DHS Initiative Seeks to Improve Case Planning for Children with Complex Needs

On October 2, 2020, the Pennsylvania Department of Human Services (DHS) released a bulletin providing guidance to all state and county agencies that serve children, all family and youth advocacy organizations, and all Medicaid physical and behavioral health managed care organizations (MCOs) regarding case planning for children with complex needs.  The goal is to develop service or case planning “best practices” at the state, county, and local levels to serve children with complex needs in the least restrictive and most appropriate setting.  

Children with complex needs are defined as those children, youth, and young adults with complex mental health, behavioral health, intellectual disability, and/or physical health needs; and who are being served by more than one child-served system (county children and youth, county juvenile probation, county mental health, county intellectual disabilities, or receiving medical assistance for a physical health diagnosis) and are in need of comprehensive, coordinated treatment. 

At the heart of this initiative is the Department’s recognition that children and youth with complex needs require services from more than one system, and that effective complex case planning engages those multiple systems and takes into account the strengths of the child and family and the multitude of the child and family’s needs.  

The October bulletin outlines three tiers to ensuring coordinated service planning for children with complex needs: a county level process, a joint county/state process, and a state process.  

County Level Process
Each county agency has a local process for service planning, which is based on the child’s individual needs.  Counties also employ cross-agency processes for situations when the child’s needs require the involvement of multiple systems.  A joint county team approach will be deployed to enable the county to resolve challenges by treating each child with complex needs as a member of the community, rather than as a child served by specific agencies in the county.   

In these complex cases, the Department recommends that all human services agencies that serve children in the county should come together with the child’s family to serve as one planning team tasked with holistically addressing all of the child’s needs.  The planning team will include the child and their family, any individuals identified by the child/family as part of their support network, and any agency or entity involved in the child’s care and needs, including caseworkers or Support Coordinators from MH/ID, CYS, Juvenile Justice, and/or Early Intervention, BH-MCO and PH-MCO care managers and special needs coordinators, and more. 

The county complex planning team should seek to define goals, develop a service plan using the Integrated Children’s Service Planning Process, develop necessary resources to implement the service plan, evaluate the progress of the plan, and conduct regular or periodic reviews of the child’s needs.  Effective planning requires county complex planning teams to be proactive as opposed to reactive; planning should begin as soon as the child’s needs are identified, not at the time of a crisis or during the transition from a child-serving system. 

Joint County/State Level Process
Despite best efforts at the county level, there are times when a joint county/state level process must be implemented.  A joint county/state process will be deployed if during the service planning process, resources are discussed and next steps cannot be identified; services and/or placement options cannot be identified; the service planning team, family, and child/youth cannot reach an agreement on services or placement options; or funding sources cannot be identified and/or resolved in a blended or shared manner.   

The local agency will refer the case to the appropriate DHS regional office, where a planning meeting will be scheduled with the county complex case planning team and the regional complex planning team, no later than two weeks from the referral date.  During the planning meeting, a plan will be developed which identifies resources and services necessary to address the challenges. 

State Level Process
Where a complex case cannot be appropriately addressed using either the county level process or the joint county/state level process described above, the case can be referred to the Department’s Complex Case Planning Team. 

A Referral Form has been developed for situations where the child’s situation meets at least one of the following: 

• The clinically appropriate solution requires support from multiple program offices/agencies or stakeholders at the county level who together cannot agree on a solution; 

• The funding solution comes from multiple sources, which may include external entities; 

• The case involves complexities that render it unresolvable through the established county or regional office process; and/or 

• The child/youth is currently in an inappropriate placement due to an inability to identify or implement the least restrictive treatment option. 
   

The completed referral form must be emailed to RAPWCMPLXCASEREFS@pa.gov to make a referral to the Complex Planning Team. A lead program office will then be identified and will be responsible for scheduling an internal meeting within two weeks of the referral, with a follow-up planning meeting within one week of the internal meeting. The lead program office will summarize the results of the meeting for all involved. If a resolution cannot be identified, follow-up meetings will need to be scheduled until an appropriate solution is identified.   

All referrals made to the Complex Case Planning Team will be monitored within the Department to ensure timely resolution as well as to track strengths, challenges, and potential gaps in service provision. Aggregated trend data will be reviewed by a multi-system Steering Team to continually assess and improve service delivery for children with complex needs. 

With the release of the October bulletin, the Department has also developed a checklist to be used as a guide in requesting assistance from either the regional office or DHS Complex Case Planning Team regarding complex case issues.  

Questions about the October bulletin and new referral process should be directed to the appropriate department’s regional office: 

Office of Children, Youth and Families (OCYF)
Western Region: 412-565-5728
Central Region: 717-772-7702
Northeast Region: 570-963-4376
Southeast Region: 215-560-2249 

Office of Mental Health and Substance Abuse Services (OMHSAS)
Western Region: 412-565-5226
Central Region: 717-705-8395
Northeast Region: 570-963-4335
Southeast Region: 610-313-5844 

Office of Developmental Programs (ODP)
Western Region: 412-565-5144
Central Region: 717-772-6507
Northeast Region: 570-963-4749
Southeast Region: 215-560-2245 

This bulletin, updating the planning for children and youth up to age 21, rescinds and replaces Bulletin #00-10-02, entitled “Complex Case Planning,” which was issued on December 28, 2010.