Service Delivery, Policy, Procedure and. Resource Manual The WISe Practitioner(s) guide the CFT in creating a document that describes the strengths of.

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0 Washington State Wraparound with Intensive Services (WISe) is a service delivery model designed to provide comprehensive services and supports to individuals twenty years of age or younger, and the family. The purpose of this manual is to direct the development and maintenance of a sustainable and consistent service deliv ery system for providing intensive behavioral health in home and community settings to Medicaid eligible children , youth , and their families .

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2 Table of Contents Introduction to the newest update .. .. .. .. 6 Section 1: Foundational Requirements .. .. .. .. 6 A. Purpose and Goals .. .. .. .. 6 Objective .. .. .. .. .. 7 .. .. .. 7 What is different about WISe? .. .. .. .. 9 B. Agency Infrastructure .. .. .. .. 11 Federal and State Requirements .. .. .. .. 11 WISe – Specific Requirements .. .. .. 12 Service Array .. .. .. .. . 13 Staffing .. .. .. .. . 14 Highlighted Staffing Requirements .. .. .. .. 15 Cross – System Collaboration .. .. .. . 15 Documentation .. .. .. .. 16 WISe Agency Website .. .. .. . 18 C. WISe acces s protocol .. .. .. .. 19 Identification .. .. .. .. . 20 Referrals .. .. .. .. .. 21 WISe Screening .. .. .. .. 22 WISe Intake .. .. .. .. 23 D. WISe service requir ements .. .. .. 25 Culturally and Linguistically Appropriate Services (CLAS) .. .. 25 Providing Intensive Care Coordination and Services Using a Wraparound Approach .. 25 Intensive Care Coordination .. .. .. 25 WISe D ocumentation Considerations .. .. .. . 25 E. Phases of WISe (Practice Model) .. .. .. 26 Engagement .. .. .. .. .. 27 Assessing .. .. .. .. . 28

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3 Teaming .. .. .. .. 29 Service Planning and Implementation .. .. .. 31 Monitoring and Adapting .. .. .. .. 33 Service Implementation/Service Array .. .. . 34 Crisis Planning and Delivery .. .. .. . 36 Transition .. .. .. .. 39 F. Guidance on Team Functioning and Facilitation of WISe .. .. . 41 The Approach .. .. .. .. 41 WISe Team Meeting Facilitation Components and Team Structure .. 41 Transition .. .. .. .. 44 Principals Evidenced in Practice .. .. .. . 45 G. WISe Training and Coaching Framework .. .. .. 46 WISe Practitioner Training and Coaching Framework .. .. .. 46 H. Client Rights .. .. .. .. 52 Decisions and Dispute Resolution .. .. .. . 52 Reaching Consensus on a CFT .. .. .. . 52 How Do I File a Grievance? .. .. .. .. 53 Right to Appeal a Denial, Termination, Reduction, or Suspension of Services .. 54 Types of Appeals .. .. .. .. . 54 How do I file an Appeal? .. .. .. . 55 How to R equest an Administrative (Fair) Hearing: .. .. . 56 Continuing Services during the Appeal .. .. . 56 Help for Youth, Families, and Caregivers .. .. . 57 I. Governance and Coordination .. .. .. .. 58 Child, Youth and Family Behavioral Health Governance Structure Component Descriptions .. 60 Developing Regional Linkages to the Governance Structure .. 62 Center of Parent Excellence .. .. .. . 63 J. Qu ality Plan .. .. .. .. . 64 Background .. .. .. .. 64

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4 Components .. .. .. .. .. 64 Quality Infrastructure .. .. .. . 64 Quality Improvement Review Tool (QIRT) .. .. .. 65 K. WISe Fee For Service .. .. .. . 66 Overview of Apple Health for Individuals Not in Managed Care, or Fee – For – Service (FFS) . 66 Participation as a WISe Fee – For – Service (FFS) Provider .. .. 66 Section 2: Specialty Teams and Guidance .. .. .. .. 68 A. BRS and WISe Integration .. .. .. . 68 Behavi or Rehabilitation Services (BRS) and WISe Delivered Concurrently .. .. 68 B. WISe and American Indian and Alaska Native Youth and their F amily .. .. 74 General Information and Map .. .. .. 74 Pulling Together for Wellness Framework .. .. .. 75 The Substance Abuse and Mental Health Services Administrat ion (SAMHSA) .. .. 75 Department of Children, Youth, and Families .. .. .. 75 Health Care Authority .. .. .. . 75 Department of Health .. .. .. . 75 C. Partnering with Transition Age Youth in WISe .. .. .. 77 WISe and TAY pilot .. .. .. 77 D. WISe Birth through Five (B – 5) .. .. .. . 81 E. Intellectual or Developmental Disabilities Including Autism Spectrum Disorder and WISe . 84 Potential Partners to include in the CFT and Cross System Care Plan: .. 84 Trauma Considerations .. .. .. .. 84 Communicatio n .. .. .. .. 85 Other Considerations .. .. .. .. 85 F. Partnering with Youth and Families Experiencing Homelessness .. .. 86 Crisis Residential Centers .. .. .. .. 86 HOPE Centers .. .. .. .. 86 Independent Youth Housing Program .. .. .. 86 Street Youth Services .. .. .. .. 86

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5 Young Adult Shelter .. .. .. . 87 Young Adult Housing Program .. .. .. 87 Section 3: Background and additional information .. .. .. 88 A. Background: T.R. Settlement Agreement .. .. 88 Background .. .. .. .. 88 Goals .. .. .. .. . 89 B. Memorandum of Understanding .. .. .. .. 90 C. WISe Terminology, Definitions, and Roles .. .. .. 95 Phases .. .. .. .. .. 95 Roles .. .. .. .. .. 95 Documents .. .. .. .. .. 101 WISe Training and Coaching .. .. .. . 102 WISe P lanning Elements .. .. .. . 102 Services and Supports .. .. .. .. 103 D. Service Array and Coding .. .. .. 104 E. WISe Attestation(s) for Managed Care Plans and Tribal Behavioral Health .. .. 105 WISe Attestation for a Managed Care Plan (MCP) .. .. .. 106 WISe Attestation for Tribal Behavioral Health .. .. 108 .. .. .. . 110 G. WISe Example Templates .. .. .. .. 111 Example Cross System Care Plan template from the WISe Workforce Collaborative . 111 Example Crisis Plan Template from the WISe Workfor ce Collaborative .. . 120 H. Affinity Groups .. .. .. .. .. 125 WISe Manual Update Crosswalk for Version 2.0 .. .. . 126

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7 youth . The WISe service delivery mode l is intended to be individualized, and tailored with room for f lexibility, creativity and youth and family voice and choice The manual will assist the community behavioral health system and allied agencies , as well as other formal, informal, and natural supports with the identification of eligible youth and the implementation and provision of WISe. It is intended to provide an understanding of: The required infrastructure and expectations of WISe The Practice Model for the core elements of WISe , in each of the following phases: Engagement Assessing Teaming Service Planning and Implementation Monitoring and Adapting Transition This manual is a living document and will be reviewed annually. M ost c urrent version of the manual will be posted on our . O bjective This manual will provide guidelines to ensure consistency in the goals, principles, service delivery, and quality of WISe across the state. We believe implementing the WISe service delivery model , utilizing the Behavio r al Health Principles (previously named the Mental Health Principles) , will: Promote recovery, increase resiliency and reduce the impact of be havioral health symptoms on youth and families. Keep youth safe, at home, in the community and making successful progress in school . Promote youth development , maximizing their potential to grow into healthy and independent adults . T he Behavioral Health Principles are outlined below . These principles guide the implementation of WISe and provide the foundation for the practice model and clinical delivery of intensive services. Behavioral Health Principles Washington State Health Care Authority ( HCA ) believe s that youth and families should have access to necessary services and supports in the least restrictive, most appropriate, and most effective environment possible. Washington State is committed to operating its Medicaid funded behavioral health sy stem that delivers services to youth, in a manner consist ent with these principles :

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8 Family and Youth Voice and Choice : Family and youth voice, choice and preferences are intentionally elicited and prioritized during all phases of the process, including planning, delivery, transition, and evaluation of services. Services and interventions are family – focused and youth – cen tered from the first contact with or about the family or youth. Team based : Services and supports are planned and delivered through a multi – agency, collaborative teaming approach. In addition to the WISe practitioners, t eam members are chosen by the family and the youth and are connected to them through natural, community, and formal support and service relationships. The team works together to develop and implement a plan to address unmet needs and work toward the Natural Supports : The team actively seeks out and encourages the full participation o f team members drawn from (e.g. friends, neighbors, community and faith – based organizations). The care plan reflects activities and interventions that draw on sources of natural support to promote recovery and resiliency. Collaboration : The system responds effectively to the behavioral health needs of multi – system involved youth and their caregivers, including youth in the child welfare, juvenile justice, developmental di sabilities, substance abuse, primary care, and education systems. Home and Community – based : Youth are first and foremost safely maintained in, or returned to, their own homes. Services and supports strategies take place in the most inclusive, most responsi ve, most accessible, most normative, and least restrictive setting possible. Culturally Relevant : Services are culturally relevant and provided with respect for the values, preferences, beliefs, culture, and identity of the participant/youth and family an d their community. Individualized : Services, strategies, and supports are individualized and tailored to the unique strengths and needs of each youth and family. They are altered when necessary to meet changing needs and goals or in response to poor outc omes. Strengths Based : Services and supports are planned and delivered in a manner that identifies, builds on, and enhances the capabilities, knowledge, skills, and assets of the youth and family, their community, and other team members. Outcome – based : Bas ed on the youth and strategies, ties them to observable indicators of success, monitors progress in terms of these indicators, and revises the plan accordingly. Services and supports are persistent and flexible so as to overcome setbacks and achieve their intended goals and outcomes. Safety, stability and permanency are priorities.

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9 Unconditional The team continues to work with the family toward their goals until the family indicates that a formal process is no longer required. What is d ifferent about WISe? Foc us on youth and family voice utilizing a strength – based approach The WISe provider intentionally seeks out youth and family voice, choice and preferences during all phases of the process, including planning, delivery, transition, and evaluation of services. S upports and s ervices are delivered in a way that honors youth – guided and family – driven care . Together, the WISe provide r, youth, and family will plan and deliver services and supports i n a manner that identifies, builds on, and enhances the capabilities, knowledge, skills, and assets of the youth and family, their community, and other team members. Primary setting WISe is intended to be provided in the home and in community locations, and at times and locations that ensure meaningful participation of youth, family members, and natural supports. Telehealth is also an option for service delivery and should be guided by you th and family choice (see note on COVID – 19 in Section 3, Part D, Service Array and Coding ). WISe is tailored for youth with intensive and complex behavioral health needs. Assessment, treatment, and support services are pro vided in the youth and ds, strengths, and challenges present themselves (such as the h ome, school and community). Flexible and creative services WISe is intended to be provided in timely, creative , individualized, and flexible ways. Those served through WISe tend to come into services with complex needs and involved histories. This approach must provide unique methods of support, as many of the youth and families served have found traditional behav ioral health care unable to meet their needs. Others remain at risk of more restrictive care , even after receiv ing traditional behavioral health services. Involvement of Family Partners and Youth Partners (Certified Peer Counselors) is Essential Family P artners and /or Youth Partners who have lived experience must be a part of the team. They must be meaningfully involv ed in the provision of WISe. The Family Partner and/or Youth Partner s are equal team members with the Care Coordinator and Mental Health Th erapist. The Family Partner and/or Youth Partner meet with the youth and/or family on a regular basis to provide support in addressing the needs of the youth and family, as defined in the Cross System Care Plan (CSCP). Youth Partners and Family Partners sh ould be educated in how to utilize the CANS results to support and educate the youth

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