Goal:

Keep children and youth safely in their homes or support a timely return to home from hospitals or other placements by coordinating the right mix of services and supports with their families. We aim to reduce avoidable hospitalizations and out-of-home placements and improve day-to-day functioning and well-being.

Strategy Description:

We will implement a multi-level Care Coordination (Case Management) model grounded in wraparound principles to keep youth at home or return them home quickly and safely. Core actions:

• Referrals & Engagement: Receive referrals, confirm eligibility, complete strengths/needs assessments, and begin services with warm handoffs within expected timelines.

• Family-Driven Planning: Convene a Child & Family Team to build an individualized plan of care with clear goals, roles, and timelines.

• Right Service, Right Time: Link to therapy, psychiatry, PRP, school supports, and community resources (housing, food, transportation, recreation). Adjust intensity (Level I–III) to step up/step down as needs change.

• Local Resource Expertise & Navigation: Maintain an up-to-date county resource directory and relationships so staff can make direct, warm linkages to services and supports.

• Stabilization & Return-Home Focus: Create crisis/safety plans, coordinate 24/7 response pathways, and manage transitions from ED/hospital/RTC to prevent readmissions and shorten stays.

• Cross-System Coordination: Align with schools, primary care, child welfare, juvenile services, and BHAs/LBHAs to close gaps and avoid duplication.

• Barrier Reduction & Equity: Address transportation, scheduling, and technology barriers so families can follow through.

• Monitoring & CQI: Track linkages, outcomes, and satisfaction; review data quarterly to improve results.

Level of Change:

Programs

Primary Focus Area:

Behavioral Health: including Substance Abuse and Mental Health

Data Category Tag:

GCHD Behavioral Health

Strategic Planning Alignment:

Estimated Implementation Date:

2025-10-27

Estimated Completion Date:

2030-06-30

Estimated Ease of Implementation:

Moderate

Estimated Cost of Implementation:

Low

Potential Community Benefit:

High

Health Equity:

Behavioral health and a family’s basic needs are inseparable. Our case management treats them together by identifying social drivers such as housing, food, transportation, childcare, utilities, and technology at intake and acting on them quickly, because unmet needs often trigger crises, emergency department use, and out-of-home placements. Using a family-driven, culturally responsive, trauma-informed approach, we create plans that reflect each family’s goals and preferences while coordinating services across schools, primary care, LBHA/LMB partners, and community providers. We make direct, warm linkages to resources and remove access barriers through flexible scheduling, tele/phone options, language access, and transportation support. The aim is simple: keep youth safely at home or return them home sooner by stabilizing both behavioral health and the conditions of daily life.

Research: