Using a family-centered approach to provide supports, the Pilot is expected to provide the following: Conduct a comprehensive assessment of the individual and family. This will identify the primary needs, which will inform the development of agreed upon areas to address through the program. This plan will be a “living document” that will be reviewed and amended over time. Develop a plan which specifically identifies mutually agreed upon needs, goals, and objectives to be addressed by staff. Progress should be reviewed regularly by the multidisciplinary team and Director managing the case and the plan updated accordingly. The plan will be incorporated into the ISP process. Actively engage families in services, meeting families where they are, including at least monthly check in with the director, and provide intensive staff assistance and support to address identified need areas, and work on established goals and objectives to help the family situation. This includes discussion and exploration with families regarding potential services that will support the home, and assistance navigating the service system. This can include behavioral health, counseling, medical, clinical, and other generic resources. Identify and facilitate referrals and access to other services and resources that may be of benefit to the family unit such as housing, transportation, public benefits and entitlement programs, and other community resources. Actively assist the families in the coordination and integration of services that are available, that may include medical services, therapies, behavioral support, and educational services, to have a comprehensive team approach...
