SET: Support, Education, & Training
The People of Color Network (POCN) will provide an array of comprehensive and diverse services to meet the individualized and unique needs of the children and families through a single program that will be named Support, Education, and Training (SET). The People of Color Network will employ 5 FTE’s designated to provide individualized services and will give priority to children and families with the following: present with complex needs, children who are at-risk of being removed from their natural environment, or are returning to a community-based place to live.
These services will be available to all TXIX/TXXI children enrolled within the PCN Network and will be identified as additional services, accounted and contracted for separately from the Qualified Service Provider (QSP) contract. Referral to these services will come through the CFT process, in which all referrals will be accepted, which develops and expands individualized Support and Rehabilitation Services for children with complex and challenging needs to help them live successfully in community utilizing a Positive Behavior Support approach to service delivery.
PCN is fortunate to serve a diverse population including Indo-Latino, African American, Caucasian, Latino, and Native American communities. Meeting the needs of children and families in a culturally and linguistically responsive manner is the goal of the SET program as well as the Mission of PCN. As an important aside, this means that POCN will place an emphasis on hiring FTE’s who can speak Spanish. Being culturally appropriate means having an understanding of the values, beliefs, myths, socializing, motivational and challenging aspects of a cultural group. Without such an understanding, it is very difficult to engage a child and his/her family, to convey to them that there is respect and support for that person’s belief system. This is especially true for immigrant parents who are raising children born in the United States. Basically, meeting a child and family “where they are”. In addition to the natural generational friction which can develop between parent and child, there is the additional potential conflict between the world view and values of the immigrant and those of their children born into or raised in another world view. It also means that the provider can challenge the child and family to move beyond certain beliefs and myths which can negatively impact their progress. All children and families of whatever group need to be able to critically reflect on themselves, their belief systems and their situation in order to make progress and learn to better cope with life’s challenges. When the process is being presented by a provider team that understands and respects the child and family, so the child and family can feel truly supported in his/her struggle to not only cope with challenges, but also make progress. Language is the crucial means by which we all communicate, but a true respect for and understanding of someone’s belief system is also essential for establishing a connection and making progress.
For us, this is the underpinning and guiding motivation of the Twelve Principles espoused by the Children’s Provider System and this is how we will approach each principle within the SET program.
Collaboration with child and family:
Respect for and active collaboration with the child and parents is the cornerstone for achieving positive behavioral health outcomes. A referral to the SET program comes directly from the Child and Family Team. Parents and children are treated as partners in the assessment process, planning, delivery and evaluation of the SET program.
Functional outcomes:
SET goals will be defined by the Child and Family Team (CFT). SET will work with the child and family by obtaining the goals and objectives that are developed by the CFT. Services will be tailored to the uniqueness of the family culture.
Collaboration to Natural Supports:
SET program is designed to assist the family and child to build connections within their community. SET is hoping to build supports through the available family’s and the child’s network of extended family, friends, neighbors and community organizations.
Unique Cultural Heritage:
SET is committed to provide generalist support services in a manner that respects the cultural traditions and heritage of the child and family. SET will consist of a diverse staff that are bi-lingual.
Accessible Services:
SET staff will be available based upon the recommendation of the CFT to ensure that the family needs are being met in a timely manner. SET staff are mobile- meaning that they will meet where the families are in the community and/or in settings identified by the CFT through the individual service plan (ISP).
Timeliness:
CFT will develop an individual service plan that will outline the service needs and timelines to guide the SET staff in delivering the services.
Stability:
SET will strive to minimize multiple placements by providing in home and/or community services. SET staff will be available based upon the recommendation of the CFT to ensure that the family needs are being met in a timely manner. The SET staff is mobile and flexible to provide services that are set forth in the ISP.
Individualized Services:
SET program will include individualized support and training for parents in meeting their child’s behavioral health needs as well as support and training for children and their family in self-management. SET staff, along with the CFT, will identify parents’ and children’s need for training and support to participate as partners in the assessment process, and in the planning, delivery, and evaluation of services. In addition, trainings and support, advance discussions, and help with understanding written materials, will be made available.
Unconditional Care:
SET staff will treat all families with respect. Each service for the child and family will be conducted in a professional manner. SET program staff will work with the families to identify their functional strengths to assist the families in working through the family’s identified challenges that are recorded in the ISP. SET staff will respect the “no reject, no eject” policy and will work with youth regardless of age or gender and provide services in their preferred language. Staff will also provide services in a location that is requested by the CFT, such as the child’s home or community environment and may provide transportation for the youth to support the service plans goals and objectives. Days and hours of the services will be flexible to allow for the changing needs of the youth and family.
The FTE’s will be flexible in meeting the needs of families, (as identified in SET’s beliefs and values), will be provided extensive on-going coaching and mentoring on the CFT process, and skilled at working with complex situations. Supervision will be a shared responsibility between the Director of Provider Support Services and the Clinical Supervisor, both employed by POCN. Service delivery will focus primarily on, but will not be limited to, the following Support and Rehabilitation Services:
H0038 Self Help/Peer Services
Self-help/peer services are provided by persons or family members who are or have been consumers of the behavioral health system. This may involve assistance with more effective utilization of the service delivery system (e.g., assistance in developing plans of care, identifying needs, accessing supports, partnering with professionals, overcoming service barriers) or understanding and coping with the stressors of the person’s disability (e.g. support groups), coaching, role modeling and mentoring.
Self-help/peer services are intended for enrolled persons and/or their families who require greater structure and intensity of services than those available through community-based recovery fellowship groups and who are not yet ready for independent access to community-based recovery groups (e.g., AA, NA, Dual Recovery).
H2014 Skills Training and Development
Teaching independent living, social, and communication skills to children and/or their families in order to maximize the person’s ability to live and participate in the community and to function independently. Examples of areas that may be addressed include self-care, household management, social decorum, same- and opposite-sex friendships, avoidance of exploitation, budgeting, recreation, development of social support networks and use of community resources.
H2016 Comprehensive Community Support Services
Self-help/peer services will be provided to a person for a period of time, which is 3 or more hours in duration. Self-help/peer services will be provided by persons or family members who are or have been consumers of the behavioral health system. This may involve assistance with more effectively utilizing the service delivery system (e.g., assistance in developing plans of care, identifying needs, accessing supports, partnering with professionals, overcoming service barriers) or understanding and coping with the stressors of the person’s disability (e.g., support groups), coaching, role modeling and mentoring.
H2017 Psychosocial Rehabilitation Living Skills Training
Refer to skills training and development definition.
H2025 Ongoing Support to Maintain Employment
Includes support services that enable a person to complete job training or maintain employment. It may also include monitoring and supervision, assistance in performing job tasks, work-adjustment training, and supportive counseling.
H2027 Psychoeducational Services
(Pre-Job Training and Development)
Services which prepare a person to engage in meaningful work-related activities may include: career/educational counseling, job shadowing, assistance in the use of education resources, training in preparation, job interview skills, study skills, work activities, professional decorum and dress, time management, and assistance in finding employment.
S5110 Home Care Training
Home care training family services (family support) involve face-to-face interaction with family member(s) directed toward restoration, enhancement, or maintenance of the family functioning to increase the family’s ability to effectively interact and care for the person in the home and community. May involve support activities such as assisting the family to adjust to the person’s disability, developing skills to effectively interact and/or manage the person, understanding the causes and treatment of behavioral health issues, understanding and effectively utilizing the system, or planning long term care for the child and the family.
PCN will take an active role in the SET program by monitoring and tracking program progress per encounters generated, programs developed and consulting, mentoring and coaching by Provider Support Team consisting of a Child and Family Team Coach, Family Support Consultant, Practice Support provided by Clinical Supervisor and Support provided by PNO QM Analyst and PCN Administrative staff. Children and families receiving services through the SET program will be given opportunity for input and future planning through the process of surveys, focus groups, parent advisory groups and the youth EVOLVE executive board.