Component: Coordinated Service Planning

Legislation: Child, Youth and Family Services Act, 2017

Service description

Coordinated Service Planning provides children and youth with multiple and/or complex special needs and their families with a seamless and family-centered service experience.

People served

Coordinated Service Planning is expected to serve

  • families of children and youth with multiple and/or complex special needs, under the age of 18 or up to age 21 if they are in school, living in Ontario, who would benefit from the added support provided through Coordinated Service Planning, due to the breadth and cross-sectoral nature of their children’s service needs and/or potential challenges in coordinating services because of external factors (outside of the child’s needs)
  • A diagnosis is not required to access Coordinated Service Planning

Program/service features

The program is delivered in accordance with the Coordinated Service Planning: Policy and Program Guidelines (June, 2017), and requires the following

  • a single Coordinating Agency in each service delivery area through which families can access coordinated service planning for a range of services across sectors
  • dedicated Service Planning Coordinators, through each Coordinating Agency, who will lead coordinated service planning for families of children and youth with multiple and/or complex special needs by working with children’s services, health, and education sectors
  • one coordinated service plan for each child/youth that considers all his/her goals, strengths, needs, as well as all the services that the child/youth is and will be receiving

At minimum, the following services will be considered, as needed, as part of a coordinated service plan

  • child/youth rehabilitation services (including speech-language therapy, occupational therapy and physiotherapy services currently delivered through the Preschool Speech and Language Program, Community-based and School-based rehabilitation services), and District School Board rehabilitation services [as provided]
  • nursing and dietician services personal support services autism services
  • children’s developmental services
  • respite services
  • child/youth mental health services health care services
  • education services

Specific service provided

Coordinating Agencies are expected to lead and deliver Coordinated Service Planning in their local service delivery area in accordance with the requirements as outlined in: Coordinated Service Planning Policy and Program Guidelines, June 2017.

Program goals

The goal of Coordinated Service Planning is to improve service experiences and outcomes for families of children and youth with multiple and/or complex special needs through the support of a Service Planning Coordinator who will connect them to the multiple cross-sectoral services they need as early as possible and monitor their needs and progress through a coordinated service plan.

As a result of Coordinated Service Planning, families, and children/youth with multiple and/or complex special needs will

  • have a clear point of contact for Coordinated Service Planning (their Service Planning Coordinator) and know who is accountable for developing and monitoring their child/youth’s Coordinated Service Plan
  • not have to repeat their stories and goals to multiple providers
  • have a single Coordinated Service Plan that is responsive to their child/youth’s goals, strengths, and needs
  • experience a family-centred process that recognizes that each family is unique; that the family is the constant in the child/youth’s life; and that they have expertise in their child/youth’s abilities and needs
  • know that providers will be communicating about the needs and goals of their child/youth and will be working toward a set of common goals identified in the plan

Ministry expectations

Services are child and family-centred and support the diverse needs of families in a way that is culturally safe, and promotes equity, anti-racism, and anti-oppression.

The Coordinating Agency is responsible for ensuring the delivery of Coordinated Service Planning Cycle as outlined in Coordinated Service Planning: Policy and Program Guidelines ( June 2017), including

  • managing all aspects of Coordinated Service Planning, including prioritization and service registries (waitlists), risk and complaints management (in relation to Coordinated Service Planning), privacy of information, records management, information management, and performance measurement of the Coordinated Service Planning functions within the service delivery area
  • the performance of Service Planning Coordinators in the service delivery area, no matter where they are employed, including ongoing training, and reporting on the activities and performance of all Service Planning Coordinators in the service delivery area
  • ensuring that referral pathways are clear, particularly intersections with children’s services, education and health sectors and other community organizations
  • maintaining responsibility for monitoring and evaluating Coordinated Service Planning, including reviewing existing processes and policies, documenting decisions, and making changes based on ongoing performance monitoring, in keeping with the parameters of the policy and program guidelines
  • developing and maintaining relationships with cross-sectoral service providers and educators in the service delivery area to deliver Coordinated Service Planning, recognizing collaborative relationships and considering the expertise of educators and other professionals
  • maintaining clear processes for collaboration and information sharing among relevant providers in the children’s services, education, and health sectors through formal agreements that address, at a minimum, how, and when to refer families, share information and contribute to Coordinated Service Planning
  • developing a relationship with the local Child and Youth Mental Health Lead Agency for children and youth with mental health needs and with the service resolution mechanism(s) to support the needs of children and youth whose needs exceed locally available services
  • communicating expectations to partner agencies/organizations about how Coordinated Service Planning will work, including how other providers will be engaged in developing plans
  • leading outreach and communications activities about Coordinated Service Planning, including
  • reaching out to families who may need the service
  • reaching out to local agencies that may have a role to play in Coordinated Service Planning or may be a source of referrals
  • emphasizing that Coordinated Service Planning is a proactive support and that families should be referred (or self-refer), before they are approaching crisis whenever possible, to avoid experiencing crisis
  • collecting and making available to families up-to-date and transparent information about locally available services, including access, intake processes, and service registries/waitlists/wait times
  • facilitating consistent knowledge sharing, both amongst service providers and with families of children and youth with multiple and/or complex special needs, regarding the delivery of Coordinated Service Planning
  • capacity building within the Coordinating Agency and partner agencies
  • capacity building at the Coordinating Agency and its partners will be an ongoing part of the service and quality improvement process as new needs and opportunities for improvement are identified

Reporting requirements

The Transfer Payment Recipient will report on performance measures for coordinated service planning for Q3 and Q4 through the Coordinated Service Planning Reporting Tool.

The following service data will be reported on at an Interim and Final period. Please refer to your final agreement for report back due dates.

Service data nameDefinition
Ministry-funded Agency Expenditures: Service Planning CoordinatorsTotal ministry-funded expenses for the Transfer Payment Recipient to administer and/or deliver this service in the Funding Year (cumulative).
# of New Referrals: SPCThe number of new referrals for Coordinated Service Planning (CSP) received by the Coordinating Agency or a CSP Provider (partner agency or partner organization) in the reporting year. The number of new referrals for CSP is calculated based on the date of referral. All referrals received are counted; this includes warm referrals (from an out-of-service-delivery-area Coordinating Agency or CSP Provider) and referrals for which the child/youth and family are deemed ineligible for CSP upon assessment. A referral for CSP may be for one or more children/youth depending on the needs and complexity of the family.
# of New Referrals Self-Referred or Referred by Family: SPCThe number of new referrals for Coordinated Service Planning (CSP) received by the Coordinating Agency or CSP Provider (partner agency or partner organization) that was referred by themselves or their family in the reporting year. A referral is only counted in one Referral Source Type, which are mutually exclusive. Consider the “primary” service of the referral source when counting referrals.  If there is more than one “primary” service, include the referral in the “other source” type.
# of New Referrals by School or Educator: SPCThe number of new referrals for Coordinated Service Planning (CSP) received by the Coordinating Agency or CSP Provider (partner agency or partner organization) that was referred by the school and/or educator in the reporting year. A referral is only counted in one Referral Source Type, which are mutually exclusive. Consider the “primary” service of the referral source when counting referrals.  If there is more than one “primary” service, include the referral in the “other source” type.
# of New Referrals by Physician Other Health Provider: SPCThe number of new referrals for Coordinated Service Planning (CSP) received by the Coordinating Agency or CSP Provider (partner agency/organization) that was referred by a physician and/or other health providers (e.g., home care, specialist) in the reporting year. A referral is only counted in one Referral Source Type, which are mutually exclusive. Consider the “primary” service of the referral source when counting referrals.  If there is more than one “primary” service, include the referral in the “other source” type.
# of New Referrals by Children's Aid Society: SPCThe number of new referrals for Coordinated Service Planning (CSP) received by the Coordinating Agency or CSP Provider (partner agency/organization) that was referred by the Children's Aid Society. A referral is only counted in one Referral Source Type, which are mutually exclusive. Consider the “primary” service of the referral source when counting referrals.  If there is more than one “primary” service, include the referral in the “other source” type.
# of New Referrals by Indigenous Child Well Being Society or Other Indigenous Organization: SPCThe number of new referrals for Coordinated Service Planning CSP received by the Coordinating Agency or CSP Provider (partner agency/organization) that was referred by Indigenous Child Well Being Society or Other Indigenous Organization. A referral is only counted in one Referral Source Type, which are mutually exclusive. Consider the “primary” service of the referral source when counting referrals.  If there is more than one “primary” service, include the referral in the “other source” type.
# of New Referrals by Other Sources: SPCThe number of new referrals for Coordinated Service Planning ( CSP) received by the Coordinating Agency or CSP Provider (partner agency or partner organization) that was referred by other sources (e.g., other children’s service providers including autism providers, out-of-service-delivery-area Coordinating Agency, CSP Providers, other) in the reporting year. A referral is only counted in one Referral Source Type, which are mutually exclusive. Consider the “primary” service of the referral source when counting referrals.  If there is more than one “primary” service, include the referral in the “other source” type.
# of Individuals Initiating Coordinated Service Planning (Total): SPCThe total number of unique children/youth for whom CSP was initiated during the current fiscal year. CSP initiation occurs on the date when the family has their first meeting/visit (in-person or by video conference) with their Service Planning Coordinator to initiate their dedicated CSP process; this is the date of first contact.
# of Individuals at Coordinated Service Planning Initiation (Ages 0 to 4): SPCThe number of individuals ages 0 to 4 for whom Coordinated Service Planning CSP was initiated during the reporting period.
# of Individuals at Coordinated Service Planning Initiation (Ages 5 to 12): SPCThe number of individuals ages 5 to 12 for whom Coordinated Service Planning CSP was initiated during the reporting period.
# of Individuals at Coordinated Service Planning Initiation (Ages 13 to 21): SPCThe number of individuals ages 13 to 21 for whom Coordinated Service Planning CSP was initiated during the reporting period.
# of Individuals Waiting for Coordinated Service Planning Initiation (Total): SPCThe total number of unique children/youth who have been referred to and are eligible for Coordinated Service Planning CSP but have not yet had CSP initiated. This is a static, point-in-time count of the number of children/youth waiting for CSP Initiation as of the reporting date. CSP initiation occurs on the date when the family has their first meeting/visit (in-person or by video conference) with their SPC to initiate their dedicated CSP process; this is also considered as the date of first contact.
Average Age at Coordinated Service Planning Initiation (Months): SPCThe average age of all individuals at Coordinated Service Planning CSP initiation (their first in-person or phone meeting/visit with their dedicated SPC) during the reporting period. CSP initiation occurs on the date when the family has their first meeting/visit (in-person or by video conference) with their SPC to initiate their dedicated CSP process; this is also considered as the date of first contact.
Total Wait Time from Referral to Coordinated Service Planning Initiation (# of Days): SPCThe total number of combined calendar days waited by all children/youth for Coordinated Service Planning CSP initiation, the date when the family has their first meeting/visit (in-person or by video conference) with their Service Planning Coordinator to initiate their dedicated CSP process; this is also the date of first contact.
Hours of Direct Service Time Spent (Total): SPCThe total number of hours spent by SPCs in direct delivery of Coordinated Service Planning CSP for a child/youth with an active Coordinated Service Plan. Direct Delivery of CSP represents the number of hours in meetings/visits between the child/youth and their family and their Service Planning Coordinator, including those during the period from CSP initiation to the development of his/her Plan.
Hours of Indirect Service Time (Total): SPCThe total number of hours spent by SPC on indirect delivery of Coordinated Service Planning CSP for families of a child/youth with an active Coordinated Service Plan. This is to capture the amount of time spent on CSP outside of direct service time (i.e., in-person and phone meetings/visits with the child/youth and their family) such as case planning, behind-the-scenes coordination with partners/service providers, and administrative tasks. This includes all indirect service time during the period from a child/youth’s CSP initiation to the development of his/her Coordinated Service Plan.
# of Full Time Equivalents (Total): SPCThe total number of Full Time Equivalents ( FTEs) identified as a Service Planning Coordinator ( SPC) for the Coordinating Agency or a Partner Agency during the reporting period. Includes FTEs whose dedicated function is for the direct delivery of CSP (this could include management roles). This should be reflected in FTEs, not individual staff. It should include existing staff of the Coordinating Agency or Partner Agencies who are identified as SPCs and create coordinated service plans, reflecting the portion of the existing staff’s role that is dedicated to CSP.
# of Individuals with an Active Coordinated Service Plan (Total): SPCThe total number of unique children/youth with an active Coordinated Service Plan that has been initiated and has involved active CSP meetings or CSP activity in the past six months. An individual is counted only once per reporting period. A Plan is considered active from the date of CSP initiation to the date the Plan becomes inactive or the child/youth is discharged.
# of Individuals Discharged that Met their Goals: SPCThe total number of unique children/youth with an active Coordinated Service Plan who were discharged because they met their goals during the reporting period. This number is calculated using the status of the Coordinated Service Plan, and the date of discharge from CSP. Children/youth with an inactive Coordinated Service Plan who are discharged in the reporting period (e.g., because the child/youth aged out, i.e., reached the age of 18 or the age of 21 if they were in school) are not included.
# of Individuals Discharged due to Family Leaving Catchment Area: SPCThe total number of unique children/youth with an active Coordinated Service Plan who were discharged due to the family leaving the catchment area during the reporting period. This number is calculated using the status of the Coordinated Service Plan, and the date of discharge from CSP. Children/youth with an inactive Coordinated Service Plan who are discharged in the reporting period (e.g., because the child/youth aged out, i.e., reached the age of 18 or the age of 21 if they were in school) are not included.
# of Individuals Discharged due to Inability to Reach Family: SPCThe total number of unique children/youth with an active Coordinated Service Plan who were discharged due to inability to reach the family during the reporting period. This number is calculated using the status of the Coordinated Service Plan, and the date of discharge from CSP. Children/youth with an inactive Coordinated Service Plan who are discharged in the reporting period (e.g., because the child/youth aged out, i.e., reached the age of 18 or the age of 21 if they were in school) are not included.
# of Individuals Discharged at the Request of the Family: SPCThe total number of unique children/youth with an active Coordinated Service Plan who were discharged at the request of the family during the reporting period. This number is calculated using the status of the Coordinated Service Plan, and the date of discharge from CSP. Children/youth with an inactive Coordinated Service Plan who are discharged in the reporting period (e.g., because the child/youth aged out, i.e., reached the age of 18 or the age of 21 if they were in school) are not included.

A supplementary report providing additional information to help the ministry monitor the performance of Coordinated Service Planning may be required.