Service Coordination

This article presents an overview of the history of service coordination for disabled and special education students in the public schools. Explanation of legislation and laws guiding social services is provided. It also discusses research and practice of service coordination and social work practice in the general community.

Keywords Case Management; Community-based Services; Early Intervention Programs; Individuals with Disabilities Education Act (IDEA); Service Coordination; Service Integration; Special Education

Overview

Service Coordination, or the coordination of services provided to families with children of special or complex needs, was mandated in the landmark special education legislation P.L. 94-142 in 1975 (now known as IDEA (2004), the Individuals with Disabilities Education Act). This mandate for the coordination of services was in response to widespread client feedback that referrals to service providers were not organized, sometimes inappropriate, and occasionally led to duplication or to gaps in services. Sometimes the specialized service providers, such as for mental health or financial assistance, did not have a holistic perspective on these families' lives, which again could lead to inappropriate referrals or gaps in service. In research considering the needs of children with complex medical needs coupled with developmental delays (Haflon & Klee, 1991), the studies found poorly coordinated services, providers who were spread over a large geographical area (or weren't available at all), poor reimbursement to providers, and cultural insensitivity.

In early social work the process of assessing all of a family's needs, problem solving and developing a plan for services, resources and treatment were considered best practices and competent, professional case management. This process of careful assessment was conceptualized and promoted by Mary Richmond in her classic social work text "Social Diagnosis" (1917) and again in her text "What is Social Case Work?" (1922). At that time, one worker would be responsible for assessing all of the family's needs and the same worker would either provide or broker resources for that client or family. As services possibilities and the number of agencies and providers of service increased, the need to coordinate these services became more important. Case management, which would include the coordination of services, assisting clients to access these services, and the development of new services, became one of the bedrock skills of the social work profession (Perlman, 1957; Compton, Galloway & Courmoyer, 2005).

The call for the coordination of services also came from insurance companies and federal and community funding sources, citing duplication of services and services being provided to individuals who may not be qualified for those services. The medical and health care systems were seeing more children with complex health needs, and were seeking a way to both expand their services to meet all of these critical needs, while cutting the costs involved in meeting those needs (Loomis, 1988). The increase in children with complex medical needs came with the increased awareness that treatment for these children may be hindered or supported by their familial, social, and economic environment (Haflon, Berkowitz, & Klee, 1993).

An additional issue that encouraged service coordination came from social work advocates of parents whose children had been removed for a variety of reasons by State Child Protection and Child Welfare services. These parents were required by the court to fulfill a wide number of requirements, many of which included connecting to treatment providers. Without coordination of these services or case management, these parents ran the risk of losing custody of their children because they could not fulfill all of the court's requirements in a timely way. The increase of drug-affected infants and children with elevated service requirements, in addition to families who needed treatment, for example, for alcoholism, domestic violence, and had their own complex medical needs underscored the need for coordination of services and careful case management between health, social work and child welfare services. These were not new problems, but there was a rising tendency for more critical problems to be concentrated in one family (Haflon, Berkowitz, & Klee, 1993). "Case management is a service delivery technique and organizing principle that can improve the coordination and integration of services and referrals, while decreasing obstacles to service access" (Haflon, Berkowitz, & Klee, 1993, p. 384).

The school systems echoed some of the same issues. When giving feedback about service delivery some of the difficulties included providers being spread over a wide geographic area, conflicting demands or directions from providers, lack of communication between providers, confusion about the availability of resources, and confusion about multiple funding sources. Adult clients and parents of children needing services wanted more say in the decision-making process, an increase in cultural relevancy in service provision and treatment goals, and a way to change the course of treatment in mid-stream, if the original plan was not working well.

The Law is Passed

Public Law 94-142, the Education for All Handicapped Children Act, was passed in 1975. It was amended in 1986 (P.L. 99-457), 1990 (P.L. 101-476), 1997 (P.L.105-17), and 2004 (P.L. 108-446) and is now know as the Individuals with Disabilities Education Act (IDEA). An additional law that affected special education was The Americans with Disabilities Act (ADA) (P.L. 101-336) passed in 1990, which guaranteed equal access and protected civil rights in the areas of private-sector employment, public services, public accommodations, and telecommunications.

IDEA, with all of its amendments, requires that children 3-21 years old with a disability be provided with a "free, appropriate, public education in the least restrictive environment." The 1986 IDEA amendment extended the provisions of the 1975 version to include children from 3-5 years, and incentives for States to develop Early Intervention Programs for children with disabilities ages birth to 3 years (Part C of IDEA). Part C also mandated Service Coordination in the 1997 amendment of IDEA. The benefits of service coordination were partially documented by Dinnebeil, Hale, and Rule (1999), Roberts, Innocenti, and Goetz (1999), and Summers, et al, (2001). Service coordination reflected best practices and in response to consumer demands, addressed many of the above-mentioned issues.

There were three specific directives in the IDEA which are necessary in the provision of service coordination. The first was a central person that was to be responsible for coordination all of the services for a specific client. The second was a document that guided the coordination and the third mandated policies for interagency coordination and cooperation (Bruder, Harbin, et al., 2004).

A service coordination team would ideally consist of a service coordinator, the client, parents of minor clients, involved family members (such as caretaking grandparents), and all of the service providers. The service provider representatives would ideally reflect all those who would meet all of the child's developmental, educational, and medical treatment needs. The team was intended to be participatory (where all stake holders have input), family-centered, and based in the community where the families reside. This also reflected the report of the US Surgeon General C. Everett Koop (1987) which called for a national system to coordinate the services for families with children with special health care needs which was family-centered and community- based. Family-centered care is defined as care in which the family is seen in the pivotal role, and their input, wishes, cultural norms, and strengths are respected and supported (Brewer, McPherson, Magrab, & Hutchinson, 1989). Community-based care supports the philosophy that children with special needs should live at home with their families and receive education and services in their local communities, as much as possible. Ideally, the service coordination team members would be living in this child's home community

Point of Entry

The point of entry for a client includes assessment of their developmental level and diagnosis of any disabilities and medical conditions. If they meet the criteria of the IDEA, they are enrolled in the available programs, where they are referred to service providers. Point of entry for children with complex health needs is usually through medical services and tends to be early in their lives, as infants and toddlers (Nolan, Young, Hebert & Wilding, 2005). Point of entry for those with uncomplicated developmental delays tends to be dependent on the nature of their delays, but tends to be through medical or educational channels. Point of entry for children and youth with serious emotional disturbance tends to come through educational channels, juvenile justice, or child welfare systems (Unger, 2005; Wright, et al., 2006).

Service Coordination in Special Education

Once a child has entered the system and found to qualify for services (therefore under the purview of IDEA) the local education agency (LEA) becomes responsible for the coordination of their services (McAffee & Grumwalt, 2001). The LEA will retain responsibility for this child's service coordination from birth (Early Intervention programs), through their pre-school, elementary school, their Individual Education Plans (IEPs), their Family Service Plan (FSP), and the writing and implementing of their transition plan (ITEP) in their early adolescence (no later than 14 years of age). The LEAs responsibility usually ends when the child graduates from high school or ages out of the system (reaches 18-21 years of age). The exception to this is if the LEA is found (usually through a legal challenge brought by the parents or guardians) to not have written an appropriate plan or adequately implemented an existing ITEP. Post-secondary education is then seen as compensatory to the free public education as required by the IDEA (McAffee & Grunwald, 2001).

The earliest coordination of services happens as part of the Early Intervention programs (EIP), for infants and toddlers 0-3 years of age. Nolan, Young, Herbert & Wilding, (2005) documented the increasing number of children who, through improved medical technology, are surviving premature birth and birth from drug-affected mothers. These infants are found to be at high risk for physical and developmental disabilities. Examples include issues such as neurological delays or deficits (such as children who are on the Fetal Alcohol spectrum (i.e. Fetal Alcohol syndrome, Fetal alcohol effect, etc.), chronic respiratory problems from underdeveloped lungs, problems with the ability to feed and digest, sensory integration issues, growth delays, inability to self-soothe, and hypersensitivity to sound, light, and touch (such as children born from drug-affected mothers). When surveying who was utilizing Early Intervention services, Nolan, et al., (2005) found that two-thirds of the children in the EIP caseloads also received service coordination from another agency, which they see as reflecting the complexity of these children's service needs. Their research also found that even though those children with complex health needs took more time for care coordination, their numbers were a small percentage of the coordinator's caseloads, relative to those children with uncomplicated developmental delays. They defined children with complex health needs as: "children who have or are at risk of having a chronic physical or developmental condition and who also require care from two or more medical specialists, for example: pulmonologists, cardiologist, neurologist, developmental pediatrician, gastroenterologist, urologist" (p. 162). They defined children with uncomplicated developmental delays as "children who have uncomplicated developmental delays (e.g., speech language delay) and who may also require care from one medical specialist (as described above)" (p. 162).

With all of these special needs, it is easy to understand why a coordinated effort is necessary for smooth delivery of services, and to keep track of changes, challenges and progress.

Applications

The Functions of Service Coordinators

Jackson, Finkler, & Robinson (1992) identified seven main functions of service coordinators, which reflect the requirements as spelled out by Part C of the IDEA (C.F. R. 303.302(d)).Their specific study focused on infants with chronic illnesses and developmental disabilities within a medical system. These functions include:

• Evaluation and assessment to determine eligibility

• Arranging for evaluations

• Providing support to families

• Making referrals to treatment providers

• Keeping in contact and exchanging information between service providers

• Providing support to the families

• Developing discharge criteria from among the service providers

Jackson, et al. found that providing support to the families and keeping in contact and sharing information with the service providers were the functions that took the most time. They reported that the younger children and those with the most severe or complex conditions had greater service coordination needs.

Service coordination/case management can differ in tasks, depth, time, and the extent to which the service coordinator is involved with each family and client. The differences could depend on the caseload, the limitations of the agency, and even on the personality of the service coordinator. Park and Turnbull (2003) reviewed the literature and summarized the differences which could enhance or impede service coordination among two dimensions: interpersonal and structural factors. Interpersonal factors which had a positive influence on relationships (both with the family and with providers in other agencies) included good communication skills, displaying openness and self-disclosure, sharing information and responsibility, solving problems together, being trusting and trustworthy, interpersonal courtesies as being on time, being organized and prepared, and following through. In addition, positive interpersonal factors included having sufficient professional expertise and knowledge about disabilities, knowing the community resources for referrals, and being family-focused (displaying cultural sensitivity, being able to convey a caring attitude about and for the child and family, etc) (O'Conner, 1995; Dinnebeil, Hale & Rule, 1999; McWilliam, Snyder, Harbin, Porter, & Munn, 2000).

Factors Hindering Effectiveness

Structural factors which hindered their effectiveness included: difficulty in coordinating schedules for interagency meetings, lack of involvement with key personnel, a caseload of up to 70 families, lack of complete information, lack of communication between agencies and providers, competition for resources, turnover of staff and providers, irresponsiveness to community needs, differing philosophies for serving families, confidentiality policies, professional and agency boundaries (turfism), and lack of clear goals (Brown, Horn, Keiser, & Odom, 1996; Dinnebeil, Hale, & Rule, 1996,1999; Farel, Shackelford, & Hurth, 1997; Harrison, Lynch, Rosander, & Borton, 1990; Martinson, 1982; O'Conner, 1995; Roberts, Behl, & Akers, 1996).

Structural factors which had a positive influence on service coordination included: Open and systemic communication, sharing and merging resources, flexibility of the program (allowing home- or center-based services when needed), an effective system of documentation and accountability, reasonable caseload size ; interagency agreements for cooperative service delivery, joint grant funding, shared ownership and credit, sensitivity to power and control concerns of others, admitting flexible working hours to accommodate family's schedule, joint training session with other agencies and including parents in staff training, co-location of services, single points of intake, and co-application procedures, and effective leadership of administrators (such as making resources available to parents, children and professional, setting up accountability, etc.) (Cormany, 1993; Dinnebeil, Hale, & Rule, 1996; Harrison, Lynch, Rosander, & Borton, 1990; Roberts, Akers, & Behl, 1996; Roberts, Behl, & Akers, 1996; and Soodak & Erwin, 2000).

Outcomes

Measuring outcomes has become one of the current topics in service coordination, especially in the field of early intervention. In one study (Bruder, Harbin, Whitbread, et al., 2005) four national studies were implemented with a high number of various stakeholders, in order to identify outcomes that could be measured. The following eight outcomes were determined:

• Families make informed decisions about services and opportunities in the community for their children with a disability

• Families acquire and/or maintain a quality of life that enhances their well-being.

• Families are self-sufficient.

• Families are knowledgeable of their child's disability.

• Children's development is enhanced.

• Children are safe and healthy.

• Children have successful transitions.

• Children and families receive early intervention services that are individualized, coordinated and effective (Bruder, et al., p. 185).

This study builds on the earlier work of Dunst and Bruder (2002) who separated the outcomes of service coordination (which assisted the families to gain access to services and supported them in an ongoing process), the outcomes of the Early Intervention services (the actual activities that the child and family were involved in to promote child development), and the outcomes of (the child) living in the child's natural environment (their home, community, early childhood settings where they can learn and practice activities of daily living, rather than in an institution). Only two outcome categories (family satisfaction and improved family quality of life) were counted as valued outcomes for all three settings.

While the above focuses on service coordination for early intervention and children with complex medical needs, service coordination has been successfully utilized in families with young people with serious emotional disturbance (SED) (Wright, Russell, Anderson, Kooreman, & Wright, 2006), as well as described in child protection and child welfare studies, such as in the neighborhood-based service collaboration study in Central Harlem (Chahine, Z., van Straaten, J., & Williams-Isom, A., 2005).

In Conclusion

Service coordination and case management have been encouraged for reasons including cost-containment, increasing accessibility to providers and services, increasing input from and empowerment of clients and their families, encouraging community-based care, and increasing accountability and responsiveness of the community to families and individuals with special needs. The question of why case management has been found to be effective may lay in the power of a person or a family to feel heard and understood. When one person can convey a sense of caring for another, that other can experience a sense of hope that change will occur. When that experience is duplicated by a group that has gathered to assist the family, the family may be more willing to participate in actually using the services available, and following the recommendations of the service providers. This reflects many of the interpersonal factors for service coordination success.

Terms & Concepts

Case Management: A framework for problem solving used in social work practice when working with a multi-needs client or family. It includes assessment of the client's issues, brokering needed services, monitoring case progress, keeping case records, assisting transition or termination of services, and evaluating services provided after the case is closed. Sometimes used interchangeably with service coordination or service integration.

Community-Based Services: A philosophy which encourages that each child or client with special needs be provided the services that they need in the community that they live in, rather than in an institutional setting. This fulfills the requirement of services being provided in the least restrictive setting as per the IDEA. An example of this would be a child with complex medical need and developmental delays living at home with his parents, while attending an accessible modified program in their local public school, and receiving medical care from a home-visiting nurse, as needed.

Early Intervention Services: Services provided to children with developmental delays from 0-3 years of age. The philosophy of early intervention is that with intervention at an early stage, many developmental delays can be alleviated and even reversed. There is a large body of research that supports this premise, especially in respect to language, speech, sensory integration, and muscle coordination. Early results on language and behavior intervention during the 6 - 18 month window for children with autism are especially promising.

Natural Environment: Describes the child's "natural habitat," that is, the family home, the neighborhood where the family lives, and the surrounding community. When children were institutionalized away from their family home, they were often not given the opportunity to learn activities of daily living that a child living at home would otherwise be exposed to. One of the outcomes of a child being raised in their natural environment is that they learn what "normal" life tasks looks like, and could possibly duplicate these tasks in their later years, especially of they are able to live semi- of fully independently.

Service Coordination: The coordinating of the services planned for a family with multiple service needs, such as complex medical needs coupled with developmental delays. A Service Coordinator, mandated by the IDEA, organizes a team consisting of the family and the service providers, brokers services, keeps track of progress and delays, and facilitates communication between all parties involved. Occasionally used interchangeably with Case Management.

Service Integration: The process by which the community of providers are able to coordinate their services so that the client or family has easy accessibility, seamless transitions between agencies, and no gaps in service needs.

Successful Transition: The movement between one developmental stage to another, or from one level of treatment or services to another. An example could be transition from Early Intervention programs to the pre-school program system, where the services are well coordinated, the child has been receiving services for three years, has benefited from those services, and now has the opportunity to make still more progress in the pre-school programs before entering elementary school.

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Sherman, M.W. (2012). Report: Better coordination needed on transition services. Education Daily, 45, 3. Retrieved December 15, 2013, from EBSCO Online Database Education Research Complete. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=78943872&site=ehost-live

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Wright, E.R., Russell, L.A., Anderson, J.A., Kooreman, H.E., & Wright, D.E. (2006) Impact of team structure on achieving treatment goals in a system of care. Journal of Emotional and Behavioral Disorders, 14 , 240-250. Retrieved August 1, 2007 from EBSCO Online Database Academic Search Premier http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=23023074&site=ehost-live

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Suggested Reading

Harrison, P. J., Lynch, E. W., Rosander, K., & Burton, W. (1990). Determining successin interagency collaboration: An evaluation of process and behaviors. Infants and Young Children, 3, 69-78.

Soodak, L. C., & Erwin, F. J. (2000). Valued member or tolerated participant: Parent's experiences in inclusive early childhood settings. The Journal of the Association for Persons with Severe Handicaps, 25, 29-41.

Spitz, B. (1987) A national survey of Medicaid case-management programs. Health Affairs . 6 , 61-70.

Unger, M. (2005). Resilience among children in child welfare, corrections, mental health, and educational settings: Recommendations for service. Child & Youth Care Forum 34 , 445-464. Retrieved August 1, 2007 from EBSCO Online Database Academic Search Premier. http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=19100139&site=ehost-live