomorrow – Care Coordination
In a web of acronyms, across Wheeler’s continuum of care, are dozens of grant-funded community-based programs, all unique but largely centered on a common theme: helping at-risk families stay together and thrive at home.
Hundreds of Wheeler staff work in these specific programs, serving hundreds more families every day, who are often referred to Wheeler through the Connecticut Department of Children and Families (DCF), which funds and closely works with staff in each program. The teams are, broadly, non-clinical, and their work focuses more on connections for the families they serve…for help, housing, health care, and resources that help them thrive.
They do similar work in each program, but they work in different ways. All are time-limited; they are not intended to be long-term solutions by themselves. And one common thread remains…the programs focus on the unique strengths within the family, and they all aim to show families that they themselves have what they need to grow, as each family, even those referred to Wheeler by DCF because of abuse and neglect, are strong in their own ways.
“They say it takes a village to raise a child, but every family’s village is different,” say Tabor Napiello, LMSW, program manager of the first program to be featured below, Care Coordination.
Planning for a Better Tomorrow – Care Coordination
- The Basics:
Care Coordination is an in-home, community-based program that collaborates with families of children and adolescents with behavioral and emotional challenges by identifying family strengths and arranging appropriate supports and services to maintain children or adolescents in the community. The program is child-centered, strengths-based, family-driven and culturally sensitive. - Referred by:
Open referrals, not just the Department of Children and Families. You may find the referral form here. - Towns Served by Wheeler’s Care Coordination Program:
Avon, Berlin, Bristol, Burlington, Canton, Collinsville, Farmington, Forestville, Hartford, New Britian, Newington, Plantsville, Plainville, Plymouth, Rocky Hill, Simsbury, Southington, Tarriffville, Terryville, Unionville, West Hartford, Wethersfield - More Information:
“There is no typical family in Care Coordination,” says Napiello. “But the most successful ones are engaged and active.”
Engaged and active in this context includes: the family working collaboratively to identify their strengths and needs; their vision of the future; how they work with Wheeler staff on a plan of care, which helps their youth remain at home or in the community; and the parents working to identify their social, mental health, family, school/work, cultural, spiritual, safety, legal, medical, finances, relationship, and other needs. Wheeler staff then use that information to work with the family and develop connections to services and organizations in the community that most effectively meet their needs and preferences.
With weekly home visits and monthly meetings with the family and its broader support network, which can include neighbors, or even pastors or friends, Napiello and her team also meets monthly with DCF, which support the teams as they work toward improved performance outcomes. While DCF funds Care Coordination, they don’t have access to family-specific data. The program uses an evidence-informed national wraparound model of care.
“We see a lot of youth struggling with school, who need more support than they’re getting. And their parents perhaps need help in addressing issues with school in a way that’s effective.”
Involvement in the program requires the family have a child no older than high school, but unlike many other programs, anyone can access the service, not just families that DCF refers. Napiello says referrals can come from unusual sources.
“In one family we serve, their neighbor saw how our family improved through the program and they then came to us for themselves.”
“We have the ability to be creative in a way that other programs may not,” she says. “Maybe the family getting together to build a tree house for a child with special needs is important; how can we help them pull that off? Maybe it’s finding unique talents inside themselves, which they didn’t even know they had, to help them succeed. It’s very individualized. We don’t have to fit people in boxes.”
“To do this work, you have to be able to understand that the family is the expert in what they need. Because they are.”
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In Care Coordination, and all of Wheeler’s community-based services, staff are entering a family’s home to work, which sets it apart from other services, like outpatient behavioral health care.
“When you enter someone’s home, someone’s environment, you’re getting a systemic view of the family,” Angeles Ramos, MS, LMFT, program manager of one other community-based service, Intensive Family Preservation (IFP). The program is different from Care Coordination, but the sentiment is the same.
“You’re seeing the hallways they walk down, how the children walk to school, and you’re experiencing their lives through the environment around them. There’s nothing like it. You gain a holistic view of the client and family, and you can more readily see the things that we can do to help them thrive in the community.”
RELATED STORIES
- Healing at Home: MST and MDFT Programs at Wheeler Health
- Planning for a Better Tomorrow – Care Coordination
- Upcoming in this series...
- Supportive Housing for Families
- Intensive Family Preservation
- SAFE Family Recovery
- Community Support for Families
- And more!
