Part 8: Roles and Responsibilities

The Coordinating Agency

The Coordinating Agency is accountable to the ministry for the delivery of Coordinated Service Planning in the service delivery area. (For a map of service delivery areas, see Appendix B)

The single Coordinating Agency in each service delivery area will be responsible for:

• Ensuring the delivery of Coordinated Service Planning Cycle as outlined in Section 3.
• Managing all aspects of Coordinated Service Planning, including 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^{footnote 9[9]}
• The performance of Service Planning Coordinators^{footnote 10[10]}
• 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 these policy guidelines, and other ministry policies/direction.
• Developing and maintaining relationships with cross-sectoral service providers and educators in the service delivery area in order to deliver Coordinated Service Planning, recognizing collaborative relationships and considering the expertise of educators and other professionals.
  • The Coordinating Agency will maintain 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) in order 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, so as 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 waitlist/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.

Service Planning Coordinators

Depending on local practice, some families may have a Service Planning Coordinator who delivers Coordinated Service Planning as well as another program or service. Other families may have a Service Planning Coordinator who provides Coordinated Service Planning full time. These guidelines apply to all Service Planning Coordinators, regardless of whether the individual delivers Coordinated Service Planning full-time or part-time. A family’s assigned Service Planning Coordinator may change if their needs change.

With appropriate consent, Service Planning Coordinators in each service delivery area will:

• Develop a strengths-based Coordinated Service Plan that addresses the service needs of the child/youth, is driven by the goals of the child/youth and family and that will support participation at home, school and in the community;
• Facilitate the active participation of the child/youth and family in Coordinated Service Planning, including goal setting;
• Facilitate the exchange of information between relevant providers in the children’s services, education, and health sectors in each service delivery area, to develop and maintain a single Coordinated Service Plan for the child/youth and their family;
• Connect families to relevant services and other community supports/resources in the service delivery area;
• Explore flexible and innovative approaches for service delivery to meet the needs of the child/youth and bring forward any barriers to innovation that may exist;
• Monitor, review, and update the Coordinated Service Plan, in collaboration with the child/youth and their family and relevant providers in the children’s services, education, and health sectors, as the child/youth and family’s needs and services change;
• Be knowledgeable and available to discuss the child/youth and family’s concerns, if applicable, regarding the service plan, and
• Facilitate working relationships with providers in the children’s services, health and educations sectors, in order to enable their regular contribution into Coordinated Service Planning and obtain and share relevant information regarding services for the child/youth.

The Service Planning Coordinator is not responsible for coordinating all services required by the family (e.g. adult mental health, settlement) but may provide contact information or initiate a referral to help families access other services and supports, where these services contribute to the overall goals for the child/youth and family. Where the Service Planning Coordinator will not be responsible for coordinating certain services, this should be communicated to the family.

Coordinated Service Planning Providers

Coordinated Service Planning Providers are agencies/organizations that employ Service Planning Coordinators within the service delivery area. These agencies/organizations will:

• Maintain formal agreements with the Coordinating Agency regarding agreed upon expectations with respect to the provider’s role and how these providers will be accountable to the Coordinating Agency;
• Report through the Coordinating Agency on the activities of their Service Planning Coordinators;
• Support Service Planning Coordinators to participate in training required by the Coordinating Agency;
• Ensure that their Service Planning Coordinators are aligned with and supporting the service delivery area’s process and model;
• Use any common tools or forms required by the Coordinating Agency; and
• Support families to have a consistent experience of Coordinated Service Planning across the service delivery area.

Coordinated Service Planning Participants

Coordinated Service Planning Participants are agencies/district school boards that provide services and/or supports to children and youth with special needs and that are expected to participate in Coordinated Service Planning. These organizations could be government-funded, community agencies, or district school boards and will have formal agreements with the Coordinating Agency regarding information sharing and participating in the Coordinated Service Planning process.

Coordinated Service Planning Participants will include, but should not be limited to, the signatory agencies to the local Coordinated Service Planning proposals:

• Children’s Treatment Centres (CTCs);
• Children’s agencies that provide inter-agency service coordination;
• Applied Behaviour Analysis (ABA)-based services and supports lead agencies^{footnote 11[11]}
• Autism Intervention Program (AIP) lead agencies^{footnote 11[11]};
• Community Care Access Centres (CCACs)/Local Health Integration Networks (LHINs); and
• District School Boards/School Authorities.

In particular, Coordinated Service Planning Participant organizations will, at a minimum, undertake the following activities. In some service delivery areas, participant organizations have agreed to involvement beyond the activities noted below:

• Participate in referrals to Coordinated Service Planning for families who need the service;
• Share information on their services with the Coordinating Agency;
• Participate actively as appropriate in the development of individual Coordinated Service Plans and in providing family-centered services according to the plan;
• Participate in the local governance structure for Coordinated Service Planning (either on the governance body or by providing input);
• Participate in capacity building as needs and opportunities to improve Coordinated Service Planning are identified by the Coordinating Agency;
• Report information required by the Coordinating Agency for performance measurement and quality improvement;
• Explore flexible and innovative child- and family-centered approaches for service delivery to meet the needs of the child/youth; and
• Actively participate in issues resolution, as appropriate, with respect to the delivery of Coordinated Service Planning within the service delivery area when conflicts arise between providers or between families and providers.

Partners from the broader service sector (e.g. child care providers; municipal partners) may also contribute to Coordinated Service Plans from time to time. Depending on how frequently they are involved in Coordinated Service Planning, the Coordinating Agency may pursue a formal agreement with these providers or arrange to share information using the informed consent of the family.

Ministry of Children, Community and Social Services

Through Transfer Payment Contracts and quarterly reporting, MCCSS Regional Offices will hold Coordinating Agencies accountable for the oversight and delivery of Coordinated Service Planning within the service delivery area.

• MCCSS Regional Offices will update contracts with Coordinated Service Planning Providers and Participants to include expectations regarding Coordinated Service Planning.
• MCCSS will monitor the functioning of local Coordinated Service Planning systems and will bring cross-sectoral and/or provincial issues forward for inter-ministerial resolution as necessary.