Leaders' Edge Advisor

Vol. 2, No. 3

Interagency Collaboration - The Individualized Care Team or Wraparound Team - Part III

The Individualized Care Team or Wraparound Team

Dedicated to the late John Burchard, Ph.D. and his pioneering work in Wraparound

“If I see farther than most men it is because I’ve stood on the shoulders of giants”
-Author Unknown


It is 1986 and I’m sitting in class at the University of Vermont for the first time in a few years. Teaching the class is a large man, very knowledgeable and obviously compassionate about children. My professor is John Burchard. So began a wonderful relationship with this gentle man, who helped so many people understand that all children are unique and different, that children thrive in the context of home and community and that all children, no matter how troubled, have gifts to offer their families, communities and the larger world. This article is a small tribute to John, his wife Sarah and his family.

Much has been written about the importance of individualizing care for children and families who are receiving services from a number of agencies. The purpose of this article will be to tease out some of the critical components of the cross-agency team, the team process and the plans that are developed from this collaborative approach to designing plans of care for children and families.

The Individualized Care Team

Given the nature of the individualized care team, the leadership style that will get the best results is clearly one of collaborative leadership. The magic of this type of team that represents various aspects of a child’s and family’s life is to allow maximum participation from all team members. Each member will bring to the forefront some aspect that in conjunction with input from the others provides a rich portrait of the child and family. This is a situation where the whole is definitely greater than the sum of the parts. The most important role the care team leader plays is to make sure that all members participate, especially parents and other family members, who very well might be intimidated by the various professionals sitting around them at the table, while at the same time being the most valuable information resource for the team. Speaking of tables, a round table is much better than a rectangular table. Again we are trying to level the playing field for all concerned, and details like this do matter.

Potential Team Membership List

  • Meeting Facilitator
  • Care Coordinator
  • Teacher/School Counselor/Special Educator
  • Child and Family
  • Family Advocate
  • Relatives
  • Friends, neighbors
  • All agencies involved with the child
  • Various professional disciplines that may be needed depending on the child’s situation

The Individualized Plan of Care

If the stage is set for creating an individualized care plan by ensuring that team members are all actively involved, that they focus on children’s and families’ strengths and that they view the community as a powerful resource for various aspects of the plan, the magic of individualizing the plan will soon follow. The plan of care is not only about looking at a menu to see what the system has to offer. In fact, if the planning is done with an eye towards wrapping services around a child and family it will be designed in quite the opposite way. The team will first look closely to see what the child and family are all about – their unique strengths, talents, interests, spiritual, cultural and ethnic background. Only then will the team begin to explore how community resources and service system resources can be brought to bear in the situation they currently are facing. For example, a young girl who was sexually assaulted may benefit greatly from martial arts lessons in order to regain mastery of her body. Therapeutic horseback riding might serve the same purpose, depending upon the child.

A real-life example of how an individualized care plan can work is a young man who was sexually assaulted, developed a substance abuse problem and one day in school hit his teacher. After he spent some time in an out-of-state facility, a team was sent to meet him and learn about him, with the focus on his strengths, interests, and unique characteristics. The team learned he loved to cook and was very artistic. His individualized plan of care upon his return to the community included an intensive case manager, a therapeutic foster home initially, and part of his school day in the kitchen of the local college. Here he took his math classes from the cafeteria accountant; he cooked in the kitchen and wrote at least two cookbooks of his own recipes. On each page he drew a picture of the dish and wrote a one-page description of the selection; this served to fulfill some of his English requirements. That is creative, flexible, planning, building on the youth’s interests and strengths.

As creative and responsive as this example is, if the system of care worked only through a focus on the individual we would not be successful. Having a local interagency governance team and the state interagency team behind the plan of care allows for all children within the target population to receive what they need with the assurance that implementation problems involving policy, programs or funds will be resolved by one or another administrative interagency team (See Leaders’ Edge Advisor, Fall, Volume II, Number 2). These local and statewide interagency structures ensure that all funds available and resources involved will be maximized to benefit the system and the individual child. Finally, having an organized system of care replaces the notion that one agency needs to do it all for a child and family with the realization that any child and family needing coordinated services and supports is the responsibility of all community stakeholders. Each interagency community team shares responsibility for making the system work for any child and family that needs help from any part of it.

Questions to ask about Individualized Care:

  • Does the individualized care team always involve the family when designing a plan of care?
  • Do plans of care consider the child and family's cultural and religious/spiritual background?
  • Do plans of care maximize all natural supports within the family's community?
  • Are all funding streams being maximized within the interagency makeup of the System of Care?
  • Does the System of Care include a flexible fund to help create nontraditional services that are essential to the plan of care for individual children and families?

This ends the three-part series on interagency collaboration as a critical part of the infrastructure of an organized community-based system of care.

Center for Community Leadership · P.O. Box 3069, Burlington, VT 05408-3069
ph: 802-863-9132 fax: 802-863-6586 · info@centerforcommunityleadership.com

Copyright 2005 Gary De Carolis. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author.

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