California Wraparound Standards

1.1 Timely Engagement and Planning. HFW staff engages families early and often, including Tribes in the case of an Indian child. First contact with families is made as soon as possible, but no later than 10 calendar days after referral; teams complete a Plan of Care within 30 calendar days; teams review the plan within the context of a HFW team meeting at least every 30-45 calendar days; teams update the Plan of Care and distribute to all team members at least every 90 days and more often as needed.

1.2 Led by Youth and Families. The HFW team prioritizes the youth and family’s perspectives and voices in developing and modifying the mix of strategies and supports to ensure the best fit with their preferences. The youth and family’s values, culture, expertise, capabilities, interests, and skills are elicited, fully understood, and celebrated. They are viewed as critical to a successful process and are the basis for decision making and problem-solving. In the case of an Indian child, the HFW team prioritizes the perspectives and voices of the youth, family and Tribe. Tribes, in the case of an Indian child, must be an equal voice on the HFW team. (Principle 1: Family Voice and Choice)

1.3 Strength-Based. Functional strengths of the youth, the family, all team members, and the family’s community are collectively reviewed and utilized throughout the HFW process. Identified strengths are functional in nature and drive decision making and service planning. Team members remain focused on solutions, rather than dwelling on negative events. The Integrated Practice- Child and Adolescents Needs and Strengths (IP-CANS) is critical and required for strengths identification. (Principle 2: Strength-Based)

1.4 Needs Driven. HFW services and supports are focused on addressing the high priority underlying needs of the youth, as well as their family members. Needs statements refer to the underlying reasons why problematic situations or behaviors are occurring, not simply stated as deficits, problematic behaviors, or service needs. The HFW process continues until needs are sufficiently met. The IP-CANS is critical and required for needs identification.

1.5 Individualized. The HFW team is committed to finding creative, highly individualized strategies that are customized to match each youth and family’s needs, strengths, values, culture, preferences and reduces harm over time. The HFW plan is uniquely tailored to fit the family and capitalize on the assets of their community and informal networks and in the case of an Indian child, the Tribe. (Principle 3: Individualized)

1.6 Use of Natural and Community Based Supports. Natural supports are integral team members. HFW teams are strengthened by the contributions of natural supports. HFW teams prioritize strategies in the Plan of Care that utilize natural supports, and that take place in the family’s community, to reduce reliance on formal supports while fostering sustainability within youth and family’s community. (Principles 4, 5: Natural Support, Community Based)

1.7 Culturally Respectful and Relevant. HFW teams recognize that a family’s traditions, values, and heritage are sources of great strength. HFW teams use strategies that are relevant to and respectful of the youth and family’s culture, including Tribes in the case of an Indian child. HFW teams work to connect families with individuals and organizations that provide culturally relevant support after the family transitions from formal HFW services. (Principle 6: Culturally Respectful and Relevant)

1.8 High-Quality Team Planning and Problem Solving. HFW teams are comprised of formal and natural supports across all Children’s System of Care partners who work together to develop, implement, and monitor the individualized Plan of Care that meet the unique needs of the youth and family. All team members take ownership over their assigned tasks and collaborate to meet the youth and family’s needs. Teams experience optimism, commitment, and energization. (Principles 7, 8: Team Based, Collaboration)

1.9 Outcomes Based Process. The HFW team monitors the success of the Plan of Care—including progress toward meeting needs, strategy implementation, and task completion. These are measured objectively, reviewed routinely, and used to inform changes to the Plan as needed. Needs statements are linked to measurable outcomes and data from standardized instruments including the IP-CANS and are integrated into the planning process. (Principle 9: Outcomes- Based)

1.10 Persistence. The HFW team views setbacks and challenges not as evidence of a youth, or family failure, but as an indicator of a need to revise the Plan. The HFW team is committed to implementing a Plan that reflects the HFW Principles, even in the face of limited system capacity. (Principle 10: Persistence)

1.11 Transitions as part of the Fourth Phase of HFW. Transitions are planned for in advance and celebrated with full youth and family participation. Transitions only happen when the youth and family have had their needs met, not due to an adverse event or an administrative requirement.

Policies, procedures, and data processes (for example, IP-CANS, satisfaction surveys, use of the Wraparound Fidelity Index (WFI), Team Observation Measure (TOM), Document Assessment Review Tool (DART), quality assurance phone calls, post HFW team meeting verbal feedback or feedback forms, documentation review, etc.) ensure that the HFW program is routinely evaluating its effectiveness in the following areas (in compliance with Standard 10.2 Evaluation Metrics and Outcomes):

2.1 Youth and Family Satisfaction. Youth and families are satisfied with their HFW experience and their progress. Policies and procedures are in place to record and evaluate youth and family satisfaction with their HFW experience. In the case of an Indian child, the Tribe is satisfied with the HFW experience. Policies and procedures are in place to evaluate the Tribe’s satisfaction with their HFW experience.

2.2 Improved School Functioning. Youth experience improved educational and vocational functioning as a result of their involvement in HFW. They have more consistent attendance, are participating at or above grade level or according to their educational plan, and/or are developing needed vocational experience.

2.3 Improved Functioning in the Community. Youth experience improved functioning in the community as a result of their involvement in HFW. Policies and procedures are in place to record and evaluate the level of justice involvement and engagement with community activities.

2.4 Improved Interpersonal Functioning. Youth and their families experience improved interpersonal functioning as a result of their involvement in HFW. There is less stress and strain at home attributed to them and they are able to develop or maintain positive family relationships and friendships.

2.5 Increased Caregiver Confidence. Families have access to effective needed services and supports. Caregivers feel increased confidence in their ability to manage future problems and they know how to find and access services and effectively address crises.

2.6 Stable and Least Restrictive Living Environment. Youth experience permanency and stability in their community-based living situation. Youth do not experience a new placement in an institution (such as detention, psychiatric hospital, treatment center, or STRTP) and/or have not moved between residential settings.

2.7 Reduction in Inpatient, Emergency Department Admission for Behavioral Health Visits. Youth experience stability with regard to their behavioral health, necessitating fewer or no visits to the hospital.

2.8 Reduction in Crisis Visits. Youth and natural supports are able to avert most crises and manage most impending crises without professional support.

2.9 Positive Exit from HFW. Youth and their families exit HFW based on stabilization and adequate progress in meeting needs; youth and families are not discharged from HFW due to an adverse event.

3.1 Orientation. The HFW team orients youth and families to the HFW process, including explaining the HFW principles and phases, addressing legal and ethical considerations, and explaining the role of each member on the team including the family’s role and the role of natural supports and Tribes in the case of an Indian child.

3.2 Safety and Crisis Stabilization. The HFW team addresses pressing needs and concerns so that the family and team can focus on the HFW process. If immediate response is necessary, the HFW team formulates a plan for immediate intervention and stabilization, including development of a crisis plan and ensures access to 24/7 crisis response when needed.

3.3 Strengths, Needs, Culture and Vision Discovery. The HFW team facilitates conversations and activities with the youth and family to identify individual and family strengths, needs, culture, and their vision for a better future. The facilitator prepares a summary document to clearly communicate strengths, needs, culture and vision to all team members, to orient new team members as they are added to the process, and to support the initial plan development process.

3.4 Engage all Team Members. The HFW team engages the participation of team members across all Children’s System of Care partners (including formal, natural supports, and Tribes, in the case of an Indian child), who care about and can aid the youth and family. The HFW team encourages and facilitates their active participation by clarifying their roles and responsibilities on the team. The facilitator intentionally engages the team in activities to ensure a positive and collaborative team culture.

3.5 Arrange Meeting Logistics. The HFW team ensures that meetings take place at a time and in a location that is convenient and accessible to all team members with priority given to family needs and family voice and choice, taking into consideration family schedules, culture, and history of trauma, and ensuring equitable access for all youth and families. The HFW team plans for and arranges meeting logistics such as transportation, interpretation, telehealth capability, etc.

4.1 Develop and Document Team Agreements, Additional Strengths, and Team Mission. Building upon the activities completed during engagement, the facilitator leads the team in:

(1) developing formal agreements on how the team will engage during meetings and make decisions,

(2) identifying and documenting additional strengths of the youth, family, other team members, and the community, and

(3) creating a team mission statement that defines the overall purpose of the HFW team in alignment with the family vision.

4.2 Describe and Prioritize Needs, Develop Goals, and Assign Strategies. The facilitator guides the team in reviewing needs identified during engagement, adding any additional needs, and prioritizing them. The HFW team uses the prioritized needs to develop specific, measurable goals and outcomes. The facilitator engages the team in brainstorming multiple creative strategies to meet the prioritized needs, goals, and outcomes before selecting strategies and assigning responsibility in the form of action items.

4.3 Develop an Individualized Plan of Care. The HFW team develops a comprehensive initial Plan of Care that is based on the prioritized needs, goals, and strategies of the family and youth. This is accomplished via a high‐quality team process across all Children’s System of Care partners, including the Tribe in the case of an Indian child, that elicits multiple perspectives, builds trust and shared vision amongst team members, and demonstrates the HFW principles. The facilitator leads the team to ensure:

(1) The Plan of Care is in alignment with the family vision and team mission statement and is based on the strengths, needs, and culture of the youth and family.

(2) The Plan of Care addresses needs across multiple life domains and Children’s System of Care partners as identified and prioritized by the HFW team.

(3) Strategies and action items are clearly documented and include who is responsible for each strategy/action item, due dates are established, and each team member understands their role. Strategies are culturally relevant and include a balance of formal services, natural supports, and community and family resources, with greater reliance on natural supports over time.

(4) The Plan of Care includes an array of services and supports that are well- coordinated across Children’s System of Care partners, tailored to meet the youth and family’s individual needs, and delivered in the community in which the youth and family live, with priority given to family needs and family voice and choice, taking into consideration family schedules, culture, and history of trauma and ensuring access for all youth and families.

(5) Natural supports and sustainable community resources are included in the Plan, or the Plan includes strategies to identify and develop community and natural supports before the youth and family transition out of the HFW Program.

(6) Transition from formal services is graduated; plans set benchmarks for transitioning to less restrictive, less intrusive, and less formal services throughout the HFW Process, taking into consideration the ability of families to move through the process at their own pace.

4.4 Develop a Crisis and Safety Plan. The facilitator leads the team in developing a crisis and safety plan that identifies and prioritizes safety needs, potential risk and crisis situations, as well as highly individualized proactive and reactive strategies for the youth, family, and team members to respond effectively. Identified strategies should be chosen by the youth and family, should be culturally relevant, and should maximize the use of natural supports wherever possible.

5.1 Implement the Plan of Care. The HFW team carries out the initial Plan of Care, monitoring completion of action items and strategies and their success in meeting needs and achieving outcomes in a manner consistent with the HFW principles. Teams celebrate successes as they occur.

5.2 Review and Update the Plan of Care. The facilitator engages the team to continually review the Plan; assess the progress and the effectiveness of strategies; and update the Plan as needed, including changing goals and strategies if the needs of the youth and family change. The facilitator documents and communicates, via meeting minutes and other forms of communication, completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the Plan. The Plan of Care is updated in an HFW team meeting and distributed to all team members at least every 90 days, and more frequently, as needed.

5.3 Build Supports while Maintaining Team Cohesiveness and Trust. The facilitator continually assesses and addresses team cohesion, trust, and commitment to ensure effective collaboration. When appropriate, teams seek and develop potential natural supports and add them to the team. Teams orient and engage new team members as they are added.

6.1 Develop a Transition Plan. When the family has reached pre-determined benchmarks indicating sufficient progress towards completing the team mission and goals, and the youth, family, and team agree the family is ready for transition, the HFW team will begin developing a formal individualized transition plan. Led by the facilitator, the HFW team will outline a purposeful transition process which identifies needs, services, and supports that will persist past formal HFW and includes strategies to transition any remaining support being provided by HFW staff to those ongoing supports. For adoptive families utilizing Adoption Assistance Program (AAP) funding, families are educated on post adoptive services that can assist with transition.

6.2 Develop a Post-transition Safety Plan. The facilitator leads the team in developing a crisis and safety plan (or adjusting the current crisis and safety plan) that identifies potential crisis situations that may occur after transitioning from formal HFW. The crisis and safety plan includes individualized, proactive, and reactive strategies for the youth, family, and other supports who will remain after HFW concludes. The youth and family play a pivotal role in identifying these strategies, which should be culturally relevant, and maximize the use of natural and community supports.

6.3 Create a Commencement and Celebrate Success. The team ensures that the conclusion of formal HFW is celebrated in a manner that reflects a positive transition, is culturally relevant, and is meaningful to the youth and family.

7.1 Youth and Family as Key Decision-Makers. Youth and family feedback is utilized to inform all levels of the HFW Program, including service planning and implementation, policy and procedure development, workforce development, and quality improvement of the CA High Fidelity Wraparound model.

7.2 Community Leadership Team. The county establishes a Community Leadership Team, which works collaboratively and engages in shared decision-making to ensure the CA Wraparound Standards are met at the organizational and systems level. Counties ensure formal communication structures are established between Community Leadership Teams and Interagency Leadership Teams (ILTs). Tribes within the region must be included in the Community Leadership Team. In addition, the Community Leadership Team works to:

(1) Ensure all other child serving entities are provided opportunities to participate in the Community Leadership Team.

(2) Actively identify and remove interagency and system barriers that interfere with interagency collaboration and effective service delivery to families.

(3) Identify and support cross-agency training and community collaboration to promote family-centered and culturally relevant practices and support high fidelity to the CA HFW model.

(4) Ensure there is a process in place to review family plans on the community and systems level based on the values, principles, and activities of the HFW process.

(5) Ensure there is a process in place to regularly review the use of, access to, and procedures around flex funds to ensure individualized family needs are being met.

(6) Ensure there is a process in place to regularly review HFW data at the organizational, community, and systems levels, and to use data to inform Continuous Quality Improvement (CQI) efforts that reflect HFW values and HFW implementation Standards.

7.3 Eligibility and Equal Access. HFW eligibility and referral criteria and processes ensure adequate, appropriate, and equitable access to HFW services, and do not exclude families because of the severity or nature of their needs. HFW is adequately publicized, available, and accessible so that youth and families who would benefit are able to participate. There is adequate program planning to ensure that once enrolled, families have access to an adequate array of services and 24/7 support to meet complex needs.

8.1 Funding Supports the CA High Fidelity Wraparound Model. The HFW Program has fiscal practices that are aligned with the values and principles of Wraparound and ensure the CA Wraparound Standards are met. Budgets and contracts at all levels, regardless of county or provider-based service provision allocate funding for essential Wraparound operations which include required staffing, workforce development data collection, and data management systems and the costs of services.

8.2 Equitable Funding Across System Partners. The HFW Program must ensure that federal, state, local, or private resources available across the Children’s System of Care are leveraged to the maximum extent to meet the needs of youth and families served by HFW so that the service is funded adequately. Collaboration and equitable contribution across systems partners are principles of HFW services. Medi-Cal may be leveraged for youth who are eligible.

8.3 Cost Savings are Reinvested. Savings achieved by HFW (i.e., total annual revenues in excess of total expenditures) are reinvested to expand or enhance services and resources for youth and families. There is a process to track the use of these reinvested funds that includes program description(s), budget(s), and reporting of outcomes achieved.

8.4 Availability, Access, and Approval of Flex Funds. The HFW Program has a process to ensure families have timely access to flexible funds to meet their urgent and individualized needs when these needs are not readily met by other resources. There is a defined approval process that ensures requests for flexible funds are evaluated based on approval/recommendation of the HFW team and whether the use of funds:

(1) adds value to the team mission and supports the individualized care plan,

(2) builds on family strengths,

(3) meets identified youth and family needs,

(4) are culturally relevant,

(5) builds on natural support and/or community capacity,

(6) represents a good deal for the investment and

(7) includes a plan for sustainability.

The defined approval process varies based on local county and provider policies. In the case of an Indian child, flex funds may be used to pay the Tribe for activities that address youth and family needs.

8.5 Collaborative Oversight of Flex Funds. There is collaboration and shared oversight amongst funders and providers regarding the use and availability of flexible funds. A process is in place to ensure flexible funds are pooled and held to meet the needs of all families served. Tracking and accounting for flexible funds whether approved or denied includes the amount, purpose, and HFW team recommendation of the request.

8.6 Funding Sources and Program Requirements do not Limit Flex Funds. The HFW Program ensures the requirements of any single funding source (e.g., BHSA, Title IV-E, CalWORKs, etc.) shall not limit the availability of flexible funding or the resources developed to meet the needs of the youth, families, Tribes and communities served by HFW.

9.1 Culturally Responsive Workforce. HFW Programs attempt to hire staff that can appropriately meet the cultural, racial and linguistic needs of youth and families. Staffing reflects the cultural, racial and linguistic diversity of the youth, families and communities served.

9.2 Tribally Responsive Workforce. In the cases of Indian children, the HFW Program shall prioritize respect for tribal sovereignty, traditions, and values and ensure respectful communication, collaboration, and advocacy. The team has the goal of promoting positive outcomes through culturally rooted support systems and services, and the team is responsible for building partnerships with tribal representatives, encouraging participation in tribal traditions and ceremonies and understanding the value of services and supports that the Tribe can offer.

9.3 Flexible and Creative Work Environment. There is a high degree of collective responsibility for program quality and improvement, cohesion among staff members, open communication, and a clear sense of mission and compliance with HFW. Programs and its leaders create structures that promote staff creativity and flexibility.

9.4 Hiring, Performance Evaluation, and Job Descriptions. Programs have rigorous hiring practices and use meaningful performance assessments. Job descriptions for all positions reflect best practices regarding Wraparound skills and expertise and have clear expectations for performance. The following are roles or functions on a HFW team, not necessarily individual people or positions. Forthcoming Medi-Cal guidance will provide additional requirements related to roles and staffing.

HFW Team Roles/Functions:

1. Youth Partner
2. Parent Partner
3. HFW Facilitator
4. Family Specialist
5. Fidelity Coach
6. Clinical Supervisor (licensed)
7. HFW Supervisor/Manager (license not required)

9.5 Workforce Stability. Programs implement strategies to maintain a stable workforce and reduce turnover, including matching wages according to the community the program is in, maintaining manageable workloads for staff, implementing promotion/advancement structures, and providing wage increases or leadership opportunities that do not require a position change to achieve.

9.6 High Fidelity Training Plan. Programs have a high fidelity training plan that incorporates initial, annual, booster trainings, and ongoing trainings. The training plan includes both general HFW training and role-specific training for all roles, including specific training for all Clinical Supervisors and Wraparound Supervisors/Managers. The training plan should also include ICWA and Tribal sovereignty training, as well as training that supports populations with specific and unique needs.

In the future, a Medi-Cal HFW Center of Excellence may prescribe more specific requirements for this training plan.

9.7 Community-Based Training Program. Administer the training plan in collaboration with community members and families with HFW experience as part of the training team. Ensure efforts are inclusive of and promoted to system and community partners to ensure comprehensive support within the Children’s System of Care and that team members from other systems have a context for HFW participation.

In the future, a Medi-Cal HFW Center of Excellence may prescribe more specific requirements for this training program.

9.8 Coaching and Supervision. Programs provide team members with initial apprenticeship and ongoing coaching that emphasizes Wraparound values, principles, phases and activities, as well as the effective use of flex funds to meet family needs. Leaders will ensure that staff have access to coaching and supervision 24/7, reflective of the flexible scheduling and crisis response needs of families and the community.

In the future, a Medi-Cal HFW Center of Excellence may prescribe more specific requirements for this training program.

10.1 Continuous Quality Improvement. Programs implement a local CQI evaluation plan for both the system and the program to routinely and reliably monitor the overall quality of the HFW initiative. The evaluation plan includes a systematic evaluation process that informs and improves practice locally, assures accountability for achievement of desired outcomes, and contributes to state-wide data collection efforts as they become available. Collected data is current and accurate and minimally includes the ongoing collection, analysis, and reporting of data on:

(1) Demographic information regarding the youth and family population(s) served

(2) Wraparound Fidelity as detailed in Section 1: Fidelity Indicators

(3) Outcomes as detailed in Section 2: Expected Outcomes

In the future, a Medi-Cal HFW Center of Excellence may prescribe more specific requirements for quality improvement.

10.2 Informed Program Practice. Collected data is utilized for program evaluation and improvement at all levels including improving practice with youth and families, improving overall program effectiveness, and improving system supports which impacts the HFW implementation.

In the future, a Medi-Cal Center of Excellence may prescribe more specific requirements for metrics and reporting.