Continuum Core Element: Collaborative Treatment Planning
& Care Coordination
The Core Team engages in a structured collaborative care coordination approach that promotes continuity in treatment planning and results in the ongoing collaborative development, implementation, and amendment of the youth and family’s Individualized Action Plan (IAP)/treatment plan. It involves an ongoing process of engaging, coordinating, and collaborating with family members, the referring agency, out-of-home treatment providers, Continuum OT and psychiatry consultants, other treatment providers and services, community resources, and natural supports as a cohesive group (Family Team). It entails the Family Team coming together around the youth’s and family’s prioritized needs, setting measurable goals and objectives, identifying interventions that are most likely to succeed in transitioning youth home or remaining at home and living safely together within their community, and specifying who is responsible for each piece of the work. The process is family-driven and youth-guided, strengths-based, collaborative, outcome-oriented, and tailored for the needs of the individual youth/family. This ongoing process takes into account the family’s circumstances, culture, and readiness to participate. The Core Team takes the lead role in facilitating collaborative treatment planning and service coordination whether the youth is living at home or in an out-of-home treatment intervention (group home).