Coordinated Service Planning

Families have said they found that navigating the system was confusing and complicated when accessing services. Coordinated Service Planning was started in 2015 as part of the Ontario Special Needs Strategy.

The Ontario Special Needs Strategy is an initiative of:

• The Ministry of Children, Community and Social Services
• The Ministry of Education
• The Ministry of Health and Long-Term Care

The Special Needs Strategy is committed to using a common approach to service coordination through all agencies based on the following values:

• Family-centred/family-defined
• Any door is the right door
• Families tell their story once
• One person to call
• Flexible, individualized support for Coordinated Service Planning
• Accessible service
• Community vision and accountability
• Shared and informed decision-making
• Timely, effective, transparent information and communication
• Holistic perspective that has a prevention lens

Children and youth with multiple and/or complex special needs rely on many services for support (for example: rehabilitation services, autism services, developmental services, respite supports, criminal justice and/or mental health services). These children and youth may have difficulty in several areas, including their physical, communication, intellectual, emotional, social, and/or behavioural development.

The Service Planning Coordinator supports the family until they no longer need the support, and this will look different for each family. Discharge from Coordinated Service Planning may happen when:

• goals are met and the family and team agree that Coordinated Service Planning is no longer needed,
• the family moves away from the area served by CHEO (Ottawa, Prescott-Russell, and Stormont Dundas and Glengarry counties),
• when the youth leaves school (between the ages of 18-21), or
• the family asks to be discharged.

Families may re-enter the Coordinated Service Planning process as needed.

Coordinated Service Planning may be initiated if the family is feeling overwhelmed with coordinating services and when the needs of the family go beyond the resources available through their current team. Coordinated Service Planning is not meant to duplicate services currently being used; instead it should ease communication between families and their team members. It provides the family with the chance to meet together with all of the professionals from different agencies and work towards creating a plan of care for the child/youth (known as a Single Plan of Care). Coordinated Service Planning is a formal process between CHEO, Service Providers, School Boards and Champlain Local Health Integrated Network (LHIN).

The Service Planning Coordinator facilitates communication and collaboration amongst your ongoing care team members.

The Service Planning Coordinator will develop a Single Plan of Care (SPOC) in partnership with you and share that plan with the team. In doing so, their role is to take the lead in helping to open a dialogue between you and your care team, strengthen partnerships between your care team members and coordinate your services so that all members of your care team are working together toward a common vision and goals.

Once you are satisfied that your care team is working together effectively to meet your shared vision and goals, service from your Service Planning Coordinator will be complete.

Service Planning Coordinators recognize that the system is complex and cannot always meet all of your needs. Although Service Planning Coordinators will attempt to bridge any gaps within the system that you are facing, this may not always be possible. However, your feedback will be communicated by your Service Planning Coordinator to the leaders of Coordinated Service Planning who will then communicate these barriers to the Provincial Ministries involved in this initiative.

Here's the steps you can expect during your journey:

• Referral
• Intake and assessment
• Strengths and needs identified
• Service Planning Coordinator assigned
• Goals set and prioritized
• Provider team identified
• Coordinated Service Plan developed/updated
• Plan is documented and shared with providers
• Services and goals are monitored

The Single Plan of Care is a strengths-based document that addresses the service needs of the child/youth with multiple and/or complex special needs. Your Service Planning Coordinator will seek the active participation of the child/youth/family/guardian(s) in the creation of this document as it is driven by the goals of the child/youth and their family/guardian(s).

The Single Plan of Care is used to facilitate the exchange of information between relevant providers in the children’s services, education, and health sectors in each service delivery area.

Throughout a child/youth and their family/guardian(s)’ time with Coordinated Service Planning, the Service Planning Coordinator will monitor, review, and update the Single Plan of Care, in collaboration with the child/youth/family/guardian(s) and relevant providers in the children’s services, education, and health sectors, as needs and services change.

Coordinated Service Planning goes beyond regular inter-professional communication and collaboration that takes place when providers work together in an effort to ensure they are integrating practice and service delivery for children, youth and families. It is a support in and of itself that is intended to decrease family stress by providing families with a formal voice in the service planning process and by assisting families in navigating and coordinating services for their child/youth.

No. The role of the Service Planning Coordinator is not to provide direct therapeutic services.

Your Service Planning Coordinator can help connect you to services that will support the achievement of your vision and goals.

Yes. If you are struggling, please connect with us.

Even if Coordinated Service Planning is not identified as the most appropriate service for you at this time, our Outreach Worker will support you in connecting with a more appropriate service that will better meet your needs.

We welcome your feedback.

As part of this provincial initiative, your Service Planning Coordinator will be asking for your feedback throughout their time with you. 

If you don't feel comfortable providing feedback directly to your Service Planning Coordinator, please connect CHEO's Patient Experience team.