Facilitating a Single Plan of Coordinated Care The CTN Experience

1. Facilitating a Single Plan of Coordinated CareThe CTN Experience Michelle BiehlerAlan Hamilton

2. Agenda • Introductions • Children’s Treatment Network of Simcoe York • The singleplanofcare.com Solution • Benefits for Families and Service Providers • Current Status • Future Direction • Questions

3. Children’s Treatment Network of Simcoe York A network of agencies and organizations providing services to children with multiple needs and their families living in Simcoe County and York Region.Using a unique collaborative approach, CTN builds on the strengths of its partners to provide timely and effective services.

4. Children’s Treatment Network of Simcoe York Vision for the Network • Support a continuum of care for children from birth to 19 years of age to address and anticipate their needs and the needs of the family • Develop a comprehensive system which integrates new and existing services to provide timely, effective service to children with multiple special needs • Increase the capacity of the service providers across the network • Minimize the need for children and their families to access services outside their region

5. Service Navigator takes Call Intake Delivery of Services by Providers Ongoing Service Coordination Service Providers complete Clinical Assessments Service Coordinator Builds on Child & Family Interview determines Visions All meet to plan and develop a Single Plan of Care Demographic Clinical Progress Notes Team Assessment Summary Child & Family Interview Initial Plan of Assessments Services Messages Single Plan Of Care Consent Referral Note Referral Note Document Manager Document Manager Service Delivery` Service Navigation ServiceCoordination

6. The singleplanofcare.com solution How the clinical application moves us forward • Supports collaboration, development and documentation of a single plan of care for the child and family • Shared electronic client record drives consistent practice across different sectors, agencies and geographies • Eliminates duplication of information and services thereby increasing efficiency • Provides a secure method for team members to communicate • Enables system wide reporting and centralized wait list management

7. The singleplanofcare.com solution Key elements of singleplanofcare.com • Role Based Workspaces • Child and Family Interview • Single Plan of Care • Stages of Care • Clinical Notes • Document Manager

8. The singleplanofcare.com solution Navigation Workspace Manage new clients, record interview and referrals to Network partners Coordination Workspace Provides view of all clients, their assessment and service status

9. The singleplanofcare.com solution Service Provider Workspace Organizes clients by status and provides easy access to view and/or update information Client Workspace Access to all elements of the client’s record

10. The singleplanofcare.com solution Child & Family Interview • Comprehensive interview information captured in child’s record • Interview details are used for priority setting and service planning

11. Team Assessment • All members of the child & family team enter assessment summaries in a common document Single Plan of Care • A single coordinated plan of care with transdisciplinary goals and activities is created

12. The singleplanofcare.com solution Clinical Notes • Child and family team members document activities in clinical notes • Viewable by all team members • Classified byrole

13. The singleplanofcare.com solution Document Manager • A repository for storing additional client documentation • Specific documents can be secured to restrict access to sensitive information

14. The singleplanofcare.com solution Management Workspace • Provides overall network statistical information • Provides network partner agency manager with statistics relevant to their agency

15. Benefits for Families • Only need to tell their story once • Holistic focus on the child and family • Development of a single plan of care in accordance with the family’s visions • One record across developmental stages from birth to adulthood • Establishment of transdisciplinary goals and activities from multiple service sectors

16. Benefits for Service Providers • A shared web based record to document assessment findings, contacts, events and interventions with the child and family • Communicate with team members in a secure way through the use of clinical notes, messages and referral notes • Ability to view information obtained by all team members and integrate this information into their own assessments and treatment interventions • Use information from multiple providers to plan together • Access to comprehensive information reduces the need for duplication • Ability to view client progress by viewing activities of all team members

17. Benefits for the Children’s Service System • Ability to define the population, needs and identify service gaps • Improved efficiency through development of consistent clinical practices and better use of all resources • More timely intervention as system moves toward transdisciplinary practice • Capacity to develop system wide waitlist management

18. singleplanofcare.com – A Vehicle for Change Management • Guides the implementation of the CTN Model • A family centered integrated approach to planning and service provision for the child and family • Ensures privacy is protected as client information is shared across agencies and sectors • Provides a multi domain common Intake Interview tool to be used across the system • Supports coordinated system wide access • Provides a mechanism for the development of a system wide waitlist management strategy • Provides an electronic documentation system to agencies using a manual system

19. Contacts Children’s Treatment Network of Simcoe YorkMichelle Biehler, Director of Accessmichelle.biehler@ctn-simcoeyork.caGoldCare – Campana Systems Inc.Alan Hamilton, Care Team Leader - Community and Project Servicesarh@campana.com