Collaborative Treatment Planning and Care Coordination

Core Element Overview

The 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 Service Plan (ISP)/ treatment plan. It involves an ongoing process of engaging, coordinating, and collaborating with family members, DMH, out-of-home treatment providers, 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; specifying who is responsible for each piece of the work; and identifying interventions that are most likely to succeed in supporting youth and family in helping the youth remain in and/ or return home in a safe and timely manner and function successfully at home, school, and in the community.

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 considers the family’s circumstances, culture, and readiness to participate. The 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 care).