Integrated Services Summary: Article Two


Summary of Integrated Services Approach: Referrals, Coaching, Data


The first of the 5-part summary of our Integrated Services Update, Review of the YCCAC Strategic Plan, was posted on the BB and sent by email to all YCCAC staff last week. It described some of the work undertaken in guidance with the YCCAC Strategic Plan over the past two and a half years, including initiatives in communications, affordable housing, and school readiness of children in Biddeford. The second installment, Summary of Integrated Services Approach: Referrals, Coaching and Data, appears today.


Simply defined, integrated services is the entirety of services and resources available to YCCAC clients/patients for which they may be eligible , need and want, offered in a seamless fashion. An example might be a HEAP client who is also in need of health services and transportation to school or work: when presented with these service options through a referral process, all of the client’s needs are met, resulting in an outcome that offers greater opportunity for improved health, wellness, and self-sufficiency. In this way, we promote our client/patient-centered approach to service delivery.


Internal referrals are characterized as “seamless, trackable, with a measurable work-flow that is closed-loop.” By closed-loop, we mean that status updates are provided with feedback of stages of process and acknowledgement of referral within 24 hours and contact with the client/patient within 48 hours. We acknowledge the following characteristics of a seamless referral:

• Client/patient permission is obtained prior to referral • Success of a seamless internal referral is measured by adhering to the determined workflow, and is not dependent on the client/patient’s outcome • The communication will include information regarding priority/urgency of the situation


An Internal Referral Pilot was launched September 14 and is set to run until October 30. The Pilot will test an Internal Referral system that supports clients/patients connecting to the services they need to achieve wellbeing, and which streamlines and tracks workflows for departments. The Pilot will provide insight into our ability to make referrals when the appropriate program/resource is known, and not known; the possibility of moving to scale across the agency; ease of making and receiving referrals; tracking referrals and outcomes; and workflows for each departments to carry out referrals.


Whole Family Coaching Model: YCCAC staff from across the agency have been engaged with families for the past two years, providing long-term coaching and support toward achieving set goals. The coaches work with families to develop “Pathway Plans,” interacting with parents and their children. YCCAC coaches offer the support and resources to help the families in service of milestone achievement. The coaches meet monthly to share insights about their work, the progress of their families, and learned best practices. Data: Our vision is one where YCCAC is a data-driven organization, methodical in evaluating the effectiveness of its programs and the impact it is having on the population.


Data will guide our work and direct our efforts to better serve our clients, patients, and our communities. As we continue our integrated services efforts, data dashboards will be developed that represent our progress toward achieving program results and agency progress toward shared results, such as well-being for families. In addition to data dashboards to communicate our work, we believe that sharing of data will better serve our clients and create efficiencies. Data can help us determine all the programs and services for which someone may be eligible and to see if those clients have enrolled or received services previously. More to come!

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