Guide to developing 15+ Care and Transition Plans: Developmentally appropriate planning across the Looking After Children domains

Guide to developing 15+ Care and Transition Plans: Developmentally appropriate planning across the Looking After Children domains

If you would like to receive this publication in another format, please phone Maria Trombin using the National Relay Service 13 36 77 if required, or email [e-mail]

This document is also available on the Internet at the Leaving care page on the Department of Human Services website

© Copyright State of Victoria 2012.

This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968.

ISBN 978-0-7311-6535-3.

Authorised and published by the Victorian Government, 50 Lonsdale Street, Melbourne.

0170712_DHS7993_07/12

Contents

Guide to developing 15+ Care and Transition Plans: Developmentally appropriate planning across the Looking After Children domains 1

Contents 4

Contents 4

Introduction 5

Introduction 5

Using this guide 5

The 15+ Care and Transition Plan 5

Good care and transition planning 6

Guide to completing the 15+ Care and Transition Plan 8

Guide to completing the 15+ Care and Transition Plan 8

1. Health 8

2. Emotional and behavioural development 10

3. Education 11

4. Family and social relationships 13

5. Identity 14

6. Social presentation 15

7. Self-care skills 17

Introduction

Using this guide

The Guide to developing 15+ Care and Transition Plans (the Guide) is designed to assist case managers, care teams and carers to identify and plan for the age appropriate needs of young people aged between 15 and 18 years of age who are living in out-of-home care. In so doing the Guide stresses that the planning, preparation and care to ensure the emotional and social health of these children and young people needs to commence from the time they enter care.

The Guide is part of a set of resources to support care and transition planning including:

Transition planning for leaving care: Victorian Practice Framework¹

The Looking After Children 15+ Care and Transition Plan².

Care and transition planning is needed to provide good ongoing care for a young person while they are in out-of-home care and also to help them to prepare for the future and make a successful transition to adulthood. It should focus on helping the young person to build on existing strengths, inner capacities and confidence, ultimately leading to sustainable independent living when they leave out-of-home care.

This Guide highlights the important areas of a young person’s development by using the seven domains in the Looking After Children Framework to identify the areas that must be considered and acted upon if a young person is to be supported to grow and mature while in out-of-home care. The domains are:

Health

Emotional and behavioural development

Education

Family and social relationships

Identity

Social presentation

Self-care skills.

The 15+ Care and Transition Plan

In Victoria, Looking After Children provides the practice framework for considering how each child or young person’s needs will be met while they are in out-of-home care. It is used for managing out-of-home care in accordance with the Best Interests Case Practice Model cycle of information gathering, assessment, planning, implementation and review.

The 15+ Care and Transition Plan³ forms part of the Looking After Children Records. It is an essential component of the overall statutory Case Plan which provides the overarching directions for the Care and Transition Plan including whether a young person will remain in out-of-home care, be reunified with their family and other significant decisions.

The 15+ Care and Transition Plan has been developed to ensure planning about the day to day care of the young person clearly identifies strategies to develop independent living skills and to prepare them for their transition from out-of-home care. It is expected to be completed collaboratively by the out-of-home care team with the young person. The community service organisation (CSO) providing the placement is responsible for leading the out-of-home care team and for ensuring that this plan is completed. For kinship care, the CSO is responsible for completing the plan unless there is no CSO involved, in which case Child Protection is responsible.

The 15+ Care and Transition Plan builds on the Looking After Children 15+ Assessment and Progress Record, which should inform the planning process. For each life area, the 15+ Care and Transition Plan documents:

the young person’s needs

how they will be responded to

by whom

by when.

The 15+ Care and Transition Plan also fulfils the requirements for a disability support plan under the Disability Act 2006 for a young person in the disability service target group who is in out-of-home care. This plan also complements and is linked to:

Cultural Support Plans⁴ – for Aboriginal children and young people in out of home care

Individual Education Plans⁵ – developed by schools via Student Support Groups which include the case manager and carer/s.

Good care and transition planning

Every young person in an out-of-home care placement should be well supported in their out-of-home care placement and actively assisted to make a successful and sustainable transition from care. Young people should be encouraged to be involved in the discussions and planning for their future, even if they appear disengaged or disinterested – it may simply be that they are afraid.

For example research identifies that young people’s greatest concern revolves around where they will live post care. It is vital they be involved in the decision making processes in this matter, but not in a manner that will confuse or alarm them.

While the Guide provides prompts for the care and transition planning process, it is not a substitute for meaningful connectedness with young people. Case managers and all the other members of the out-of-home care team including carers must collaborate with their young person to identify the skills they need to learn, or develop in their transition toward adulthood.

Care teams should:

identify someone with whom the young person has a rapport

keep discussions simple

ask the young person what they want from life

provide them with opportunities to explore and experience what our community has to offer

always check in with the young person and assure them that they will be helped and supported whatever they decide to do

ensure information is recorded and handed over, as the participants in the care team may change over time.

Aboriginal young people, in addition to the strategies set out in this Guide, should be engaged in the development of their Cultural Support Plan, and consultation with the Aboriginal Community Controlled Organisation (ACCO) that provides leaving care support services for Aboriginal young people⁶ must occur.

If the young person is identified as having a disability, consult with Disability Services about how to ensure their disability related needs can be addressed. If the young person is in the Disability Services target group, Disability Services must be involved in leaving care planning from 16 years of age.

Guide to completing the 15+ Care and Transition Plan

This section outlines a series of prompts that should be used when completing the 15+ Care and Transition Plan. The seven subsections are organised around the seven Looking After Children life areas of health, emotional and behavioural development, education, family and social relationships, identity, social presentation and self-care skills and should be based on the Looking After Children 15+ Assessment and Progress Record.

Each subsection contains the primary goal of the area, the essential tasks to be considered as part of good care and preparation and the approximate age or stage at which the young person would be encouraged to undertake the tasks. The tasks and ages/stages are a guide only and young peoples’ capacity must be taken into account alongside their developmental as well as their chronological age.

Important tasks appear at the end of each domain as a prompt for the final six months of a young person’s custody or guardianship order.

Case managers, care teams and carers may use the information in this section as checklists to ensure planning is comprehensive and effective.

1. Health

Goal 1.1

Goal: The young person understands how to maintain optimal health

Task 1.1.1

Age/stage

10–18 years

Task description

If the young person has a suspected disability or cognitive delay, discuss with Disability Client Services whether a Target Group Assessment is required to determine eligibility.

Ensure the young person has a consistent General Practitioner or links to a community health centre where:

general health checks and treatment are undertaken

immunisations are completed and up-to-date

mental health assessment considered along with appropriate referrals

medication is regularly reviewed

plan for any long-term health conditions

pay attention and support for a healthy lifestyle, including facilitating, diet, exercise practices and healthy weight

eyesight test and treatment as required

dental check and treatment as required

hearing test and treatment as required.

Seek specialist assessments (neuropsychological or cognitive) where indicated to understand the function of the young person’s presentation to enable a targeted response.

Arrange Medicare Card and Health Care Card for eligible children/young people – A guide to concession cards – PDF download from the Commonwealth Department of Human Services website

The care team process identifies the best person to engage with the young person and ensures:

the young person is helped to understand about puberty, body changes, self care, including provision of sexual health information

assist young person with making health appointments and accompanying them to these appointments

if young woman is pregnant or caring for a baby – refer to Cradle to Kinder program

assist young person to understand the impact of tobacco, alcohol, drugs, safe sex practices, sexual health and positive mental health

Task 1.1.2

Age/stage

16–18 years

Task description

Confirm services with Disability Client Services (if in Disability Services target group) for leaving care preparation

Young person is encouraged, gradually to make and keep appointments. If not able, appointments are made in consultation with the young person and they are assisted to attend them. Young person is also:

assisted to apply for their own Medicare Card and Health Care Card

linked with their General Practitioner (GP) or community health centre

assisted to monitor their own health needs, according to their abilities and circumstances.

Goal 1.2

Goal: At least six months prior to the expiration of the custody or guardianship order a final transition plan must include arrangements for the health life domain.

Task 1.2.1

Age/stage

Final 6 months of a young person’s custody or guardianship order

Task description

Final arrangements should include:

confirm services with Disability Client Services (if in Disability Services target group) for leaving care preparation

identification of ongoing health services, adult mental health support services

appropriate drug and alcohol services connections where relevant

links to ongoing therapeutic support that the young person can financially sustain

access to transition or post-care brokerage funds to maintain necessary health plans.

If the young person is unwilling to engage in transition planning, workers should ensure that they are provided with relevant post-care support information.

2. Emotional and behavioural development

Goal 2.1

Goal: The young person heals from the impact of trauma and develops resilience and skills to be able to self-regulate their emotions

Task 2.1.1

Age/stage

10–18 years

Task description

Coordinate a trauma-informed care team process, which ensures all parties understand the impact of trauma and a referral to therapeutic counselling is arranged where indicated.

Seek secondary consultations for the care team and the young person if necessary.

Referral to specialist support service (if applicable), for example, mental health, counselling or Centres Against Sexual Assault.

Young person is exposed to appropriate role models, for example they:

observe adults resolve issues appropriately

observe adults treat each other with mutual respect

observe adults using manners and telling the truth.

Develop opportunities for the young person to experience a wide range of activities, people and circumstances in an enjoyable, non-threatening manner so they may learn to relate positively in social situations – transition brokerage may be utilised.

Develop strategies to help the young person identify and manage their emotions and behaviour.

Specialist safety planning includes ‘keep safe’ plans with back-up plans and emergency plans as indicated.

Proactively plan responses to day-to-day living situations including challenging, trauma-related behaviours.

Ensure collaboration with Youth Justice if the young person has involvement with police and/or Youth Justice.

Task 2.1.2

Age/stage

15–18 years

Task description

Young person is supported to make appropriate choices, for example:

not succumbing to peer pressure

abstinence or harm minimisation (dependent the young person’s situation)

developing self -control/restraint – delaying gratification

consideration of others and their feelings and responsibilities

relationship/friendships are developed and sustained

recognition of risk taking and its consequences.

Explore appropriate volunteer involvement to promote connectedness to the community, such as Landcare, CFA or SES for young people in country regions.

Goal 2.2

Goal: At least six months prior to the expiration of the custody or guardianship order a final transition plan must include arrangements for the emotional and behavioural development life domain

Task 2.2.1

Age/stage

Final 6 months of a young person’s custody or guardianship order

Task description

Final arrangements should include:

early preparation and planning for post-care accommodation as this is the most anxiety provoking aspect of transition for young people ( main reference though in self care skills)

clarity about post-placement support – who will provide it, what the support will be and for how long.

If the young person is unwilling to engage in transition planning, workers should ensure that they are provided with relevant post-care support information.

3. Education

Goal 3.1

Goal: The young person has support to access and maintain education, training or employment to assist them in their future endeavours

Task 3.1.1

Age/stage

10–18 years

Task description

Encourage ongoing learning in placement through homework, reading (school-related material and reading for pleasure such as comics, magazines, books), writing letters, using a computer (appropriate access to internet, word processing, email), managing money (see also the section on self-care), checking change received, budgeting, telling the time on the clock, maths (add, subtract, multiply, divide).

Support the young person to develop personal goals and steps to achieve them.

Young people in formal education:

identify young person’s strengths and interests

ensure they have all relevant books and stationery

arrange tutoring if required

consult with Partnering Agreement Contact officer (DHS regional position) about supporting the school enrolment

liaise with the school about an Individual Education Plan and Student Support Group Meetings

access an educational needs assessment though the school

develop an agreed safety plan or behaviour response plan, with the opportunity to restore relationships as required

encourage young person to speak up about any issues they have at school with an identified key person either at the school or of the care team

for students preparing to commence VCE, consult the Victorian Tertiary Admissions Centre guide listing all post-secondary school courses available and timelines for applying

TAFE apprenticeships, traineeship programs, work experience

link young person with a careers advisor.

Young people not in formal education:

explore the underlying causes for not being in formal education, in consultation with the Partnering Agreement Contact officer (DHS regional position)

access an educational needs assessment through the health and education assessments initiative. Access accredited training if appropriate.

explore alternative options through consultation with the Partnering Agreement Contact officer (DHS regional position)

engage young person in discussions about what they want to do (for example pre-apprenticeships, traineeships or employment)

access Children in Residential Care (CIRC) support if eligible.

Task 3.1.2

Age/stage

16–18 years

Task description

Refer to the Springboard program (residential care and lead tenant young people only) for young people requiring support to re-engage with education, training or employment.

Access zero training tuition fees initiative if applicable.

Determine if transition brokerage is available for additional education or learning needs, such as tutoring or access to pre-apprenticeship programs.

Young person is supported to make appropriate choices, for example regarding:

income management

Centrelink requirements

education, vocational training and/or employment.

Goal 3.2

Goal: At least six months prior to the expiration of the custody or guardianship order a final transition plan must include arrangements for the education life domain

Task 3.2.1

Age/stage

Final 6 months of a young person’s custody or guardianship order

Task description

Final arrangements should include:

ongoing education, vocation, training opportunities and employment support services

confirm services with Disability Client Services for leaving care preparation as required including available training and Disability Employment Service – Transitioning to employment page on the Department of Human Services website

consideration of post care brokerage funds if young person is continuing in study or training.

If the young person is unwilling to engage in transition planning, workers should ensure that they are provided with relevant post-care support information.

4. Family and social relationships

Goal 4.1

Goal: The young person develops and maintains positive and safe connections with their family, extended family (where possible), partner and wider social networks

Task 4.1.1

Age/stage

10–18 years

Task description

Promote placement activities where the young person is involved, for example meal preparation and eating together, going to the movies, picnics.

Link with school social events to promote contact with same-aged peers.

Link with school holiday camps.

Promote opportunities for the young person to pursue their interests and hobbies including sporting clubs.

Develop a clear family contact strategy with immediate and extended family members and where necessary support the young person in their contacts.

Support the young person to organise small, simple outings with someone with whom they are comfortable.

Develop a clear social contact strategy, for example contact with school friends and friends of the family.

Task 4.1.2

Age/stage

14–18 years

Task description

If the young person is pregnant, or partner to a pregnancy, plan for future care of the child and living arrangements, refer to the Cradle to Kinder program in the region.

Goal 4.2

Goal: At least six months prior to the expiration of the custody or guardianship order a final transition plan must include arrangements for the family and social relationships life domain

Task 4.2.1

Age/stage

Final 6 months of a young person’s custody or guardianship order

Task description

Final arrangements should include:

accommodation planning if young person is remaining with their carer – plan contingencies

ongoing connection with family, friends, cultural and community activities and family contact post care

post-placement support – is in place and the young person has met the support workers

consider transition or post care brokerage funds to assist the young person in their family and social support networks.

If the young person is unwilling to engage in transition planning, workers should ensure that they are provided with relevant post-care support information.

5. Identity

Goal 5.1

Goal: The young person develops a positive sense of self and where they fit within their family, culture and community

Task 5.1.1

Age/stage

10–18 years

Task description

Check their Looking After Children Essential Information Record is up to date and ensure the young person has the necessary personal documents with safe storage arranged for:

photo ID

birth certificate

Medicare card

Health Care Card

Create Life Story Records with photos and narratives of the young person’s life.

Support the young person to pro-socially stand up for what they believe in and feel strongly about.

Help them to explore community, social, recreational and cultural connections, remembering they may need significant support.

Share information as appropriate with the young person about their past and parents or extended family members they may not know but have asked questions about.

Explore family and significant others’ relationships and connections that can be sustained into the future safely.

Ensure the young person can engage with the religious affiliation they have.

Task 5.1.2

Age/stage

15–18 years

Task description

Find out where the young person sees themselves in the future, as appropriate for their age, for example what they want to be when they grow up.

Support the young person to develop personal goals and steps to achieve them.

Ensure they have:

Tax File Number (15+ years)

learner’s permit/ and driving opportunities (120 hours) (16 years and 9 months)

registered for the electoral roll (17+ years)

an address for post.

Goal 5.2

Goal: At least six months prior to the expiration of the custody or guardianship order a final transition plan must include arrangements for the identity life domain

Task 5.2.1

Age/stage

Final 6 months of a young person’s custody or guardianship order

Task description

Final arrangements should include:

ongoing connection with family, friends, cultural and community activities and family contact post care

post-placement support for Aboriginal young people to maintain connection with culture

consider transition or post care brokerage funds to assist the young person in activities related to their identity

provision of Freedom of Information (FOI) pack

Same-sex attracted young people provided assistance and advice regarding supports – e.g. Same-sex attracted support group page on the Family Planning Victoria website

If the young person is unwilling to engage in transition planning, workers should ensure that they are provided with relevant post-care support information.

6. Social presentation

Goal 6.1

Goal: The young person successfully interacts and functions within their community

Task 6.1.1

Age/stage

10–18 years

Task description

Encourage the young person to develop their language and communication skills.

Help the young person with any physical social presentation needs such as clothing and self-care needs.

Promote good care that assists young people to learn how to processes information, including problem solving, goal setting and planning, and picking up on social cues.

Promote positive interactions and connections with same-aged peers through school and social activities.

Promote positive interactions and connections with adults through interaction with teachers, family, social networks and workers.

Educate about appropriate interactions with peers and others as required.

Assist the young person to restore relationships that may have been strained (to develop empathy, consideration for others and accountability for actions). For example, help the young person understand the impact of certain behaviours and responses, and support them to apologise and resolve the issue.

Explore ways that the young person can help other and contribute to the community, for example volunteer work, peer mentoring, involvement with the CREATE Foundation.

Facilitate a referral to post-care support services and involve the program in post-care planning.

Goal 6.2

Goal: At least six months prior to the expiration of the custody or guardianship order a final transition plan must include arrangements for the social presentation life domain

Task 6.2.1

Age/stage

Final 6 months of a young person’s custody or guardianship order

Task description

Final arrangements should include:

opportunities where the young person is able to develop skills necessary for attending interviews for housing/accommodation, sharing accommodation

ensuring young person understands how to dress and present for different purposes (confirm they have appropriate clothes for job and housing interviews). Support them to learn how to shop smart and cheaply for clothes, shoes and other items

consider transition or post care brokerage funds to assist the young person in activities related to social presentation.

If the young person is unwilling to engage in transition planning, workers should ensure that they are provided with relevant post-care support information.

7. Self-care skills

Goal 7.1

Goal: The young person develops the skills to live sustainably in the community

Task 7.1.1

Age/stage

10–18 years

Task description

Young person is assisted to:

progressively manage small to complex household tasks and personal care

engage in age-appropriate personal care and social presentation such as visits to the hairdresser and purchase personal choice of soap, shampoo, after shave, acne cream

manage money via pocket money based on participation in chores

support in understanding how to budget, including paying debts, bills, necessities before luxuries, gambling knowledge

allow young person to make some mistakes with their money (unless it impacts on safety) to encourage learning

open a bank account and encourage savings

become familiar with the Charter for children in out-of-home care

become involved with the CREATE Foundation if they wish.

Assist the young person learn to solve problems and plan ahead:

thinking and planning ahead for safe social outings e.g. safe consumption of alcohol, localities, knowing how to identify risk laden situations, how to remove oneself

support the young person to integrate their thoughts, feelings and actions – that is, to have insight into their own behaviour

support the young person to learn about and pick up on different social cues, for example predicting how another person is feeling through their body language, tone of voice

encourage discussion regarding ethical choices, consideration of others.

Ensure early planning for any disability or long-term health condition that may impact on the young person’s capacity to live independently.

Task 7.1.2

Age/stage

10–15 years

Task description

Between 10–15 years young person should be assisted by:

transport to and from all appointments and family contact

transport to and from approved locations, to be dropped out the front, not around the corner.

Make clear after hours arrangements to pick up the young person if they are absent.

Ensure carer support is provided for night- time activities.

Task 7.1.3

Age/stage

15–16 years

Task description

Provide opportunities for the young person to organise and take themselves to:

school, training and/or employment

appointments and locations via public transport (if appropriate)

to and from all family contact

friend’s homes

recreational and sporting events during the day.

Goal 7.2

Goal: Balancing care with increasing responsibility

Task 7.2.1

Age/stage

16–18 years

Task description

Young person supported to book appointments and take themselves to the appointment (with a worker meeting them there, if required).

negotiate with the young person about getting themselves to locations independently in appropriate time and safely e.g school, training and/or employment

assist them to manage social outings independently

assist young person to obtain their driving Learner’s Permit and facilitate driving lessons or access to the L2P program

commence planning for accommodation 12 months prior to cessation of custody or guardianship order.

Have crisis plans in place in case housing proves unsustainable and/or provide the young person with information regarding emergency housing providers.

Goal 7.3

Goal:At least six months prior to the expiration of the custody or guardianship order a final transition plan must include arrangements for the self-care skills life domain

Task 7.3.1

Age/stage

Final 6 months of a young person’s custody or guardianship order

Task description

Final arrangements should include:

consult with the Aboriginal Community Controlled Organisation (ACCO) that has the Leaving Care Support Service for Aboriginal Young People about culturally sensitive and appropriate considerations for leaving care

consider transition or post care brokerage funds to develop and improve self-care skills eg. Cooking, driving lessons

arrange for the Commonwealth Transition to Independent Living Allowance (TILA) – Transition to Independent Living Allowance website. TILA is not for crisis situations and is a one-off payment to the young person. Applications for TILA are best managed via a referring agency

accommodation – assist the young person as much as possible to practice for interviews for accommodation and employment

case manager or support worker and the housing provider should have determined the young person has a high chance of obtaining the accommodation before they are encouraged to attend the interview.

the young person leaves care with relevant documentation, possessions and life records

provision of a Freedom of Information (FOI) pack

knowledge of relevant ‘leaving care’ website – Leaving care page on the Department of Human Services website

knowledge of Leaving Care Help Line (1300 532 846) and Kids Help Line: 1 800 551 800 (telephone calls are free)

it is very important that the young person is helped to prepare for interviews, understands the tenancy requirements and has the capacity both emotionally and financially to meet their obligations.

If the young person is unwilling to engage in transition planning, workers should ensure that they are provided with relevant post-care support information.

1^ Leaving care page on the Department of Human Services website

2^ Funded Agency Channel website

3^ For children under 15 years of age, the Care and Placement Plan is used.

4^ Information about Cultural Support Plans is available at the Cultural support plans section of the Child Protection Practice Manual on the Department of Human Services website

5^ Information about Individual Education Plans is available at the Individual education plans section of the Child Protection Practice Manual on the Department of Human Services website

6^ Transitioning from out-of-home care support for Aboriginal young people page on the Department of Human Services website