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A FAMILY’S JOURNEY AT DRUM

Family contacts DRU/M Healthy Families

Contact by Referral or Community Outreach

Risk Indicators Check List (Screen to determine initial eligibility for Program)

Family Assessment Provides Initial Support to Families
Intake

Initial Assessment/Life Experiences (Family Stress Check List)

  • Childhood History
  • Life Styles/Behavior/Mental Health
  • Current/Past Child Protective Services History
  • Isolation/Self-Esteem/Coping/Problem Solving/Pre-natal Care
  • Stressors/ Concerns
  • Potential for Violence
  • Parents’ Expectations of Child
  • Plans for Discipline
  • Perception of Infant
  • Bonding and Attachment

Pre-natal Risk Factors Questioner

  • Substance Abuse
  • Alcohol Use
  • Domestic Violence
  • Mental Health
  • At Risk Behavior
  • Tobacco Uses

Pre-Orientation

Explain and has family sign General Consent Signed

When there are urgent needs or concerns, FAW discusses with supervisor and makes immediate referrals, as appropriate

Document Conversation with Family (Intake)

Supervisor Reviews Documented Narrative and Pregnancy Information

Assigns family to Family Support Worker (FSW)
Case Staffing with Family Support Worker, Family Assessment Worker
And Supervisor who meet to review files.

  • Reviews Initial Assessment Information
  • Examine Strengths
  • Discuss Challenges and Pre-natal Risk Factors
  • Family Support Worker Attempts Contact with Family within 5 days of Case Assignment
  • Makes Appointment for Initial Home Visit


Initial Home Visit Conducted by Family Support Worker (FSW)
(Establishing Positive Relationships with Families)

  • Complete Orientation Packet
  • Partner in Review of Rights and Responsibilities of Families and FSWs
  • General Consent Signed
  • Referrals made if there are initial pre-natal risk factors

Content of Subsequent Home Visits (A Minimum of One Time per Week)

  • Continue to Build Trusting Relationships with Family
  • Educate Family on Pre-natal Health and Adherence to the Prenatal Care Plan
  • Make referrals and Promote Advocacy
  • Assist Parents in identifying their strengths and learning how to use their strengths to promote the family’s well being
  • Assists Parents in Securing Resources to meet their needs, to achieve Family’s Goals and to Move Family Towards Self- Sufficiency
  • Assess family’s residence for Environmental Safety; if deficiencies exist discuss with parents and make referrals, as appropriate
  • Educate Parents on Preterm Labor/Risk
  • Discuss with Families their Challenges and Barriers to Success
  • Support the Family as Goals Related to Healthy Outcome of Child are Identified
  • Support Family as Goals Related to Individual and Family Self Sufficiency (Individualized Family Plan) are Identified
  • Inform Parents about the Literacy and Learning Playgroup, Describe the Activities of the Group, and Discuss with Parents the Value of Attending
  • Inform Parents about the Parent-Support Groups and Talk with them about Topics that may be address at these groups
  • At Each Visit Introduced Family Appropriate Curriculum (developmental and school readiness activities),
  • FSW Models activities
  • Parents participate in activity with child while FSW is present
  • Parent and FSW discuss the interactions between parent and child.
  • FSW leave activities or information with parents to be used between visits
  • At the next visit, before introducing a new activity, parent explains how they used the material to interact with their child between visits.
  • Use established curriculums during home visits
    • PAT ( Parents as Teachers
    • Partners for a Healthy Babies
    • Others

Note: MANY OF THE ABOVE ACTIVITIES TAKE PLACE IN ONE FORMAT OR ANOTHER DURING FUTURE HOME VISITS

P2 is a level that occurs naturally when a mother reaches the third trimester of pregnancy.

BABY IS BORN

Level 1 Services

Note: Family is upgraded to Level One Services after the child is born and is home from the hospital

  • FSW visits Parent and Child a minimum of one (1) time per week for at least the first six (6) month after the birth of the baby
  • On this level, all of the appropriate activities from subsequent visits above continue
  • Educate parents on ways to determine that their child is well and comfortable.
  • Assess physical and mental wellness of mother (Family Service Worker’s Observation and Parents’ Self Assessment and Self Reporting)
  • Assess wellness of Child (Family Service Worker Observation)
  • Educate parents on child’s developmental milestones
  • Assess child development milestones by using Ages and Stages Questionnaire (ASQ) tool
  • Discuss any suspected delays with parent.
  • FSW makes Referrals as necessary to address any developmental issues identified for the child
  • FSW follows up on Referral
  • Support parent in bonding activities to strengthen appropriate parent-child interaction
  • Support parent in understanding developmental milestones and in developing realistic expectations of their children
  • FSW uses directive and interactive teaching that promotes positive and appropriate parent-child interactions
  • Educate don the importance of a post-partum check-up of the Mother
  • Educate parents on the necessity of keeping all scheduled well-baby medical appointments

Level 2 Services

Note: Family is upgraded to Level 2 Services after the following conditions are satisfied:
a) Child is thriving and parents understand appropriate developmental milestones,
b) Child’s immunization schedule is up to date and
c) Family is working towards meeting their goals.

  • FSW visits Mom and Child a minimum of two (2) times per month for a minimum of six (6) months
  • Continues to select and use curriculums necessary for visit
  • Evaluate IFSP to determine progress made by family and then to support the family as goals are attained and other goals that the family want to reach are determined
  • Support families in identifying necessary steps to achieve goals in IFSP
  • Support families and continue to dialogue with them on self reliance empowerment


Level 3 Services

Note: Family is upgraded to Level 3 Services after the following conditions are satisfied:
a) Parents are able to cope through crisis and access community resources
c) Child’s immunization schedule is up to date

  • FSW visits Mom and Child a minimum of one time per month for a minimum of six (6) months
  • Assess physical and mental wellness of mother (Family Service Worker)
  • Educate parent on the need to begin looking early for a progressive day care center and for Head Start Program
  • Intensify dialogue with parent on school readiness and on exactly what knowledge and skill the child should have when entering Pre-kindergarten and Kindergarten the Revisit IFSP. Partner with parent in securing resources needed to enhance school readiness for their children.
  • Intensify dialogue with parent on life skills that build self-esteem and promote self-sufficiency
  • As the child approaches Head Start age encourages parents to obtain information, provide parent information about various Head Start Programs in the area, and discusses information with parent
  • Parents take a proactive role in setting goals and identifying steps to take to reach those goals and assessing appropriate resources

Level 4 Services

Note: Family is upgraded to Level 4 Services after the following conditions are satisfied:
a) Family can identify alternate sources of support, maintain adequate coping skills, and are better prepared to advocate for their family’s health, education, and social needs,
b) Child’s immunization schedule is up to date

  • FSW visits Mom and Child a minimum of one (1) time every 3 months for a minimum of one year
  • Continue activities discussed at subsequent home visits and levels above with focus on dialoguing with parents about school readiness, long term goals, and extensive discussions on parents independently advocating for themselves, locating appropriate resources to meet family needs, exploring most appropriate school settings for their child, and on activities that promote school readiness
  • Partner with parent on ways to assess school readiness
  • Partner with parents to identify resources necessary to enhance child’s school readiness
  • Partner with parents and encourage them to identify support systems needed after they graduate from the Program
  • Parents take a proactive role in setting goals and identifying steps to take and resources needed to meet those goals
  • FSW and parents continue to dialogue about what actions parents can take in the future to enhance their current level of self-reliance.

Families Graduate from Program