Complex Care Management
Family Anchored Care Team
The Family Anchored Care Team (FACT) provides Clinical Care Management to children and youth with complex needs due to other system involvement, trauma history, and crisis behavior
What is FACT?
FACT is a team-based planning process. Goals are developed using the family’s strengths and respect for their culture. The FACT care coordinator builds a team that includes family, natural supports, and community members.
During monthly Family Team Meetings, the entire team’s voices are considered to build a Family Action Plan to help the family reach their goals. The FACT process continues until the family has made progress toward their goals, leads their own meetings, and feels comfortable asking for help when needed.
Who do we serve?
- CBH members ages 5-21 who have experienced at least one behavioral health crisis requiring intervention within the past year.
- Must also be diagnosed with a behavioral health disorder and currently be receiving clinical treatment. Referrals can also be considered for members who are referred to clinical services but are waiting for an initial appointment.
Tier 2 vs Tier 3?
FACT Teams and system partners work with the child and their family to ensure their voice and choice are heard and respected. Based on the level of need, FACT Teams will use two levels of the same evidence-informed intervention, called Family-Driven Teaming.
- FACT Tier 2 will be used with members identified as having intermediate Care Management needs.
- Designed to serve families whose child is experiencing emerging crisis behaviors.
- The family may have no system involvement (DHS/CUA, JJS) or lower-level system involvement.
- A FACT case manager (care coordinator) provides the entire intervention.
- Designed to be short-term (9-12 months) and support the family’s self-efficacy.
- Currently provided through PATH or Merakey.
- FACT Tier 3 will utilize the full High-Fidelity Wraparound model and will be used with members identified as having Intensive Care Management needs.
- Also called “High-Fidelity Wraparound”
- Designed for children and youth who have a long-standing history of crisis behavior combined with system involvement (such as DHS/CUA or JJS).
- The workforce is an entire team, including a care coordinator, a Family Support Partner, and a Youth Support Partner.
- The Support partners share their experiences as a youth or a parent to better support the family.
Mommy’s Helping Hands
The Mommy’s Helping Hands program recognizes that pregnant women who are struggling with or who are in early recovery from substance use disorders need an all-inclusive approach to care. We offer care coordination services for pregnant and postpartum women aged 18 and older for up to 1 year after giving birth.
A Care Manager will work with the individual and those involved in their care to help meet their health goals. A Care Manager will also assist with the following:
- Plan in-person visits or phone calls
- Help to access substance use treatment, including Medication-Assisted Treatment (MAT)
- Work with medical insurance to coordinate care
- Communicate and coordinate with the treatment team and help set up care with any needed doctors and/or specialists
- Help connect with community resources and supports
- Help the individual and/or their supports better understand behavioral health condition(s), medications, and treatment
Abilities First: Nothing for Me Without Me
Abilities First: Nothing for Me Without Me is a program for adults aged 18 and older who have an intellectual disability as well as a behavioral health diagnosis. We recognize that some adults may need help connecting to support and services that will enhance their well-being. This program is an all-inclusive approach to care that can help address care needs.
A Care Manager will work with the individual and those involved in their care to help meet their wellness goals. A Care Manager will also assist with the following:
- Plan in-person visits or phone calls
- Work with medical insurance to coordinate care
- Communicate and coordinate with the treatment team and help set up care with any needed doctors and/or specialists
- Help connect with community resources and supports
- Help the individual and/or their supports better understand behavioral health condition(s), medications, and treatment
Interested in getting more information about these programs for yourself or someone you know, including how to be referred? Please call 1-888-545-2600 for more information, or send us a message by filling out the form below, and we will get back to you shortly.
