Rosie D.
Reforming the Mental Health System in Massachusetts

Step 5:  The Care Planning Team 


Convening the care planning team is another responsibility of the intensive care coordinator.  A single team that includes all relevant persons, agencies, and community members involved with the child enhances coordination among agencies and providers, allowing for a more coherent delivery of services and supports.


Care Planning Teams:  A hallmark of home-based services is a single care planning team.  Every child has one care planning team that plans all home-based services as well as all other supports and services. 


Selection of Care Planning Team members:  The intensive care coordinator convenes and oversees the child’s treatment team.  The family decides who will be on the team.  In addition to the child and his or her family, members of the team may include state and educational agencies and all other persons involved in the child’s life.  For example, with the family's consent, members may include existing or prospective mental health professionals and home-based services providers, representatives of involved state or local agencies, school representatives, and other natural supports, such as neighbors, friends or extended family members. 


Responsibilities of the Care Planning Team:  Based on the comprehensive home-based assessment and other reports and information, the team determines the both the type of home-based services that will best benefit the child, as well as the amount, intensity and duration of the home-based services.  The team will develop an individual care plan that most effectively meets the child’s needs.  Responsibilities of the team include:


·         using the comprehensive assessment to elicit strengths, needs and goals of the child and his/her family, and identifying the need for further evaluations that support development of a care plan which effectively meets the child’s needs and results in improved health outcomes;

·         identifying and arranging for the provision of all Medicaid-covered services identified in the child’s care plan; and

·         collaborating with all individuals and entities to ensure coordination and delivery of necessary services to enable the child to achieve positive outcomes.


The care planning team will convene periodically to assess the effectiveness of the plan and the services, and make changes and update the plan as needed to reflect the child’s changing needs.  


For a detaield description of the responsibilities of the care planning team, read the Feature on the Roles, Responsibilities and Membership of the Care Planning Team.


Click here for Step 6, The wraparound planning process


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