1. Developing a Single Plan of Care That Supports Student Success in School and Home Therapy/Supports at Home and School Working Together Presented by: Judy Andersen Childrens’ Treatment Network Single Plan of Care Coordinator

2. Getting Started Introductions Who Am I? What do I do? Who Are My Clients? Who Are You?

3. Initiating the Single Plan of Care Process: Getting Started Referral Process Child and Family Interview and Consent SPOC Assignment Reviewing the Record

4. Child and Family Child and Family Interview Core Strengths able to communicate using gestures, sounds responds to music loving extended family – Core Needs physical ADLs communication – Family Considerations who does what?

5. Identifying the Visions Suppose when you go to sleep a miracle happens and this issue is solved. What will be different when you wake up?? What would it look like? Visions are captured in the family’s words, documented in the electronic record and identified as the family’s priorities for their child. What do you envision for your child and family in the next 12 months?

6. Visions S. aggressive behaviour will be understood and diminish at home and school S. will be able to feed herself at school and home S. will be toilet trained

7. Initial Plan of Assessment and Service Assists the family to determine the focus of their child’s Single Plan of Care for the next 12 months Based on the identified strengths and needs of the child and family SPOC Coordinator: – records in electronic record AND – gathers reports, contact information for any other professional working with the family and child, AND – establishes times when parent is available for meeting with team

8. Who Is Your Team? Home School Medical Community

9. Working with the Team At the beginning of the Single Plan of Care Process, team members/providers: Meet Discuss their roles and reflect on the process of teaming for an integrated team approach Briefly discuss child/family strengths, needs and visions Establish a Single Plan of Care meeting date

10. Roles and Responsibilities Team MemberResponsibilityCommunicationEnvironment ParentParentingEveryoneHome TeacherEducationParents/school providersSchool PrincipalMinistry and BoardTeacher/parentsSchool EA/HA/CYWSupport teacherTeacherSchool CTN/EIS SLPAugmented communication Parents/school teamSchool and Home CTN OTRehabParents/school teamSchool and home CTN PTRehabParents/school teamSchool and home Shift NurseNursingParentsAs assigned DieticianParents/school team as requestedAs assigned Behaviour ConsultantBehaviourParentsHome School Board OT, PT, SLPTeacher consultation/IEP School team with permissionSchool CCAC Case ManagerManaging servicesParentsSchool and home Private therapistsAs directed by parentsParentsHome

11. Setting the Meeting Set the date Set the location Send out the invitation to all Prepare for the meeting – Set the Agenda – Include Attendees – Include Visions

12. At the Meeting

13. Meeting Agenda Introductions Share the agenda and timeframe of meeting-stay on task and on time-respect the participants Establish norms Share the Visions – Set a Baseline – Set New Goals – Identify Activities and Leads Check in with family and team Set a Follow-up date for meeting-frequency of SPOC meetings determined by timelines

14. S.M.A.R.T. Goals Specific What exactly do we want to achieve? Where? How? When? With whom? What are the conditions and limitations?

15. S.M.A.R.T. Goals Measurable Identify exactly what it is you will see, hear and feel when you reach your goal. e.g. Sam will make a choice between 2 pictures to request an activity independently at home and school by June 2016.

16. S.M.A.R.T. Goals Attainable Be realistic with your goals-losing 10 lbs. a week is not realistic, losing 2 lbs is Weigh the effort, time and other costs your goal will take against the other obligations and priorities you have in life.

17. S.M.A.R.T. Goals Really Relevant Is reaching this goal relevant to you/your child/your family/the team? Ask yourself: – why do we want to reach this goal? – What is the objective behind the goal? – Will this goal really achieve that?

18. S.M.A.R.T. Goals Timeline Agree upon deadlines and go after them Keep the timeline realistic and flexible

19. Set Activities How will we achieve the goals? What needs to happen? Who will take the lead? GoalGoal LeadActivity H. will use a stander at school and home for at least 20 minutes daily in each environment y by the fall of 2016. CTN PTSchool team and family will provide preferred books to keep H. busy while he is in the stander. H. will wear his AFOs while in the stander. CTN PT will observe H. in his stander at home and school and make adjustments as needed.

20. After the Single Plan of Care Meeting SPOC Coordinator: – Records collaborative goals with supporting activities in the shared electronic record after the meeting – Shares completed Single Plan of Care with family and any team members who do not have access to electronic record – Reviews notes in record and visits with family re. progress/ satisfaction/new concerns Team members document progress towards goals in record

21. Developing a Single Plan of Care 1.Gather Information 2.Set the Direction 3.Develop the Plan 4.Carry out the Planned Activities 5.Review Progress

22. Questions/Thoughts?