Services delivered: Service coordination process

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Component: Services For Children And Youth With Complex Needs

Legislation: Child, Youth and Family Services Act, 2017

Service description

Service Coordination Process involves service planning and coordination activities which contribute to timely and effective intervention for children and youth.

People served

Children and youth under 18 years of age with multiple and/or complex special needs and in need of timely, effective intervention.

Program/service features

Service planning and review

This process involves developing a service plan for service delivery to meet the needs of the child/youth and reviewing progress in meeting the goals of the service plan.

This service plan identifies the child or youth’s needs to be addressed and the services to be provided. The plan also outlines who has responsibility for services (where multiple service providers are involved), and goals and objectives to be achieved through the services provided. The service plan must be developed, reviewed, and updated in collaboration with the child or youth and family, and, if appropriate, the team of providers who are involved in the child/youth’s life.

The service plan is used to monitor client outcomes and status of current client need as services are being delivered, to account for changing needs or priorities. Service plans are to be reviewed on a regular basis by service providers and updated when needs change, services are added or changed, or services are complete.

Referrals may be part of a service plan or occur following the intake process, as additional needs are identified or if current services are not meeting the needs of the child or youth. Referrals may also occur when the child or youth transitions out of child/youth services and has ongoing needs for services or treatment. The objective is a smooth transition. Rather than simply providing information to the client, assistance is provided for the client’s transition to a new provider and other services, as appropriate. The assistance to transition is supported by providing appropriate background information, as needed, to expedite the transfer to other services, reducing the number of times the client and/or their family needs to repeat their story, connecting directly, where appropriate with the new service provider, and by providing follow-up after transition/exit.

Where it is identified that a child/youth has multiple and/or complex special needs and the child/youth or family’s need for service coordination goes beyond the scope of inter-professional collaboration to address, the service provider should provide the family with information on Coordinated Service Planning (CSP) and support an effective referral and pathway to CSP, as appropriate. Through CSP, a Service Planning Coordinator, in partnership with the family and their service providers (e.g., mental health service providers), develop a Coordinated Service Plan for the child/youth and family. Individual service providers remain involved in the implementation and monitoring of the Coordinated Service Plan.

CSP does not replace individual planning required for a clinical service, such as mental health services. If a child/youth and family is participating in CSP, it is expected that information from clinical service plans will be shared, with consent from the parent/guardian, for the purpose of the development, implementation and monitoring of a special needs Coordinated Service Plan.

Case management and service coordination

Case management and service coordination are processes which place the child or youth and family at the centre and bring together the key partners in service delivery to provide an integrated and coordinated response to best meet the needs children, youth and their families. Case management and service coordination are particularly important where a child or youth’s needs are complex (level three or four on the continuum) and where they receive multiple services from one provider, or multiple services from multiple providers and/or sectors.

Case management and service coordination involves

identifying the parties responsible for executing a service plan monitoring progress
adjusting services
connecting with other service providers, as needed
helping with issues and questions as they arise planning discharge
measuring impact and outcomes

These processes are adjusted, based on needs and complexity. The case management function addresses the client’s service plan, while the service co-ordination function addresses the need for coordination among multiple agencies. Effective case management/service coordination requires communication between and among providers and sectors and the identification of clear pathways to care. Where multiple services from more than one provider are required to meet the child or youth’s needs under their service plan, one provider should be identified as the primary provider.

The primary provider is responsible for contacting the other service providers to discuss service delivery requirements and coordinate services. The primary provider may be the lead agency, another service provider, service coordinator, or a cross- sectoral provider.

Children/youth with multiple and/or complex special needs may require multiple specialized services in addition to mental health services. Where it is identified that a child/youth has multiple and/or complex special needs and the child/youth or family’s need for service coordination goes beyond the scope of inter-professional collaboration to address, the service provider should provide the family with information on CSP and support an effective referral and pathway to CSP, as appropriate. Through CSP, a Service Planning Coordinator, in partnership with the family and their service providers (e.g., mental health service providers), develop a Coordinated Service Plan for the child/youth and family. Individual service providers remain involved in the implementation and monitoring of the Coordinated Service Plan.

Monitoring and evaluating client response to service

The process of monitoring and evaluating a child or youth’s response to service, perception of care, service experience, as well as the clinical outcomes of service, is carried out through a variety of means, including interviews, observations and repeated administrations of standardized, evidence-informed tools. Both quantitative and qualitative information is used to monitor impacts and make appropriate adjustments to services. Any such adjustments are discussed with the child or youth and family, before being incorporated into the individual’s service plan.

Ongoing monitoring provides evidence as to whether treatment is having the intended impact and, if it is not, ensures the necessary changes in treatment will be reflected in the service plan. The process may identify the potential need to increase or decrease the intensity of services and can be used to inform transitions to more or less intensive services or treatments or for discharge planning. Ongoing monitoring also provides a basis for outcome measurement and reporting.

Transition planning and preparation

Transition planning prepares children, youth, and families for transitions to other community supports, to adult services, back to school or for discharge from services. Planning is accomplished through the setting of clear goals for treatment, as well as ongoing analysis and use of information to track progress and determine timing for transitioning to a new service or for discharge. It is important that transition planning and preparation occur at an early stage for all services.

Transition planning and preparation supports continuity of care and results in minimal disruption to treatment gains. Early planning and preparation may involve the identification and provision of transition supports when a child or youth’s needs are chronic. It is important for service providers to recognize the chronicity of some cases and to be prepared to facilitate the transition of youth to adult services in a way that limits service disruption for the client.

Following discharge from services, a follow-up with the client is performed as a "check- in" to monitor status, facilitate re-entry to the service system, if required, and/or provide time- limited support to help discharged clients connect with or access needed services. Planning for discharge or transitions between services should start as early as the initial service plan.
Following discharge from service, it is considered a best practice that follow-up contact be made within three to six months of discharge to discern status and facilitate service access where needed. At the point of follow-up, if the child or youth reports or displays deteriorated functioning, it is determined whether the service plan needs to be re-opened or the child or youth’s needs and strengths need to be reviewed and services recommended based on the reassessment results. Where appropriate the client may re-enter service to address new or unmet needs.

Specific service provided

Processes to support service delivery

Key processes contribute to the client experience and support the delivery of services to children, youth, and their families throughout their involvement with the child and youth mental health services.

These processes support a coordinated, collaborative, and integrated approach to the delivery of community-based services for children, youth, and their families. The processes emphasize a child- and family-centred approach to service delivery that engages children, youth and families at every turn, from the moment the need for a service is identified, through the delivery of that service, and transition out of that service, to the point at which feedback is provided on how well the service has met their needs.

Key processes to support the provision of mental health services to children and youth include

coordinated access
intake, eligibility, and consent identifying strengths, needs and risks child, youth, and family engagement service planning and review
case management and service coordination monitoring and evaluating client response to service transition planning and preparation

Program goals

Services are delivered based on the principles of child-, youth- and family-centred service; seamless service delivery and information sharing; and meeting diverse needs through inclusive, accessible, and culturally safe practices.

Child/youth and family-centred service

Services are delivered in a way that is family-centred and ensures the family, children and youth are actively engaged and their input is incorporated throughout service delivery
Family-centred service recognizes that each child, youth, and family is unique; that the family is the constant in the child/youth’s life; and that the family has expertise in their child/youth’s abilities and needs
Through family-centred service, service providers work with the family, and the child/youth as appropriate, to make informed decisions about the services and supports the child/youth and family receive. The strengths and needs of all family members are considered

Seamless service and information sharing

As a result of Service Coordination Process activities, families will experience seamless service and information sharing. With consent, information about a family’s needs will be shared between providers. Families should not feel like they are repeating intake and assessment information or repeating their stories unnecessarily; however, families should be encouraged to share information with providers and can share their stories with new providers if they wish

Meeting diverse needs

Service Coordination Process delivery will be inclusive, accessible, and culturally safe for all families and children/youth. Services will be respectful of the values and meet the diverse needs of children, youth, and their families
Service providers will be aware of distinct approaches required to address the needs of First Nations, Metis, Inuit and urban Indigenous children and youth. This includes providing culturally safe services and linkages and referrals to Indigenous service providers and other community resources as required

Ministry expectations

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

Service planning and review

The service planning and review process focuses on the child or youth’s strengths and resources, within the context of their family, agreed-upon goals and objectives, the management of safety and risk issues, and what can reasonably be achieved. This is informed by an assessment of strengths, needs and risks, and on the professional judgment of the service provider
Each child or youth and family has a written service plan developed in collaboration with the child, youth, or family as appropriate, to guide and monitor the intervention and treatment process
Information contained in the service plan is subject to applicable legislation, regulation, and policy directives, including privacy and consent requirements
Protocols for communicating changes to the service plan to clients and issues that may be related to all service providers involved must be clearly established at the outset
Intervention, treatment, and referrals are reviewed and recorded in the child or youth’s service plan on a regular basis. The review of intervention and treatment is used to modify the child or youth’s service plan where necessary
There are written policies and procedures with other service providers that define the relationship and referral process to intake points/processes in the service system
Where a referral occurs, the transition is supported by providing background information, as needed, to expedite the process; reducing the number of times the client and/or their family needs to repeat their story; and connecting directly, where appropriate, with the new service provider. These activities may involve sharing client information with appropriate providers, subject to applicable legislation, regulation, and policy directives, including privacy and consent requirements
The service plan makes provision for transitions and follow-up from service, between services, and where the overall responsibility for treatment shifts to another service provider

Case management and service coordination

Service coordination will take place through collaboration with all service providers who are involved in the service plan
Where the child/youth and family are participating in Coordinated Service Planning, the Service Planning Coordinator will lead the development, implementation, and monitoring of the Coordinated Service Plan. Individual service providers will remain involved in the development, implementation and monitoring of the child/youth and family’s Coordinated Service Plan, as appropriate
Case management and service coordination includes the clear identification of respective roles and responsibilities of all service providers involved, and the documentation and communication of these across involved providers and to the child, youth, and their families
Case management and service coordination activities will respect the preferences of children, youth, and their families
Where appropriate, service providers will work with the education sector to support service delivery that minimizes school transfers and maintains education programming
Where a service provider is the primary provider, they will, to the extent possible
provide the family with a stable point of contact from the start of their involvement in service through to their transition out of service or between services
work with other involved providers to support service planning, coordination, and treatment
monitor services regularly to ensure that services are scheduled and delivered according to the child or youth’s service plan
maintain effective and clear communication with involved parties, including the child, youth, and family
Should work with service providers, and broader sector partners to establish written policies and procedures that define case management/ service coordination in the service area. These should also describe the relationship(s) with, and referral processes between other intake processes in the service system to support effective pathways to, through and out of care. Written policies and procedures must be transparent to all parties, including clients and families
Where a child or youth has multiple and/or complex special needs and requires multiple specialized services in addition to mental health services (e.g., rehabilitation services, autism services or respite supports), their family may benefit from additional supports provided through CSP and should be referred to the special needs Coordinating Agency in their service delivery area
It is expected that clients are connected with the Coordinating Agency, to develop pathways with the goal of providing coordinated services for children and youth with mental health concerns who also have other special needs
Clients who are newly identified as having special needs should be referred beyond mental health needs services to the local Coordinating Agency as they may also benefit from additional supports provided through Coordinated Service Planning
Service providers will work with the family’s Service Planning Coordinator to include mental health services in the child or youth’s Coordinated Service Plan where the child/youth is a recipient of services available through the local Coordinating Agency
When a mental health service provider takes a lead or substantive role in a community service plan on behalf of a child or youth involving multiple agencies and/or informal supports, services are coordinated and integrated

Monitoring and evaluating client response to service

the service provider will review and record intervention and treatment on a regular basis
the service provider will share information among involved service providers to monitor and evaluate the client’s response to services. Information sharing will take place subject to applicable legislation, regulation, and policy directives, including privacy and consent requirements
the review of intervention and treatment, including the use of evidence-informed tools, is used to modify the service plan, if necessary
services are designed with intended clinical outcomes, and progress towards clinical outcomes is measured, evaluated and services adjusted as needed

Transition planning and preparation

Planning for discharge and transition begins from the point when a child or youth enters treatment or service
Discharge is a planned process in which service provider staff and the child or youth, and family negotiate a plan for case closure
Where case closure is unplanned, efforts are made to inform and involve the client, as appropriate under the circumstances
There is a written discharge report for each child, youth and/or their family, with details appropriate to the nature of service provided
Where a child/youth is transitioning to another service provider, or to another service system (e.g., education system), the service provider should work in partnership with all (including the child or youth, their family, and involved providers) to develop a seamless transition approach. This will support reducing the number of times the child, youth and/or their family needs to repeat their story
Transitioning to another service provider must be planned, agreed-upon between child or youth and family, and all the providers, and communicated to everyone involved
Where appropriate, service providers will work with the education sector to support service delivery that minimizes school transfers and maintains education programming
These activities may involve sharing client information with appropriate service providers, subject to applicable legislation, regulation, and policy directives, including privacy/consent requirements

The following minimum expectations apply to all key processes that support the delivery of mental health services

Service providers are expected to use evidence-informed approaches to support the key processes, the high quality of services, and effective delivery of services to children, youth, and families
Information gathered from the child, youth, family or practitioners that is necessary for the delivery of services is to be shared among all relevant service providers, to the extent permitted by privacy and consent requirements (including applicable legislation, regulation, and policy directives). This will promote a client- focused approach to service delivery that is responsive to the needs of clients and will help reduce the need for children, youth, and their families to repeat their stories
Key processes are delivered by individuals with an appropriate range of skills and abilities necessary to respond effectively to the needs of children, youth, and their families

Individual planning and goal setting

Each individual will have a current Plan of Care (POC) that reflects an assessment of his/her needs and preferences. The POC will identify the specific services/supports received by the individual, the expected outcomes and be based on the principles of person-centred planning, self-determination, and choice.

Service system planning

In carrying out these requirements, the service provider will work in collaboration with the special needs Coordinating Agency in their service area, where one has been identified, to plan for and align local services) so that children, youth and their families

know what child and youth mental health services are available in their communities
how to access the mental health services and supports that meet their needs

Availability of service

Service coordination processes are provided in every service area.

Reporting requirements

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

Service data name	Definition
# of Children/Youth:6-10yrs: Service Coordination Process: former CYMH	Number of children and youth who are deemed eligible and have consented to service and who are between the ages of 6 and 10 (inclusive) at the date of intake or at the start of the fiscal year if service carries over.
# of Children/Youth: Service Coordination Process: 0-5yrs: former CYMH	Number of children and youth who are deemed eligible and have consented to service and who are between the ages of 0 and 5 (inclusive) at the date of intake or at the start of the fiscal year if service carries over.
# of Children/Youth: Service Coordination Process: 11-14yrs: former CYMH	Number of children and youth who are deemed eligible and have consented to service and who are between the ages of 11 and 14 (inclusive) at the date of intake or at the start of the fiscal year if service carries over.
# of Children/Youth: Service Coordination Process: 15-17yrs: former CYMH	Of the total number of unique clients, the number of children and youth who are deemed eligible and have consented to service and who are between the ages of 15 and 17 (inclusive) at the date of intake or at the start of the fiscal year if service carries over.
# of Children/Youth by Gender Identity: X: Service Coordination Process: former CYMH	Of the total number of unique clients, the number of children/youth eligible for mental health having a third gender identity (i.e., Trans/Transgender, Non-Binary, Two-Spirited, or Binary as well as anyone who chooses not to display their gender identity). Gender identity: Each person’s internal and individual experience of gender. It is their sense of being a woman, a man, both, neither, or anywhere along the gender spectrum. A person’s gender identity may be the same or as different from their assigned sex at birth. Gender identity has nothing to do with a person’s sexual orientation. Children/youth would be counted only once in this data element.
# of Children/Youth by Gender Identity: Female: Service Coordination Process: former CYMH	Of the total number of unique client, the number of children/youth eligible for mental health services having identified their gender identity as female. Gender identity: Each person’s internal and individual experience of gender. It is their sense of being a woman, a man, both, neither, or anywhere along the gender spectrum. A person’s gender identity may be the same or as different from their assigned sex at birth. Gender identity has nothing to do with a person’s sexual orientation. Children/youth would be counted only once in this data element.
# of Children/Youth by Gender Identity: Male: Service Coordination Process: former CYMH	Of the total number of unique clients, the number of children/youth eligible for mental health services having identified their gender identity as male. Gender Identity: Each person’s internal and individual experience of gender. It is their sense of being a woman, a man, both, neither, or anywhere along the gender spectrum. A person’s gender identity may be the same or as different from their assigned sex at birth. Gender identity has nothing to do with a person’s sexual orientation. Children/youth would be counted only once in this data element.
# of Children/Youth Eligible for Service: Service Coordination Process: former CYMH	The total number of unique children/youth who were eligible and consented to receive CYMH services from the service provider or its partners/sub-contractors, and for whom a record has been created, within one fiscal year. A child/youth cannot be counted more than once in a fiscal year in this data element. A child/youth is to be reported once in the initial quarter in which he/she was first deemed eligible and consent was provided to receive CYMH supports and services. If active service occurs across more than one fiscal year, the child/youth is to be counted once in each fiscal year. For example, a child/youth started receiving service on March 15 and ended this instance of service on July 15. On July 15, the individual is placed on a waitlist to receive another service and starts a second service on September 12 which ends on January 20. This individual would be counted as a unique client once in the fourth quarter of the first fiscal year and once again in the first quarter of the second fiscal year.
# of Children/Youth: Active Coordinated Service Plan	The total number of children/youth that have an active Coordinated Service Plan (an active plan is one that has been initiated and has involved active CSP meetings or CSP activity in the past six months). Specific to those individuals for whom their first coordinated service plan was created in a previous fiscal year. This is to complement #NEWCSPINI and capture any individual receiving CSP who is not a new client. An individual should not be counted more than once per fiscal year
# of Hours of Direct Service: Service Coordination Process: former CYMH	Number of hours of Direct Service. The total number of hours of "direct" service provided by staff to individuals during the fiscal year for a particular service. "Direct" hours: The hours spent interacting, whether in a group or individually; face to face or on the phone. It does not include work done "on behalf of" clients, such as telephone calls, advocacy, etc. Administrative support to the service is not to be included. For group service, one hour of service equals one hour of service for the entire group. For example: one hour of group service with five participants equals one Hour of Direct Service. (Note: each individual in the group is recorded under ’no. of individuals served’ where there is a record).
# of Hours of Indirect Service: Service Coordination Process: former CYMH	The total number of hours of service provided by staff "on behalf of" clients, such as telephone calls, advocacy, and administrative support to the service
# of Initial Needs Assessments: Service Coordination Process	Number of children/youth with an initial needs assessment performed at or following intake, using a standardized tool to identify strengths and needs to inform service/treatment planning. If a child/youth has two or more needs assessments completed during service, only the initial needs assessment would be counted in this data element.
Service Coordination Process: Ministry-funded agency expenditures: former CYMH	Total ministry-funded expenses for the Transfer Payment Recipient to administer and/or deliver this service in the reporting year (cumulative).

Updated: May 23, 2023

Published: May 23, 2023