This procedure relates to establishing a care team for young people with complex needs.

 

When to use this procedure

When providing case management to young people with complex needs and/or young people exhibiting risk behaviours.

 

What else you need to know

 

Practice context and legislation

  • Young people with complex needs or high-risk behaviours need intensive support and frequent interaction with a range of departmental programs, professionals and service providers.
  • A care team is often established in these cases to address the practical need for regular communication between workers, monitor the young person's safety and to quickly make and activate service delivery decisions.
  • When a group of programs, professionals and/or service providers meet regularly to improve care, this is sometimes referred to as a care-team approach.
  • Client service planning for young people with complex needs often involves several case managers who independently deliver support and services to one young person. Each program, professional or service provider may have a different focus on interventions and outcomes.
  • Forming a care team helps with planning coordinated interventions, and promotes change and an effective and prompt response to concerns.
  • Care teams help cut across service barriers, clarify roles, make immediate decisions, allocate tasks and share responsibility for complex young people or young people exhibiting risk behaviours.
  • Planning for how workers will manage crisis situations is also best undertaken when events are calm and thinking is clear and logical. Crisis plans developed by a care team should be incorporated into the client service plan.
  • The objective for establishing a care team is to develop shared vision for the young person and define shared and specific responsibilities.
  • This approach also provides support to case managers through shared responsibility for outcomes for young people.
  • A care team approach between youth justice, community agencies, other relevant supports and professionals is a key feature of the support and case management of all young people referred to the Youth Justice Community Support Service.
 

Roles and key tasks

Case manager

  • Assess young person's needs and identify programs that are, or should be, involved.
  • Refer to YJCSS where appropriate.
  • Identify appropriate person to coordinate care team.
  • If youth justice worker is primary case manager, plan, coordinate and prepare documentation for care team meetings.

Team leader / team manager

  • Provide consultation and supervision to case manager.
  • Attend care team meetings when required.
  • Consult with other services on disputes that can't be resolved within care teams.

Individual and Family Support Manager/Assistant Director

  • Provide oversight, direction and monitoring of the area youth justice program.

Youth Justice Senior Practice Advisor

  • Provide case consultation and dispute resolution in cases of disagreement within care teams. This should occur subject to local area agreements between Assistant Director / Manager Individual Family Support and the Senior Practice Advisor.
 

The procedure in detail

What are the young person's complex needs?

Determine the young person's needs and evident risk factors.

High and complex needs may be indicated where young people display two or more of the following:

  • multiple and complex behavioural and emotional difficulties
  • emerging or diagnosed psychiatric or psychological disorders
  • depression or anxiety
  • suicidal ideation or self-harming behaviour
  • use of drugs/alcohol to the extent that safety, stability and development is at risk
  • transience, homelessness or risk of homelessness
  • a history of abuse, violence or sexual offending
  • arson
  • escalating offending
  • sex working or association with exploitative adults
  • persistent or continual extreme risk-taking behaviour
  • experience as a refugee or asylum seeker
  • being a young parent
  • being a sole parent
  • severe conflict with parents or family
  • isolated from family and peers
  • a history or present involvement with child protection
  • involvement with the adult criminal justice system
  • cognitive disability such as acquired brain injury (ABI)
  • intellectual disability
  • learning impairment
  • obsessive, ritualistic, stereotyped and rigid behaviours as observed in conditions such as autism or Asperger's
  • neurological disorders such as epilepsy or multiple sclerosis physical or sensory disability
  • other diagnosed medical or health conditions.

List the programs, professionals or service providers currently working with the young person.

Identify the programs, professionals or service providers not involved with the young person, but which should be consulted for an expert opinion or secondary consultation.

Why have a care team?

The purpose for establishing a care team will vary between cases but generally relates to:

  • clarifying roles and responsibilities
  • advocacy for the young person
  • joint planning for risk management
  • regular communication and feedback
  • monitoring and reviewing goals
  • decision making
  • resolving differences
  • coordinating services.

Has the young person been referred to the YJCSS?

With a care-team approach between youth justice, YJCSS consortiums and other relevant supports and professionals, it is critical to maintain regular discussions between all services to monitor progress and review case planning.

Care-team meetings will be scheduled to review all young people involved with youth justice who are referred to the YJCSS.

As part of case-management responsibilities, these meetings should be chaired by youth justice and involve support workers from the YJCSS and other relevant professionals and service providers.

The initial meeting should be scheduled to occur within 14 days of the referral from Youth Justice being accepted by the YJCSS consortium.

The frequency and structure of ongoing meetings will vary according to need.

The YJCSS consortium may assume case management of young people after the expiry of youth justice orders, as negotiated with the regional youth justice unit during the exit planning process.

On acceptance of full case management, YJCSS support workers also assume responsibility for the scheduling and maintenance of care team meetings.

Who is likely to be a member?

The team could include one or more representatives from the following sectors:

  • youth justice
  • child protection
  • placement and support
  • mental health services
  • alcohol and drug services
  • disability services
  • YJCSS support providers
  • police
  • Department of Education and Early Childhood Development (DEECD)
  • intensive case management services
  • culturally and linguistically diverse (CALD) or Aboriginal services.

In some cases the young person, young person's family or other significant people will participate in the care team, or attend meetings to discuss specific issues.

Involvement of the young person, family or significant others

Participation of the young person can be critical to the success of a care team.

In some cases the young person, young person's family, friends or significant people may be invited to participate in the care team, or attend meetings to discuss specific issues.

Links with family, friends, and significant people need to be supported and strengthened for all young people with youth justice involvement.

Young people with multiple or complex needs have often lost connections with the significant people in their life.

Where possible, support the young person to re-establish and retain some level of connection with family, friends and significant people.

If appropriate, involve the young person's family, friends or significant people in client service planning, decision-making and support processes. This can strengthen links and connectedness and result in better outcomes for the young person.

In some instances, young people may find attending a care-team meeting overwhelming, particularly large meetings where multiple service providers are involved.

In these circumstances, use alternative ways to seek or provide feedback to the young person about decisions made within the care-team meetings.

For example, follow up individually with the young person before or after the meeting, or provide a simple written version of the meeting minutes or key decisions made.

What is the role of a care team?

It is important to clarify the purpose of the care team from the outset.

Some of the following roles give purpose to the team:

  • clearly identify who will take the lead role in the team
  • identify tasks and allocating responsibilities
  • provide access to secondary consultation
  • build confidence in casework decisions
  • joint planning
  • monitor and review of client service planning goals
  • respond to crises and changing circumstances
  • crisis management planning.

Role of care-team coordinator

Young people on dual statutory orders with youth justice and child protection may also be involved with disability services, housing and placement and support, who also have case management responsibilities for the young person.

Young people with multiple workers frequently require a collaborative response and coordinated team approach.

For the care team to work effectively, establish and agree which program will have lead case management responsibility.

Primary case management responsibility will usually be held by the program with the most involvement with the young person. This is negotiated on a case-by-case basis.

In determining this, the nominated lead worker will establish information sharing and communication arrangements for the care team and that facilitate purposeful planned outcomes.

Elements of a good care team

The elements of a good care team include:

  • participation of the young person
  • identification of a care-team coordinator
  • respectful interaction among all participants
  • time spent understanding each participant's role and perspective
  • each worker's professional expertise and opinion is valued
  • input and commitment of all participants
  • dispute resolution processes
  • staying positive and focused on solutions, especially during challenging times
  • documentation and recording of all decisions and actions
  • dissemination of information to all members and following up actions and subsequent meetings.

Administration of the team

Participants in the care team should:

  • decide on roles and responsibilities – who will chair the meeting, call for agenda items, who will take minutes, and what are the expectations of those roles
  • decide frequency of meetings and the minimum attendance needed for meetings to proceed
  • set meeting dates, times and the meeting venue
  • have a set agenda for each meeting
  • decide which program has overall case-coordination responsibility
  • discuss how disagreements will be resolved.

Planning for the first meeting

When planning for the first care team meeting, ensure all invited services and participants are authorised to share information.

At the first meeting, clarify the team's purpose, role, any terms of reference and privacy expectations.

Participants should identify if meetings at different levels are required to manage different issues, for example, managing the media or making funding decisions.

Each program or professional area should describe their involvement with the case, key issues and priorities.

There should be discussion of differences and agreement reached on overall priorities and how each service will contribute.

Crises management planning

As part of crisis management planning determine:

  • other professionals who may need to be invited to the team
  • the need for any secondary or expert consultation
  • that the strengths of the young person and his or her family are also a focus of planning
  • update the possibility of Central After Hours Assessment and Bail Placement Service (CAHABPS)contact on the Client Relationship Information System (CRIS).
  • how the crisis management plan is to be discussed with the young person and their family
  • roles and timelines associated with the plan.

Minutes

Document and record all decisions and actions.

Ensure actions are allocated to specific people.

Disseminate information to all members and follow up actions at subsequent meeting.

Process of review

Review the client service plan every three months as part of the client assessment and planning process.

The youth justice worker is responsible for review of the client service plan review.

Case coordination, team planning and decisions can be drawn from the care team.

Relevant programs and professionals from the care team may be invited to the review meeting.

Link with high risk adolescent register or MACNI

Dual order young people who are particularly vulnerable to risk of harm and require specific, intensive and strategic case management and planning may be included on the divisional high-risk adolescent register.

Planning for how programs, professional and service providers will manage crisis situations and the ongoing wellbeing of the young person will in some instances be undertaken by the allocated case manager, the high-risk adolescent team and the care team.

Young people over the age of 16 years of age with complex needs may also be eligible to be referred to the Multiple and Complex Need Initiative (MACNI).

Divisional MACNI coordinators can help with determining eligibility for referrals to this initiative.