California Wraparound Standards

1.1 Timely Engagement and Planning. 

Wraparound staff engages families early and often, including Tribes in the case of an Indian child. First contact with families is made within 10 calendar days of referral; teams complete a Wraparound plan of care within 30 calendar days; teams review the plan within the context of a Wraparound team meeting at least every 30 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 Wraparound team prioritizes the youth's 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's 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 (Principle 1: Family Voice and Choice). Tribes, in the case of an Indian child, must be an equal voice on the Wraparound team.

1.3 Driven by Strengths

Functional strengths of the child or youth, family, all team members, and the family’s community are collectively reviewed and utilized when developing and choosing strategies. Identified strengths are functional in nature and describe how the individual successfully copes with challenging situations. Team members remain focused on solutions, rather than dwelling on negative events. The Child and Adolescents Needs and Strengths (CANS) is the building block for strengths identification (Principle 2: Strength-Based).

1.4 Needs Driven. 

Wraparound 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 Wraparound process continues until needs are sufficiently met. The CANS is the building block for needs identification.

1.5 Individualized. 

The Wraparound team is committed to finding creative, highly individualized strategies that are customized to match each youth and family’s needs, strengths, values, culture, and preferences. The Wraparound plan is uniquely tailored to fit the family and capitalize on the assets of their community and informal networks. (Principle 3: Individualized)

1.6 Use of Natural and Community Supports. 

Natural supports are integral team members. Wraparound teams strengthen the support provided by natural and informal supports. Wraparound teams prioritize strategies in the Wraparound plan of care that utilize informal and natural supports, and that take place in the family’s community, to reduce reliance on formal supports while fostering sustainability within the youth and family’s community. (Principles 4, 5: Natural Support, Community Based)

1.7 Culturally Respectful and Relevant. 

Wraparound teams recognize that a family’s traditions, values, and heritage are sources of great strength. Wraparound 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. Wraparound teams work to connect families with individuals and organizations that share their cultural identity and can be essential sources of culturally relevant support after the family transitions from formal Wraparound services. (Principle 6: Culturally Respectful and Relevant)

1.8 High-quality Team Planning and Problem Solving.

Wraparound teams are comprised of formal, informal, and natural supports across all Children’s System of Care partners who work together to develop, implement, and monitor individualized service plans 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's and family’s needs. Teams experience optimism, commitment, and energization. (Principles 7, 8: Team Based, Collaboration)

1.9 Outcomes-Based Process.

The Wraparound team monitors the success of the Wraparound plan—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 CANS and are integrated into the planning process. (Principle 9: Outcomes-Based)

1.10 Persistence.

The Wraparound 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 Wraparound team is committed to implementing a plan that reflects the Wraparound Principles, even in the face of limited system capacity. (Principle 10: Persistence)

1.11 Intentional Transitions.

Transitions are planned for in advance and celebrated with full youth, and family participation. Transitions only happen when the youth and family has sufficiently met their needs, not due to an adverse event or an administrative requirement.

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

2.1 Youth and Family Satisfaction

Youth and families are satisfied with their Wraparound experience and their progress.

2.2 Improved School Functioning.

Youth experience improved educational and vocational functioning as a result of their involvement in Wraparound. They have more consistent attendance and 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 Wraparound. The youth has experienced less frequent contacts with emergency service providers, including medical and law enforcement providers, and they are participating in community activities.

2.4 Improved Interpersonal Functioning.

Youth and their families experience improved interpersonal functioning as a result of their involvement in Wraparound. 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. Children and youth do not experience a new placement in an institution (such as detention, psychiatric hospital, treatment center, or Short Term Residential Treatment Program (STRTP) and/or have not moved between residential settings.

2.7 Positive Exit from Wraparound.

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

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 and family, other team members, and the community, and
3. creating a team mission statement that defines the overall purpose of the Wraparound team in alignment with the family vision.

4.2 Describe and Prioritize Needs, Develop Goals and Assign Atrategies.

The facilitator guides the team in reviewing needs identified during engagement, adding any additional needs, and prioritizing them. The Wraparound 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 Child or Youth and Family Plan. 

The Wraparound team develops a comprehensive initial plan of care that is based on the prioritized needs, goals, and strategies of the youth and family. 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 Wraparound principles. The facilitator leads the team to ensure:

1. The plan is in alignment with the family vision and team mission and is based on the strengths, needs, and culture of the youth and family.
2. The plan addresses needs across multiple life domains and Children’s System of Care partners as identified and prioritized by the Wraparound team.
3. Strategies and action items are clearly documented and include who is responsible for each strategy and action item, due dates are established, and each team member understands their role. Strategies are culturally relevant and include a balance of formal services and informal community and family resources, with greater reliance on informal supports over time.
4. The plan includes an array of services and supports that are well- coordinated across Children’s System of Care partners, tailored to meet the child or youth and family’s individual needs, and delivered in the community in which the child or youth and family live.
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 child or youth and family transition out of the Wraparound Program.
6. Transition from formal services is graduated; plans set benchmarks for transitioning to less restrictive, less intrusive, and less formal services throughout the Wraparound Process, taking into consideration the ability of families to move through the process at their own pace.

4.4 Develop a Safety Plan. 

The facilitator leads the team in developing a written safety plan that identifies and prioritizes safety needs, potential risk and crisis situations, as well as highly individualized proactive and reactive strategies for the child or 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 Wraparound team carries out the 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 Wraparound 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; update the plan as needed to reflect successes; meets new needs; or adjusts strategies and assigns new action items. 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 informal supports, use of flex funds, and updates to the plan. The plan of care is updated in the context of a Wraparound 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 informal and natural supports, adding 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, the youth, family, and team agree the family is ready for transition, the Wraparound team will begin developing a formal individualized transition plan. Led by the facilitator, the Wraparound team will outline a purposeful transition process which identifies needs, services, and supports that will persist past formal Wraparound and includes strategies to transition any remaining support being provided by Wraparound staff to those ongoing supports. For adoptive families utilizing Adoption Assistance Program (AAP) funding, families are educated on post adoption services that can assist with transition.

6.2 Develop a Post-Transition Safety Plan.

The facilitator leads the team in developing a written safety plan (or adjusting the current safety plan) that identifies potential crisis situations that may occur after transitioning from formal Wraparound. The plan includes individualized, proactive, and reactive strategies for the youth and family, and other supports who will remain after Wraparound 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 Wraparound 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 Wraparound Program, including service planning and implementation, policy and procedure development, workforce development, and quality improvement of the Wraparound model.

7.2 Community Leadership Team.

The county establishes a Community Leadership Team, which may include all or part of the Interagency Leadership Team (ILT), with the addition of other team members as needed) who works collaboratively and engages in shared decision-making to ensure the Wraparound Standards are met at the organizational and systems level. In addition, the Community Leadership Team works to:

1. Ensure relevant child serving agencies (e.g., mental health, child welfare, juvenile justice, schools, Tribes, tribal organizations and consortia, and courts) participate actively and “buy in” to the Wraparound initiative.
2. Actively identify and remove interagency and system barriers that interfere with interagency collaboration and effective service delivery to families that is characterized by creativity and individualization, the use of family- driven strategies, and the engagement of natural supports.
3. Identify and support cross-agency training and community collaboration to promote family-centered and culturally relevant practices and support alignment to the Wraparound 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 Wraparound 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 Wraparound data at the organizational, community, and systems levels, and to use data to inform Continuous Quality Improvement (CQI) efforts that reflect Wraparound values, Wraparound Standards, and a commitment to diversity, equity, and inclusion.

7.3 Eligibility and Equal Access.

Wraparound eligibility and referral criteria and processes ensure adequate, appropriate, and equitable access to Wraparound services and do not exclude families because of the severity or nature of their needs. Wraparound 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 High-Fidelity Wraparound.

Wraparound has fiscal practices that are aligned with the values and principles of Wraparound and ensures the Wraparound Standards are met. Budgets and contracts at all levels regardless of county or provider-based service provision are created with funding for Wraparound operations which include required staffing, workforce development processes, and effective data collection and data management systems and the costs of services which include accessing needed supports and services to meet the immediate individualized needs of youth and families.

8.2 Equitable Funding Across System Partners.

Wraparound has a process in place for identifying federal, state, local, or private resources available across Children’s System of Care partners that ensures funding and resources are leveraged to the maximum extent to meet the needs of children and families served by Wraparound. This process includes a mechanism to ensure collaboration and equitable contribution across systems partners, including Tribes, in funding Wraparound services.

8.3 Cost Savings are Reinvested.

Savings achieved by Wraparound (i.e., total annual revenues in excess of total expenditures) are reinvested to expand or enhance services and resources for children or 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 Wraparound 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 Wraparound 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 child, youth, and family needs,
4. is culturally relevant and realistic for the family,
5. builds on natural support and/or community capacity, and
6. represents a good deal for the investment, and
7. includes a plan for sustainability.

There is an appeals process for denied requests which incorporates communication with teams, youths, and families regarding why the funds were denied. The defined approval process varies based on local county and provider policies, including AAP funded Wraparound.

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 Wraparound team recommendation of the request.

8.6 Funding Sources and Program Requirements do not Limit Flex Funds.

The Wraparound Program ensures the requirements of any single funding source (e.g., Medi-Cal, 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 Wraparound.

9.1 Culturally Responsive Workforce.

Wraparound Programs attempt to staff accordingly to meet the racial, diversity, and equity needs of youth and families. Staffing reflects the cultural diversity and language needs of the youth and families, and communities served.

9.2 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 alignment with Wraparound. Programs and its leaders create structures that promote staff creativity and flexibility, such as creative arrangements with other organizations, flexible contracting, or the capacity to reassign staff roles to meet the needs of families.

9.3 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. Counties and Wraparound providers are required to have the following roles or functions (but not necessarily separate positions) available to support youth and their families.

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

9.4 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.

9.5 High-Fidelity Training Plan.

Programs have a written high-fidelity training plan that incorporates initial, annual booster trainings, and ongoing trainings The training plan include both general Wraparound training and role-specific training for all roles, including but not limited to, specific training for all Clinical Supervisors and Wraparound Supervisors/Managers. The training plan should also include ICWA and Tribal sovereignty training.

9.6 Community-based Training Program.

Administer the training plan in collaboration with community members and families, including children, youth, and families with Wraparound 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 system of care and that team members from other systems have a context for Wraparound participation.

9.7 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.

10.1 Systematic Evaluation Process.

There is an evaluation process for the system, for the program, and for the individual child or youth and family, to monitor the overall quality of Wraparound routinely and reliably. Youth, parents, stakeholders, and staff are involved in systematic evaluation processes that inform and improve practice locally, assure accountability for achievement of desired outcomes, and contribute to state-wide data collection and information.

10.2 Evaluation Metrics & Outcomes.

• Programs implement a local CQI evaluation plan that minimally includes the ongoing collection, analysis, and reporting of current and accurate data on:
• Demographic information regarding the youth and family population(s) served
• Wraparound Fidelity (as detailed in section 1 Fidelity Indicators) to minimally include: Adherence to the 10 Principles and 4 Phases of Wraparound; Timely Engagement and Planning; Team Composition, Including Ratio of Formal, Informal, and Natural Supports participating in the Wraparound team
• Outcomes (as detailed in Section 2: Expected Outcomes) to minimally include: Youth and Family Satisfaction; Improved School Functioning; Improved Functioning in the Community; Improved Tribal Engagement and Collaboration; Improved Interpersonal Functioning; Increased Caregiver Confidence; Stable and Least Restrictive Living Environment; Positive Exit from Wraparound
• Positive System of Care Outcomes: Improved system collaboration and integration; Improved maximization of resources and cost effectiveness; Improved program-specific outcomes; Decrease in racial disparity or improved social equity.

10.3 Informed Program Practice.

Program evaluation results are routinely communicated to stakeholders (including staff, administrators, families, Tribes, community partners, etc.). Data is integrated into coaching, supervision, training delivery, and program management and is used to improve performance over time.