Community-Based Positive Supports

Improving Service Coordination and Communication

Wraparound and person-centered teams play an important role in making sure a person and their family or caregivers have a clear plan for coordinating supports in a manner that ensures positive outcomes. Teams that are meeting to support transitions often have additional challenges because new team members may be joining and new services are often being integrated into a person’s life.

A common challenge in many states is that team members are not always sure how to help improve the communication across services. As a result, information is not shared. For example, in the quote below, children who engage in challenging behaviors are suddenly transferred home but the mental health provider isn’t notified:

"...if they were placed, say, in [town name] and they were coming back to [town name], and they were being reunified, we might not always know that until the parent called in to make an appointment. We’ve had that happen many times, and sometimes then it can be a month or two or three in between them coming home and us finding out they’re even there. ‘Cause maybe we knew them before; maybe we didn’t..." -[focus group participant]

-Matthews et al., 2018

In another story, during a focus group session, the person sharing their story described how they attended a meeting with multiple professionals to support a transition plan back into the community. The meeting included a number of people from different state and local services. It was not clear in the meeting what the roles each person served were or who was responsible for leading key transition steps. The person stated that in this situation: “It can be difficult to know what questions to even ask.”

  • Document the roles and responsibilities of each person in the meeting
  • Spend time as a team understanding each service involved
  • Work on establishing a common language including terms related to different supports
  • Consider a glossary or simple list of acronyms and terms that team members can refer to in meetings
  • Make a list of the key steps needed for the transition and who is involved in communicating at each step
  • Create an agreement that notification of submission to or from the hospital is immediately communicated with all key partners
  • Write memorandums of agreement when communication barriers are encountered
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