HEALTHY FAMILIES MASSACHUSETTS POLICIES & PROCEDURES

SERVICE TRANSITIONS
A participants transition out of program services occurs for many reasons: s/he is no longer eligible for continuing services as the child has aged out (a.k.a. graduation), is no longer pregnant or parenting, or has lost contact, elects to end services, and/or leaves the program catchment area. Transition out of program services is an important event in a participants life. Some participants may not have had positive experiences with past changes or transitions in their lives. HEALTHY FAMILIES MASSACHUSETTS (HFM) can help participants build the planning and self-care skills to not only weather their transition from HFM, but also other transitions they may experience within their families. Effective use of transitioning strategies may increase the long-term value of HFM services to young families. HFM policies and procedures on service transitions are divided into the following sections: Transition planning; Discharge; Types of transitions; Transfers within HFM programs; and Re-enrollment in HFM programs. Attached to this policy are the following appendices: Appendix A: Transfer Consent Form Appendix B: Transfer Tracking Form Appendix C: Program Site Codes I. TRANSITION PLANNING In HFM, planning for transition from the program begins at enrollment: staff inform participants of the maximum time they may spend in the program. Home visitors provide participants with concrete resources and help them to develop their parenting skills with goal of empowering those participants to take the lead in advocating for themselves and their children throughout their involvement in the program. Early focus on the inevitable transition out of services sets the stage for a positive experience at the end of services and conveys the strengths-based belief that young parents are capable of successfully navigating their own lives. When a participant informs the home visitor that s/he will be leaving the program for any reason or the child will be turning three, the participant, home visitor, and supervisor should develop a thoughtful transition plan. Development of a thorough transition plan, with tasks geared toward maximizing time in the program and acknowledging the next
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phase in their lives, reinforces the idea that participants can manage change and loss effectively, intentionally, and proactively. The plan should include: Review of participant goals and successes; Review of any incomplete service referrals or other service needs; Collaboration with the participant to develop a plan for any logistics of transition (e.g. change of address, new program contacts, new program intake, etc.); Review the limits of participant eligibility in the program and future access after discharge; A timeline with tasks leading up to the transition; and Activities to formally say goodbye and mark the time in HFM. In planning these tasks, staff need to take into consideration the length of time between the announcement of the plan to leave HFM and the participants last day in the program. The goal of transition is to ensure support and closure of one phase of a participants life and prepare the participant, as much as possible, for the next phase. II. DISCHARGE Discharge describes the final date of HFM services and is the date that must be recorded in the PDS. All participants discharged before their childs third birthday receive a Final Closing letter notifying them of their eligibility status and the last day of current access to HFM services. Closing out a case refers to the tasks and responsibilities for completing documentation related to a participants discharge. A closing date may be the same date as discharge or afterwards, until the 10th day of the following month. Once a program completes the discharge form, it becomes read-only access and cannot be modified. Should a former participant contact the HFM program for any other reason than seeking re-enrollment, there is no documentation recorded for Healthy Families purposes. Programs should seek guidance from within their agency regarding any requirements for documenting contact with former participants. III. TYPES OF TRANSITIONS A. Transition From HFM Because of Childs Age (a.k.a. Graduation) Some participants stay involved in HFM until their children turn three years old (i.e. they graduate from HFM). If a participant family is involved in services when their child is 30 months old, programs must prioritize transition planning. Home visitors should include all elements of the transition plan (outlined above) in their work with participants graduating from the program. B. Transition From HFM Because Participant is No Longer Pregnant or Parenting Participants lose their eligibility for HFM if, for any reason, they are no longer parenting their children. Examples of situations in which a participant is no longer parenting include loss or transfer of custody, death of child/fetus, or miscarriage/termination of a pregnancy. According the HFM Eligibility Policy & Procedure, programs are encouraged to work with participants in these circumstances for up to two months to
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make a thoughtful transition plan that meets participants needs and facilitates access to other community resources. C. Transition From HFM With No Program Notice At times, participants leave the program with little or no notice, or are lost to follow up. In these cases, transition activities may only consist of attempts to contact the participant prior to discharge. In some cases where a working relationship had been developed, it is recommended that the home visitor send a personalized letter that consists of transitions tasks such as reviewing accomplishments, identifying continuing goals, and offer of support in identifying other community resources. Programs should ensure that all documentation of secondary activities, service level changes, and discharge are completed and documented appropriately in the PDS. Before the program end services programs must send a final closing letter please see Appendix D: Final Closing Letter in HFM SERVICE LEVEL POLICY. Should a participant who has left with no notice attempt to return to re-enroll, programs must reassess that parents eligibility at that time. B. Transition From HFM When Participant States S/he No Longer Wants Services Participants also choose to transition from the program before their child turns age three. Programs should develop a transition plan with participants and complete as many activities as possible. This transition should include a thorough discussion of the impact on ongoing eligibility. Programs should ensure that documentation (secondary activities, service level changes, referrals, etc.) is complete. Should a participant who has left before their child turns age three attempt to re-enroll, programs must reassess that parents eligibility at the time of attempted re-enrollment. Please contact the HEALTHY FAMILIES MASSACHUSETTS Implementation Team (HFMIT) by submitting a Technical Assistance (TA) ticket via the TA Help Desk at CTF_TAhelpdesk@massmail.state.ma.us if there is any question regarding the initial eligibility of a referral. C. Transition From HFM Due to Participant Leaving the Catchment Area Participants may move and in so doing, leave their current HFM catchment area. Sometimes they know that the change will be permanent, they let their home visitor know in advance, they are staying within Massachusetts, and they want to continue (i.e. transfer) within HFM. At other times, they may not give much notice to the program, they may be moving out of state, or they may not want a transfer. Each of these situations carries its own unique challenges and issues. Program practice must adapt itself to adequately meet the participants needs while still working within the program model. HFMIT is aware that, given HFMs especially mobile population, there may not be much time to prepare for a transition when a participant leaves the catchment area. In fact, program staff may only find out with little or no advance notice and not be able to develop a thorough plan or prepare for transitions at all. In these situations, the goal should be to complete as many tasks as possible.
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1. If the participant is moving out of state a. Coordinate services as much as possible in the new location. b. Move the participant to Re-Engagement service level for at least one month; in the event that the move is unsuccessful, the participant retains all eligibility if a return to Massachusetts occurs. c. Seek permission to contact the participant, in the new location, one month after last contact. This can confirm whether the participant anticipates a return to Massachusetts, and if there is any further support the program can offer. If the participant gives permission, then After this final contact, if the participant will not be returning to Massachusetts, discharge the participant. After this contact, if the participant anticipates returning, develop a plan to transfer or re-engage the participant. If the program is unable to successfully contact the participant within a month, the program should begin formal discharge tasks. These tasks include notifying the participant in writing of the date the program will formally will formally end services. 2. Transition from catchment area with participant indicating she/he does not want to transfer within HFM: Participants may have many reasons for not transferring. Some reasons will not change over time. However, some will shift. Loyalty to the former program or home visitor, fear of having to start over again, and overestimation of the level of support in the new situation are typical reasons why a participant might change his or her mind. a. The home visitor should discuss with the participant the possibility of transferring to a different HFM program and continuing services, even if the participant feels they do not want to transfer. b. Coordinate services as much as possible in the new location. c. Move the participant to Re-Engagement service level for at least one month; ensuring that the participant retains all eligibility if a transfer or reenrollment is requested. d. Seek permission to contact the participant, in the new location, one month after last contact. This can confirm whether the participant anticipates a return to HFM, in the original or the new location. If the participants gives permission, then After this final contact, if the participant will not be returning to HFM, discharge the participant. After this contact, if the participant anticipates returning to HFM, develop a plan to transfer or re-engage the participant. If the program is unable to successfully contact the participant within a month, the program should begin formal discharge tasks. These tasks include notifying the participant in writing of the date the program will formally will formally end services.
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IV. TRANSFERS WITHIN THE HFM STATEWIDE PROGRAM One of the benefits of having a statewide program is that if a participant moves to another city or town within Massachusetts, there is an HFM program providing services. Participants can transfer to or re-enroll in another site without considerable service disruption. If a participant requests a transfer to another HFM site, the following protocol should be followed to ensure ease of transition. This protocol represents the most promising practice for HFM participants. NOTE: These steps may be completed over several visits. A. At the Sending Program 1. Confirm the following information: The date the participant will leave the current program and the date the participant expects to be relocated in the new programs catchment area. The HFM program covering the town where your participant is moving. Be sure to give the participant contact information for the HFM program in their new community in case communication is disrupted prior to the completion of the transfer. NOTE: Please see Appendix B of the HFM PROGRAM ADMINISTRATION POLICY for a listing of HFM program catchment areas.
2.

Share the Consent to Release Information: Transfers within Healthy Families Massachusetts form with the participant (Appendix A), have the primary participant read the consent form or explain to him/her verbally the information covered in the consent and have the primary participant sign. (If a secondary participant is involved in this family and information has been collected about him or her, seek his or her consent as well. However, this consent is not necessary to complete the transfer.) NOTE: As with any other release of confidential information to an agency outside of the program in which the participant originally consented to participate, the sending program MUST have a signed release to share information with another HFM program. While HFM is a statewide program, participants consent to participate in a specific program site. Thus, a written consent to release information is required; verbal consent is not sufficient to share confidential information beyond name and date of birth, between HFM programs. a. Begin the Transfer Tracking Form (Appendix B of this policy) Gain as much contact information for the new location (phone, address, cell phone, alternate contact) as possible, including contact information for a relative or someone close who would know how to reach the participant if this contact information doesnt work.
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 Record the new contact information on the Tracking Form and in the
home visit record summary box so it can be easily referenced.

When the Tracking form is as complete as possible, fax it to the receiving

program. b. Contact the receiving program by phone to alert them of a transfer, discussing time frames for discharge and transfer. NOTE: If the receiving program has a closed intake because it has no capacity to take new referrals, it must accept the transfer and create an ad hoc waitlist to ensure continuity of services for that participant. c. Inform the participant of the availability for services at the receiving program and continue transition activities. If at all possible, before a participant is transferred from the sending program, arrange to have a joint visit between the current home visitor and the new home visitor. d. Update all records in the Participant Data System (PDS), in participant paper records, and in the supervision log. e. Discharge the participant after service delivery has ended and all PDS records are up to date. PDS NOTE: To transfer participants in PDS, discharge them with a reason of Transferred to other Healthy Families and select Other Healthy Families in response to the prompt What new program, if any, is the child moving to? After selecting the appropriate receiving program site code and saving the discharge form, the PDS automatically moves the participant into the Transfer Queue, making his or her record available to the receiving program immediately. SEE THE HFM PDS USERS MANUAL SECTION 2.2.2 2.2.5 OF DISCHARGING A PARTICIPANT.

Update the Transfer Tracking Form and fax it to the receiving program. Remember that because the participant is waiting:

A discharge record should be completed as soon as possible after the last home visit was completed at the sending program to ensure continuity of services; and All records in PDS become read-only once a discharge is completed; they cannot be modified. Ensure that all home visits, secondary activities, supervisory review, etc., are completed before discharging the participant.

f. When the receiving program has alerted the sending program that the participant has engaged in services, the sending program should send the receiving program copies of any of the existing documents: Family Profile tools & summary ; Most recent Individualized Family Support Plan (IFSP); and Most recent Ages & Stages Questionnaire. The original should stay with the program that completed them.
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NOTE: If there was no prior assessment completed or partially completed at the sending site, the receiving program must complete a full Family Profile (not just the PTF). B. At the Receiving Program 1. After receiving the Transfer Tracking Form (Appendix B of this policy), contact the transferring participant to: confirm the participants interest in continuing services; and schedule a home visit. If possible, coordinate with the sending program. 2. Once the sending program alerts you that the participant has been discharged, extract the participant record from the PDS Transfer Queue. SEE THE HFM PDS USERS MANUAL USING THE TRANSFER QUEUE. 3. Review the record to become familiar with services provided. 4. Make frequent and regular attempts to contact the transferred participant, following the three month engagement requirement. a. When you have an outcome of contact: If the participant does not enroll or is lost to follow-up: complete the third box of the Referral for Transfer Tracking Form, and fax it to the sending program. If the participant does enroll: complete the third box of the Transfer Tracking Form, requesting copies from the participant paper record, and fax it to the sending program. 5. Initiate home visiting services with the transferred participant. If at all possible, arrange to have a joint visit between the previous home visitor and the current home visitor. a. Complete the Family Profile Participant Transfer Form (PTF) and My View. The PTF must be completed within the first four visits or 6 weeks of the receiving programs date of first contact with the participant. This tool was adapted to specifically meet the needs of a newly-moved/transferred participant. It provides useful information that can facilitate program efforts in supporting the participant in their new location.

If the participant transfers while pregnant, complete a PREG-SI form once

the baby is born, following the timeline as described in the HFM STANDARDIZED ASSESSMENT AND INFORMATION GATHERING POLICY. b. Check in with the participant about his or her most recent IFSP to determine if the goals remain relevant given the change in residence, looking to develop more up-to-date goals as a way to build relationship and focus services. NOTE: Timely completion of all documentation is important to the smooth transition of participants. Delay in completing the transfer steps and documentation can negatively affect ongoing service delivery.
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V. RE-ENROLLMENT AT SAME SITE Participants who transition out of HFM services and then later wish to return may re-enroll if they are still eligible for the program, according to the eligibility requirements detailed in the HFM ELIGIBILITY POLICY. All requests for re-enrollment should include a conversation with the parent on whether or not Healthy Families continues to be an appropriate program for the parent. Programs should keep in mind that former participants may seek to re-enroll in HFM to get more information that does not require a commitment to program services. Programs can always provide information and referral to former participants at any time after their enrollment in Healthy Families ends. HFMIT recommends that programs complete the My View form with all participants reenrolling in Healthy Families to get an assessment of the participants current circumstances. VI. RE-ENROLLMENT AT A NEW SITE A re-enrolled participants experience in a different HFM program can impact their expectations of services from the current program. Despite the statewide nature of the program and all programs attention to high quality services, there remain differences between how each program implements the program and provides services. It is important, therefore, that when a participant re-enrolls either at the same site or a new site, programs must thoroughly discuss with the participant the following: His/her previous circumstances and experience in HFM; Reasons he/she left the program previously; and His/her ongoing commitment to services. Participants sometimes attempt to return to HFM services at a new program location without having requested a transfer. Most often, programs discover that the participant has previously received services when they attempt to enter the new referral into the PDS. Under such circumstances, this is not considered a transfer because the original program did not guide the transition to the next program. If the participant is interested in re-engaging in services, programs must honor this request as long as the participant meets eligibility requirements. Programs must establish eligibility before the participant is formally offered reenrollment in the program. PDS NOTE: To re-enroll a participant, programs create a new referral in the existing family record, and upon first contact, select Re-Enroll as the outcome of contact. PLEASE SEE APPENDIX O: PDS USERS MANUAL OF THE PROGRAM ADMINSTRATION POLICY SECTION CREATING A REFERRAL. Once a program determines that a participant is eligible for re-enrollment, the program should confirm with the participant that s/he did receive services at another HFM program site and seek the participants permission to exchange information with that site. Honoring the voluntary nature of the HFM program, the participant may still choose not to authorize that the new program communicate with the original program.
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HFMIT recommends that programs complete the My View form with all participants reenrolling in Healthy Families to get an assessment of the participants current circumstances. 1. If the participant agrees to share information from his/her previous HFM program: Obtain a signed release of information from the participant to request information from the previous program site; Submit a ticket to CTF IT to merge the participants records in PDS; and Contact the previous site to request copies of any of the existing documents: o Family Profile tools & summary; o Most recent IFSP; and o Most recent Ages & Stages Questionnaire. Complete the Family Profile Participant Transfer Form (PTF) and My View within four visits or six weeks from the date of first contact.
REMINDER: If a participant re-enrolls while pregnant, complete the PREG-SI Family Profile form once the baby is born in addition to the PTF and My View Family Profile forms.

2. If the participant elects not to share any information from the previous enrollment or states that s/he never received services from another HFM program: Notify the PDS Help Desk and Program Specialist that the participant enrolled as new referral. These HFMIT staff will guide the program in how to create an appropriate PDS record for this family. Treat the participant like any other new referral to the program.

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CONSENT TO RELEASE INFORMATION: TRANSFERS WITHIN HEALTHY FAMILIES MASSACHUSETTS As a current participant in a HEALTHY FAMILIES MASSACHUSETTS (HFM) program, you are requesting a transfer to another Healthy Families program. The purpose of this consent is to exchange information between HFM programs to ensure the best possible services. By signing it, you are permitting your current Healthy Families program ______________________________________________________________________________ to send to the new Healthy Families program ______________________________________________________________________________ the following information: Your Healthy Families Massachusetts electronic record The following components of your HEALTHY FAMILIES MASSACHUSETTS paper record: A copy of your Family Profile/assessment tool The most recently completed Ages & Stages Questionnaire (if applicable) The most recently completed Individualized Family Support Plan (IFSP) (if applicable) Your contact information so that the new program can contact you to discuss providing services. Any information necessary to facilitate this transition of services. Your personal information will be given to the above named Healthy Families program with the sole purpose of facilitating this transfer of services. The rules of confidentiality are the same as explained in the original consent form you signed when you enrolled in this program. As always, you have the right to review your record and may choose to do so now. I have read this information about Healthy Families or had it explained to me. I understand that by requesting a transfer, my records and contact information will be shared with the Healthy Families program to which I am transferring. ______________________________________________ Participants Signature ______________________________________________ Participants Signature ______________________________________________ Witness Signature __________ Date __________ Date __________ Date

HEALTHY FAMILIES MASSACHUSETTS September 2010

CONSENTIMIENTO PARA LIBERAR INFORMACIN: TRANSFERENCIA DENTRO DE EL PROGRAMA FAMILIAS SALUDABLES DE MASSACHUSSETS Usted como participante actual del programa Familias Saludables de Massachussets esta pidiendo una transferencia a otro programa de Familias Saludables. El propsito de este consentimiento es para intercambiar informacin entre los programas de Familias Saludables para asegurar el mejor servicio posible. Al firmar este documento usted le da permiso a su programa actual de Familias Saludables a mandar la siguiente informacin al nuevo programa de Familias Saludables: Su registro electrnico (electronic record) de Familias Saludables. Los siguientes componentes de tu registro escrito (paper record) de Familias Saludables: o Una copia de Evaluacin Familiar (Family Profile/Assessment Tool) o El cuestionario mas reciente y completado de Edades y Etapas. o l mas reciente y completo Plan De Apoyo Individual de Familia (IFSP) o Su informacin de contacto para que el nuevo programa se pueda contactar con usted y pueda discutir servicios. Cualquier otra informacin necesaria para facilitar la transicin de servicio.

Su informacin personal se le dar al mencionado programa Familias Saludables con el nico propsito de facilitar la transferencia de servicios. Las mismas reglas de confidencialidad que fueron explicadas en el documento original de consentimiento que usted ha firmado cuando comenz el programa estarn en efecto. Como siempre, usted tiene el derecho de revisar su registro o optar a no revisarlo. He ledo esta informacin sobre Familias Saludables o me lo han explicado. Entiendo que al pedir una transferencia mis registros y informacin de contacto sern compartidos con el programa Familias Saludables en cual yo estar transfiriendo. ________________________________________________ Firma de Participante ________________________________________________ Firma de Participante ________________________________________________ Firma del Testigo ________________ Fecha ________________ Fecha ________________ Fecha

HEALTHY FAMILIES MASSACHUSETTS September 2010

AUTORIZAO PARA TRANFERNCIA DE INFORMAES: TRANSFERNCIA ENTRE HEALTHY FAMILIES MASSACHUSETTS (Familias Saudveis Massachusetts) Como um participante ativo do programa HEALTHY FAMILIES MASSACHUSETTS (HFM), voc est requerendo uma transferncia para um outro programa da Healthy Families. O propsito dessa autorizao consentir a troca de informaes entre os programas de HFM para garantir o melhor servio possvel. Assinando-a, voc estar permitindo e autorizando que o seu atual programa da Healthy Families _______________________________________________________________________ envie para o seu novo programa da Healthy Families _______________________________________________________________________ as seguintes informaes: O seu registro (histrico) eletrnico da Healthy Families Os seguintes components do seu registro da Healthy Families Massachusetts: Uma copia do seu perfil familiar/ instrumento de avaliao O mais recente e completo questionrio Ages and Stages (se aplicvel) O mais recente e completo Plano Individual de Suporte Familiar (IFSP) (se applicvel) A sua informao para contato para que o novo programa possa entrar em contato para discutir e oferecer servios. Qualquer informao necessria que facilite na transferncia de servios. A sua informao pessoal ser compartilhada com o programa de Healthy Families descrito acima com o nico propsito de facilitar a transferncia de servios. As mesmas regras de sigilo esto em efeito como explicadas na autorizao original assinada quando voc quando se registrou nesse programa. Como sempre, voc tem o direito de revisar o seu registro (histrico) e pode optar fazer isso agora. Eu li essa informao sobre Healthy Families ou foi explicado pra mim. Eu entendo que requerendo essa transferncia, o meu relatrio(histrico) e informao para contato sero compartilhados com o programa de Healthy Families para o qual eu estou transferindo. ______________________________________________ Assinatura do Pariticipante ______________________________________________ Assinatura do Participante ______________________________________________ Assinatura da Testemunha __________ Data __________ Data __________ Data

HEALTHY FAMILIES MASSACHUSETTS September 2010

Transfer Tracking Form Sending Program Complete this Section Healthy Families Program:_____________________________________ Contact Person:________________________________________ Phone___________________ Fax_____________________ Referral date:_______ __________________________________ (DOB ___________) is requesting a transfer to your HFM program ________________________________ . Name of Baby: _____________________ DOB or EDC: ________________

Expected date of relocation is ___________. Contact information in the new catchment area Address______________________________________________________ Phone____________________ Phone____________________

Alternate contact________________________________________________ Alternate contact________________________________________________ **Fax to receiving program when this section is complete** Sending Program Complete Receiving Program Complete this Section Date of discharge______________ The participant PDS records are now in the Family Transfer Queue **Fax to receiving program when this section is complete** Outcome of Referral ____ Participant re-enrolled ____ Participant declined services ____ Lost to follow up ____ Paper records requested ____ Paper records received on _________

**Fax to sending program when this section is complete** To be filed in participant record
HEALTHY FAMILIES MASSACHUSETTS Appendix B: Service Transitions Policy Transfer Tracking Form September 2009

HEALTHY FAMILIES MASSACHUSETTS Site Codes

PA071 PN070 BH023 CH011 RO087 HC085 CC051 JF025 PI078 MI058 HS020 FC075 HA074 RC019 HV093 HO072 LA031 LO036 HH029 NB053 NS091 NW063 PL054 WE061 SP090 TA093 DO088 MS059 Healthy Families Berkshire County Healthy Families Berkshire County Blue Hills Healthy Families Boston Neighborhoods Healthy Families Boston Neighborhoods Healthy Families Brockton Healthy Families Cape Cod Healthy Families Early Childbearing Program Healthy Families Central Middlesex Greater Fall River Healthy Families Collaborative Healthy Families Framingham Milford Healthy Families Framingham Milford Healthy Families Franklin County Healthy Families Hampshire County Harbor Area Healthy Families Healthy Families Haverhill Holyoke Healthy Families Healthy Families Lawrence Healthy Families Lowell Healthy Families Melrose/Wakefield Healthy Families New Bedford Healthy Families North Shore Healthy Families North Worcester County Greater Plymouth Healthy Families Healthy Families Southern Worcester County Healthy Families Springfield Healthy Families Taunton/Attleboro Urban Neighborhoods Healthy Families Greater Worcester Healthy Families

HEALTHY FAMILIES MASSACHUSETTS Appendix C: Service Transitions Policy HFM Site Codes September 2010 Page 1