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Clinical-Community Relationships Measures (CCRM) Atlas

Wrap-Around Observation Manual—Second Version

Wrap-Around Observation Manual—Second Version

CCRM Atlas Measure(s): 7, 8
Contact Information: Contact information unavailable.
Copyright Details: The copy of the measure instrument that follows is reprinted with permission from Michael Epstein, EdD.

Wraparound Observation Manual—Second Version

Michael H. Epstein
Philip D. Nordness
Melody Hertzog

January 2002
(Draft 7)

Observation Manual

1. Information about resources/interventions in the area is offered to the team.

The team mentions at least one specific resource/intervention (e.g., A.A, vocational rehab, Teammates) to the parent or asks if the parent is involved or needs community resources/intervention. The team provides specific information about accessing these resources/interventions if the parent expresses a wish to utilize the resource/intervention. *Parent need not be present for a Yes response to occur.

Scoring

  1. Yes if the team mentions or asks if the parent is involved in resources/interventions. Score Yes if the team asks about or mentions resources/interventions and the parent is already involved or does not show an interest in such services, and thus the team does not provide contact information.
  2. No if the team mentions support resources/interventions but does not provide a contact person/number or the parent expresses an interest in accessing the resource/intervention, but it is not followed up by the team.

2. Plan of care includes at least one public and/or private community service/resource.

The team specifically identifies at least one public (e.g., HHS, Lincoln Public Schools, SSI) and/or private (e.g., private therapists/counselors, drug rehab centers) community service/resource in the plan of care. It is clear that these services are easily accessible from the family's home community (i.e., no services are far from home community).

Scoring

  1. Yes only if one public and/or private service is included in the plan. These agencies must be accessible from the client's community.
  2. No if at least one public and/or private services in the client's community are not included in the plan.

3. Plan of care includes at least one informal resource.

The team specifically identifies at least one informal resource (e.g., YMCA, Big Brother/Big Sister, recreation program, family member providing respite). It is clear that the resource is not provided by a public agency. If service is purchased by flexible funds it is a formal resource.

Scoring

  1. Yes only if one informal resource is included in the plan.
  2. No if at least one informal resource in the child/family community is not included in the plan.

4. When residential placement is discussed, team chooses community placements for child (children) rather than out-of-community placements, whenever possible.

The team discusses, recommends, and plans for community placement. Out-of-community placements are not recommended or planned for unless no home community alternative exists.

Scoring

  1. Yes if the placement the team recommends and plans for the child/family is in the community.
  2. No if the team plans for a placement that is out of the community.
  3. NA if residential placement is not discussed.

5. Individuals (non-professionals) important to the family are present at the meeting.

Individuals important to the family and who are from the family's community or natural support system are present at the meeting. This may include extended family members, community leaders, ministers, and friends. However, professional service providers (e.g., therapists, homemakers) are not considered here.

Scoring

  1. Yes if at least one individual like those described above attends the meeting.
  2. No if no individual like those described above attends the meeting.

6. If an initial plan of care meeting, the parent is asked what treatments or interventions he/she felt worked/didn't work prior to F3.

The team explicitly asks the parent what services, treatments or interventions (e.g., drug treatment, psychotherapy, medication, vocational training, token economy) that have been attempted in the past worked or did not work. Treatments or interventions include only formal services received by the family.

Scoring

  1. Yes if the team asks the parent about previous services, intervention(s) or treatments.
  2. No if question is not asked.
  3. NA if family has never received services, or, if this is not an initial plan of care meeting, past events may not be discussed.

7. Care Coordinator advocates for services and resources for the family (e.g., identifies and argues for necessary services).

At least one Care Coordinator assertively identifies (i.e., continues to state the importance of) a necessary service for the family and is persistent in securing (or persists in attempting to secure) that service. If other professionals disagree, at least one Care Coordinator continues to convey the importance of that service or resource to the team.

Scoring

  1. Yes if at least one Care Coordinator worker assertively identifies (to the team) a needed service or intervention for the family member and continues to pursue the importance of that service (when necessary) even if others (e.g., team members) disagree.
  2. No if needed services or interventions are not identified by a Care Coordinator worker OR services or interventions are identified but their importance is not pointed out when necessary.

8. All services needed by family are included in plan (i.e., no needed services were not offered).

All services the family and team identifies as necessary for the family are written into the plan of care. The team does not exclude a needed service from the plan.

Scoring

  1. Yes if all identified needed services are included in the plan of care.
  2. No if the team excludes from the plan of care any service needed by the family.

9. Barriers to services or resources/interventions are identified and solutions discussed.

If barriers were identified team members discuss possible solutions. Examples of barriers include transportation, funding, location, eligibility, etc. Solutions may not be possible but at least one solution must be discussed.

Scoring

  1. Yes if at least one barrier identified and solution discussed.
  2. No if at least one barrier identified and no solution discussed.
  3. NA does not apply if no barriers were identified.

10. The steps needed to implement the plan of care are clearly specified by the team.

The team clearly specifies the steps needed to implement the plan. Specific services, resources, interventions, or other actions are discussed in specific behavioral/operational terms. Examples would include the steps needed to attend outpatient therapy once a week, or attend drug therapy once a week, or how to obtain public aid or food stamps.

Scoring

  1. Yes if the team clearly specifies (i.e., in behavioral/operational terms) how the plan of care will be implemented.
  2. No if the steps for achieving service plan goals are not specified, or if they are specified only in general terms, without mention of specific interventions, services, resources and/or actions to be taken.

11. Strengths of family members are identified and discussed at the meeting.

Care Coordinators identify and discuss the behavioral, emotional, familial, and/or social strengths of individual family members or of the family unit. A strength can include a skill, action, and/or knowledge competency.

Scoring

  1. Yes if a strength of at least one family member is identified and addressed at the meeting.
  2. No if no strength of at least one family member is identified and addressed at the meeting. Merely complimenting a youth in a general manner is scored a No.

12. Plan of care that includes life domain(s), goals, objectives, and resources/interventions is discussed (or written).

Life domain(s), goals, objectives, and resources/interventions necessary for child/family's plan of care are discussed.

Scoring

  1. Yes if the goals(s), objectives, and resources/interventions for at least one life domain are completed/discussed and agreed upon by team members.
  2. No if a goal(s), objective, and resource/intervention for at least one life domain is excluded or at least one life domain is not completed.
  3. NA if this is a discharge meeting.

13. Plan of care goals, objectives, or interventions are based on family/child strengths.

Team develops (discusses or writes) plan of care based on strengths of the child or family member.

Scoring

  1. Yes if at least one goal or objective in plan is developed (or written) based on at least one strength of the child or a family member.
  2. No if plan of care is developed (or written) without being based on child or family strength.
  3. NA if this is a discharge meeting.

14. Safety plan/crisis plan developed/reviewed.

Safety plan/crisis plan to protect the safety of the child/family or to implement in the event of a crisis is discussed, written or reviewed. Crisis may include but is not limited to substance abuse, running away, hospitalization, domestic violence, etc.

Scoring

  1. Yes if the team clearly specifies (i.e., in behavioral/operational terms) the goals, objectives and resources/interventions in discussing, writing or reviewing of a safety plan/crisis plan.
  2. No if the steps for implementing a safety plan/crisis plan are not specified, or if they are specified only in general terms without mention of specific interventions, resources, or services.
  3. NA does not apply if child/family safety is not an issue or if child/family are not expected to experience a crisis.

15. Convenient arrangements for family's presence at the meeting are made (e.g., location, time, transportation, day care arrangements).

F3 staff arranged the meeting at a time convenient to at least one family member and transportation to the meeting and day care were offered, if necessary.

Scoring

  1. Yes if it is evident that F3 workers scheduled the meeting at a time that at least one family member was available to attend AND transportation and day care was offered if the family needed it.

    Note: If this is not alluded to, the observer may have to ask the family members if this occurred (AFTER the meeting).
  2. No if it is not evident that efforts were not made by F3 staff to schedule the meeting at a time convenient to family OR score No if they provided a time that was convenient but neglected to offer transportation or day care if needed.
  3. NA if observer cannot ascertain whether or not family was consulted about the meeting or observer cannot speak with family member or if child/family member is not present.

16. The parent/child is seated or invited to sit where he/she can be included in the discussion.

The parent/child is seated where he/she is not isolated from the rest of the group and is seated in a size-appropriate chair. If the parent/child does not initially sit with the group, the team invites him/her to do so.

Scoring

  1. Yes if the parent/child is seated where he/she is not isolated from the rest of the group and is seated in a size-appropriate chair. Also, Yes if the parent is seated away from the group but has been invited to sit with the group.
  2. No if the parent/child is not seated with the group and was not invited to do so. Also, No if parent/child is seated in a chair that is too small.
  3. NA if child/family member is not present.

17. Family members are treated in a courteous fashion at all times.

Examples include, but are not limited to: The team establishes eye contact with family members, family is listened to, the team speaks to family members in a calm, non-confrontational tone of voice.

Scoring

  1. Yes if the team interacts with the family courteously at all times.
  2. No if the team is not courteous to the family at all times (give specific instance by writing on form.)
  3. NA if family members are not present.

18. The family's perspective is presented to professionals from other agencies. (*If NA, include 25, 28, 29)

Care Coordinator(s) ensures that the family's view of their problems/situation is presented to all other professionals at the meeting. This can be either a) Care Coordinator speaks on behalf of the family or b) family members are given time to speak for themselves. Family's perspective includes such areas as identifying needs, strengths, goals, services required, etc.

Scoring

  1. Yes if the family's point of view is expressed by either Care Coordinator or the family themselves.
  2. No if the family's point of view is not discussed at any time in the meeting.
  3. NA if other professionals are not present.

19. The family is asked what goals they would like to work on.

The team explicitly asks the family about what goals they would like help with. This could include (but is not limited to) asking the family what they would like to work on, improve, or change.

Scoring

  1. Yes if the team asks this type of question.
  2. No if question is not asked.
  3. NA if the family is not present.

20. The parent is asked about the types of services or resources/interventions he/she would prefer for his/her family.

The team specifically asks the parent about the types of services or resources/interventions he/she would or would not want to be used with their family. Examples include medication, psychotherapy, homemaker services, drug counseling, housing, vocational training.

Scoring

  1. Yes if the team asks the parent about the services or resources/interventions he/she would prefer.
  2. No if question is not asked.
  3. NA if the child or family is not present.

21. Family members are involved in designing the plan of care.

The family's ideas about the plan of care are elicited by the team. The family is allowed to contribute ideas in the formulation of the plan of care. The team specifically asks the parent/child to participate in the design of the plan of care.

Scoring

  1. Yes if the team allows and asks the parent to contribute ideas to the design of the plan of care.
  2. No if the team does not allow nor asks family members contributions.
  3. NA if family is not present.

22. In the plan of care, the family and team members are assigned (or asked) tasks and responsibilities that promote the family's independence (e.g., accessing resources on own, budgeting, maintaining housing).

Team members write goals or objectives in the plan of care that require family members to complete tasks and accept responsibilities that will help build their independence from formal service providers. Examples include taking GED classes, enrolling in vocational training, learning to budget, etc.

Scoring

  1. Yes if at least one family member is assigned tasks and responsibilities that will enable him/her to increase their level of independence from formal service providers.
  2. No if the team does not assign tasks/responsibilities to any family member in the plan.
  3. NA if family is not present.

23. The team plans to keep the family intact or to reunite the family.

The team writes goals or objectives in the plan of care that outline the steps necessary for either a) keeping the family intact OR b) reuniting family members in placement. Look at plan of care (permanency plan) to see that it states that the family will be reunited or remain intact.

Scoring

  1. Yes if goals or objectives are written in the plan of care to fulfill either of the above criteria. (This question refers to the child remaining or reuniting with one or both of the parents. A child moving in with a brother or sister would not qualify as a Yes.)
  2. No if the team does not include goals or objectives in the plan of care that is not directed towards family preservation (keeping family intact, reunification).
  3. NA if reunification is not an option for the family (e.g., parents rights have been severed, permanent foster care is the child's goal) or if child is age of majority.

24. Family members voice agreement/disagreement with plan of care.

As the plan of care is being developed a family member states whether he/she agree/disagree with the plan's goals, objectives, and/or resources/interventions. Family member(s) statements may be unsolicited or solicited by Care Coordinator or team member.

Scoring

  1. Yes if the family member voices opinion with plan of care's goals, objectives, and/or interventions/resources.
  2. No if the family member does not voice an opinion or Care Coordinator does not solicit opinion.
  3. NA if the family member is not present.

25. Staff from other agencies who care about or provide resources/interventions to the family are at the meeting.

At least one professional (other than F3 care coordinator) that provides services is present at the meeting.

Scoring

  1. Yes if at least one professional from another agency is present at the meeting.
  2. No if no outside professional(s) attend the meeting.

26. Staff from other facilities or agencies (if present) have an opportunity to provide input.

If professionals from other facilities or agencies are present, the team specifically asks them to provide input.

Scoring

  1. Yes if professionals volunteer input for the plan, or if the team specifically asks other non-F3 professionals to provide input, even if other professionals do not provide any.
  2. No if the team does not ask for input from other non-F3 professionals present at the meeting.
  3. NA if professionals from other agencies are not present at meeting.

27. Informal supports (if present) have an opportunity to provide input.

If informal supports are present, the team specifically asks them to provide input.

Scoring

  1. Yes if informal supports volunteer input for the plan, or if the team specifically asks at least one informal support to provide input.
  2. No if the informal supports do not volunteer input for the plan or if the team does not solicit input from at least one informal support.
  3. NA if informal supports are not present.

28. Problems that can develop in an interagency team (e.g., turf problems, challenges to authority) are not evident or are resolved.

There are no obvious conflicts among team members OR if conflicts between professionals arise, team members identify them and make every effort to achieve their resolution.

Scoring

  1. Yes if there are no conflicts among professionals OR if problems arise, Care Coordinator acknowledges them and makes reasonable efforts to resolve them.
  2. No if conflicts arise and attempts are not made to resolve them OR if conflicts are identified but there is little effort towards finding agreement.
  3. NA if professionals from other agencies are not present.

29. Staff from other agencies describes support resources/interventions available in the community.

If professionals from other agencies are present, they volunteer or are asked by the Care Coordinator to identify support resources/interventions available in the community.

Scoring

  1. Yes if a professional provides information (either voluntarily or being solicited) on support resources/interventions available in the community.
  2. No if a professional does not provide information on support resources/interventions in community or if such information is not solicited by Care Coordinator or other team member.
  3. NA if professionals from other agencies are not present.

30. Statement(s) made by a staff member or an informal support indicates that contact/communication with another team member occurred between meetings.

Verbal (e.g., telephone, in person) or written communication between two or more team members (i.e., professional/informal supports) occurred between the last and present meeting.

Scoring

  1. Yes if verbal or written communication occurred between two or more team members.
  2. No if verbal or written communication did not occur between two or more team members or it is not evident.
  3. NA if professionals/informal supports are not present or initial meeting.

31. Availability of alternative funding sources is discussed before flexible funds are committed.

Team member(s) discuss alternative sources of funding (e.g., Medicaid, community grants, United Way, juvenile justice) before using flexible funds. If it is not clear whether flex funds were being discussed or used ask the care coordinator.

Scoring

  1. Yes if at least one alternative funding source is discussed.
  2. No if no alternative funding source is discussed.
  3. NA if funding of services or resources/interventions is not discussed.

32. Termination of F3 Services is discussed because of the multiplicity or severity of the child's/family's behaviors/problems.

Team discusses termination of F3 services based solely on the severity or number of difficult behaviors/problems experienced by the family or any of its members.

Scoring

  1. Yes if termination is discussed.
  2. No if termination is not discussed.
  3. NA mark NA if termination is discussed because of funding issues, or if a family is, at that time, not presenting significant behavioral issues.

33. Termination of other services (non-F3 services) is discussed because of the multiplicity or severity of the child's/family's behavioral problems.

Team discusses termination of other services (non-F3) based solely on the severity or number of difficult behaviors/problems experienced by the child/family.

Scoring

  1. Yes if termination of other services is discussed.
  2. No if termination of other services is not discussed.
  3. NA mark NA if a family is, at that time, not presenting significant behavioral issues.

34. For severe behavior challenges (e.g., gangs, drugs) discussion focuses on safety plans/crisis plans (e.g., services and staff to be provided) rather than termination.

When discussing severe behavior problems (e.g., gang activity or drug abuse), Care Coordinator talks about possible solutions, additional services or increasing intensity of services. Discharge is not identified as an option.

Scoring

  1. Yes if team discusses, writes or refers to the safety/crisis plan.
  2. No if team does not discuss, write or refer to the safety/crisis plan, or if termination is discussed.
  3. NA does not apply if severe behavior challenges are not discussed.

35. The plan of care goals are discussed in objective, measurable terms.

The goals that are discussed define changes in behavior, living situation, placement, etc. Goals are described in objective, behavioral terms. Target behaviors are clearly identified and defined in behavioral terms.

Scoring

  1. Yes if plan of care goals are discussed in a way that meets the criteria in the above definition.
  2. No if plan of care goals are not discussed, or if they are discussed only in general, non-specific terms.
  3. NA, if a discharge meeting.

36. The criteria for ending F3 involvement are discussed.

The team discusses the criteria in terms of the discharge from services (i.e., from F3). Level of achievement is clearly defined in behavioral terms. The team discusses the time period during which services will be provided.

Scoring

  1. Yes if the team discusses the criteria for discharge of services in clear, specific, and behavioral terms. The discussion should be focused on specific criteria that need to be achieved within a specified time period.
  2. No if termination of services is not discussed, or if it is discussed only in general, non-behavioral terms.
  3. NA if the family has received services from F3 for 6 months or less.

37. Objective or verifiable information on child and parent functioning is used as outcome data.

Specific behaviors or actions of the child, parent, and/or other family members are identified and used by team members as a measure to assess whether or not the goals/objectives in the plan of care have been achieved. For example, a parent providing adequate supervision of her children, a parent secures public aid for her/his family, a child's school attendance increases, etc.

Scoring

  1. Yes if team members discuss specific child/parent behaviors and use these behaviors as criteria for rating the client's progress toward a goal/objective in the plan of care.
  2. No if the team does not use child/parent behaviors as criteria for rating client's progress towards a goal/objective in the plan of care.

38. Key participants are invited to the meeting (i.e., family members, CPS worker, teacher, therapist, others identified by the family).

Care Coordinator has invited the necessary participants to the family meeting. This includes: family members, professionals and paraprofessionals involved with the family, and members of the family's natural or informal support system or community.

Scoring

  1. Yes if it is mentioned or implied that the Care Coordinator has invited at least 2 key people other than F3 staff and immediate family members to the meeting.
    Note: The observer may need to ask Care Coordinator who was invited AFTER the meeting.
  2. No if it is evident that at least two key participants were not invited.
  3. NA if a team has not been assembled yet.

39. Current information about the family (e.g., social history, behavioral and emotional status) is gathered prior to the meeting and shared at the meeting (or beforehand).

There is enough basic demographic and current functioning information about the family, such as name, date of birth, current identifying information and current functioning data, so that the meeting can proceed in a timely manner, without undue time being spent gathering this information. It is clear that this information was gathered prior to the meeting and shared with meeting participants (or beforehand).

Scoring

  1. Yes only if the two criteria (information gathered and shared) in the definition are met.
  2. No if one of these two criteria is not met.

40. All meeting participants introduce themselves (if applicable) or are introduced.

Everyone present at the start of the meeting states his or her name and agency/occupation (e.g., psychiatrist, probation officer, HHS worker).

Scoring

  1. Yes only if all meeting participants state their name and agency or occupation (role) at the start of the meeting.
  2. No if only some of the participants introduce themselves or if they only state their name but not their occupation (role).
  3. NA does not apply if all team members have worked with family for a reasonable period of time (i.e., 4 months based on enrollment date).

41. The family is informed that they may be observed during the meeting.

The family is told that he/she may be observed during the meeting by the evaluation staff. The team explains to the parent that the observers are there to assess the Care Coordinator's performance and that all note taking reflects staff actions, not client information.

Note: If not mentioned at meeting, observer will ask parent if they were informed of the observer's presence prior to the meeting.

Scoring

  1. Yes if the family is told that he/she is being observed and why.
  2. No if an observer is present and the family is not informed and told why.
  3. NA if family member is not present OR if the observer has missed the beginning of the meeting, or is unable to ascertain whether or not these criteria have been met.

42. Plan of care is agreed on by all present at the meeting.

All meeting participants agree to a plan of care by the end of the meeting.

Scoring

  1. Yes if the service plan is agreed upon either implicitly or explicitly by all present.
  2. No if the service plan is not agreed upon either implicitly or explicitly by all present.

43. Care Coordinator makes the agenda of meeting clear to participants.

At the beginning of meeting Care Coordinator states the agenda and purpose of meeting to those in attendance.

Scoring

  1. Yes if Care Coordinator verbalizes or hands out printed agenda.
  2. No if written or verbal agenda is not provided by Care Coordinator.
  3. NA if the observer has missed the beginning of the meeting.

44. Care Coordinator reviews goals, objectives, interventions, and/or progress of plan of care.

Present plan of care is reviewed by Care Coordinator for the participants early in the meeting.

Scoring

  1. Yes if Care Coordinator reviews (verbally or in writing) present plan of care for team early in the meeting.
  2. No if Care Coordinator does not review present plan or reviews plan later in the meeting.
  3. NA if observer has missed the beginning of the meeting, or if an initial meeting.

45. Care Coordinator directs (or redirects) team to discuss family/child strengths.

Team participants discuss family/child strength(s) at the direction (redirection) of Care Coordinator.

Scoring

  1. Yes if Care Coordinator directs team to talk about specific strength(s) at the beginning of the meeting or later on in the meeting.
  2. No if Care Coordinator does not direct team to discuss strength(s) after a substantial amount of time of discussing child deficits.

46. Care Coordinator directs (or redirects) team to develop/revise/update plan of care.

Plan of care (life domain, goals, objectives, or resources/interventions) is revised or updated at the direction (redirection) of Care Coordinator.

Scoring

  1. Yes if Care Coordinator directs (redirects) team to develop/revise/update plan.
  2. No if Care Coordinator does not direct (redirect) team to revise/update plan.

47. Care Coordinator summarizes content of the meeting at the conclusion of the meeting.

At the conclusion of meeting Care Coordinator summarizes the content (i.e., what was discussed and agreed upon) of the meeting.

Scoring

  1. Yes if Care Coordinator verbally summarizes the meeting.
  2. No if Care Coordinator does not verbally summarize the meeting.

48. Care Coordinator sets next meeting date/time.

At the conclusion of the meeting, Care Coordinator sets next meeting date/time and asks family member if time/date are convenient.

Scoring

  1. Yes if the Care Coordinator sets date/time for next meeting and if it is convenient for family.
  2. No if one of above criteria is not satisfied.
  3. NA if discharge meeting.

Publication:
13-0334-EF

Page last reviewed March 2013
Page originally created March 2013

Internet Citation: Wrap-Around Observation Manual—Second Version. Content last reviewed March 2013. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-measures-atlas/ccrm-atlasapd3.html

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