Coordinated Planning

Traumatic Brain Injury

In the Beginning:

• Person is discharged from hospital to rehab program or home
• At same time is referred to Head Injury Service Coordinator (SC)
• SC meets person/family or other important persons in his/her life
• SC gathers information on needs and resources available
• Puts together a profile of person before/after injury
• Listens to and understands the person/family's goals and priorities
• Creates a vision of the future (big picture) - what is it that the person wants to achieve/change about his/her life?
• The role of the SC at this point is helping to clarify the person's priorities for the future
• Life has changed since the TBI
• Abilities are different; adjustments have to be made in family responsibilities, work, social activities, etc.

Decision Point:

• To have or not have a multi-agency planning meeting?
• Questions to ask:
• Is the person interested in working to better his/her situation in some way?
• What would be the purpose/outcome desired?
• Who are the right people to involve?
• What special addition can each offer?
• Who else is available to the person besides state agency folks, especially those that will be around for a long time and are interested in having the person reach an outcome (natural supports)?
• Would it help if these supports were organized so efforts are cohesive?
• Some possible reasons to proceed with a multi-agency meeting:
• The person's problems are many, and he/she will need a variety of services from different agencies over a period of time
• The agencies identified to be on a team can identify strengths/capacities, and create opportunities consistent with those
• He/she is unsure what he/she will be able to do in the future, or what he/she wants - life is feeling chaotic
• There are some natural supports, but those may be underdeveloped and also struggling with a need for direction

Preparing for Meetings:

• Gather information - be clear about who the person was, is now and current priorities
• Living arrangement
• Social environment
• Family support
• Education/occupation
• Friends, hobbies, interests
• Develop questions about items that are unclear or unknown
• Develop a list of issues/problems which will need to be addressed
• Identify key people who will be involved and will help with planning and carrying out steps of plan. Note: this should not be just "funding sources", but people who can keep the individual's best interests at the forefront over the long haul
• Learn about the players and what motivates them
• Know their capabilities and what is feasible to expect from them
• Determine the role you will play - who makes sense to be the primary facilitator - recognize that this may change over time as goals shift

Decision Point:

• To include or not include the client in the meeting
• Option may be to have a brief meeting with others first and then include client

Conducting Meetings:

• Be clear about the purpose of the meeting - keep in mind that the focus person is the priority
• Plan adequate time, especially for the first meeting
• Schedule the meeting in as comfortable, neutral place as possible
• Be clear about your role
• Watch for opportunities to mentor other facilitators, such as family members, to foster independence and self direction
• Encourage honesty and integrity
• Recognize group dynamics
• Set up the mindset of joint (side by side) problem solving rather than hard line positions that end up defeating the purpose
• Analyze how well people work together (spend some time thinking what went well, and what didn't, so you can take action next time if necessary)
• Be prepared to advocate for the client's priorities - it can be intimidating for the person to face an array of professionals
• Ask "what can we do to make this happen" - question agency policies if necessary
• Struggle for difficult goals that are meaningful to the person - not too easy, yet not unachievable
• Be aware of when the discussion is unproductive or off topic and take steps to refocus the group toward capacity building - think ahead of time what could happen to get people side-tracked so you are prepared for this and keep the focus on the task at hand
• Be aware when members are not participating, and encourage open and active discussions
• Be aware when members are disrupting the work (could be a family member)
• Ask questions when suggested activities do not seem to be essential to the outcome desired
• Communicate in ways that are clear and non-threatening to participants
• Get commitments from others about what they will do
• Create timelines and benchmarks to show consistent progress toward the outcome (what will be done, by whom, by when)
• Make sure notes of the meeting are written and disseminated to all

Monitoring Progress:

• The plan over time may have changes, and guidance for the group will be needed to ensure the focus remains on the person's target outcome
• Plan meetings frequently enough to keep people informed and motivated to participate - consider setting a rough schedule at the beginning, such as meeting quarterly, adjust if needed
• Make sure there is a purpose to each meeting
• Take time to think through the issues beforehand and develop an agenda of discussion points/action items needed:
• Barriers that need problem solving
• Accomplishments to celebrate
• Opportunities that benefit from "group think" to determine the best course of action
• Check in on whether the time line is still on target, or is there a need to discuss a "Plan B"
• Identify the options, and giving the options weight to help make decisions about them
• Are the right people still involved?
• If it's not working, STOP AND RETHINK
• Crisis prevention - anticipate what could go wrong and plan accordingly
• Dealing with "crisis situations" - When to call an interim meeting

Transition:

• Some signs for deciding that facilitation of meetings is no longer necessary:
• The person has accomplished the main goal, and is busy working or going to school, etc.
• The person or someone else in his/her personal network emerges as a leader, and will continue in that role - roles have shifted to a natural support rather than an agency support

Key Teaching Points:

• Resources are stretched, and it is necessary to be efficient in how we work and accountable for funds expended
• Clients should hear a consistent and realistic message from agencies involved
• Outcomes should be meaningful to the person/family
• Services should be essential to achieving the outcome
• Services should reduce the level of disability and the overall cost of care
• All team members have a role and responsibility, including the client/family
• Managing efforts up front can reduce the need for long term intervention