A guide to:
Toronto Coordinated
Service Planning for
Families
The Special Needs Strategy:
Coordinated Service Planning
Coordinated Service Planning is part of the Special Needs Strategy, an initiative
of the Province of Ontario. Coordinated Service Planning is about linking you to
services and bringing together the group of professionals who are working with
your child to help them become a dedicated team that works in collaboration to
ensure your child and your family’s needs are met.
You may benefit from coordinated service planning if:
▶ you have a child or youth with complex special needs and;
▶ you are waiting for or receiving services from more than one agency and;
▶ you need support to navigate the system
What is Coordinated Service Planning?
Coordinated Service Planning is a family-centred approach focussed on making it
easier for families with children and youth with multiple and/or complex special
needs to connect to the right eservices and support.
A service planning coordinator will work with your child and family to:
▶ Identify your strengths and needs
▶ Identify what would really make a dierence over the next little while – that
is, getting clear about your vision and priorities
▶ Make appropriate referrals if other supports or services are indicated
▶ Set up team meeting that bring together you child’s team of professional
▶ Develop a coordinated service plan that makes sure everyone is working
together
You play an essential role in the development and delivery of your child’s
coordinated service plan: You are part of the team and involved in planning and
decision making. Meetings are planned at a time that is convenient for you and
your family, and you are encouraged to attend and to provide input on what is
working, where changes need to be made, and where you feel your family needs
extra help. The plan identifies strategies to ensure everyone is working together
in a coordinated and eicient way. Our approach To Coordinated Service
Planning takes into account each family’s unique situation. And, as your child
grows and developed, the plan is revised to reflect changing needs.
Coordinated service planning happens when everyone who is involved with the
child/youth works as a team to:
▶ listen to your concerns
▶ identify goals and a coordinated plan
▶ work together to address goals
▶ keep you informed
Who delivers Coordinated Service Planning?
Surrey Place is the lead agency for Coordinated Service Planning in Toronto.
In this role, Surrey Place and its Core Service Delivery Partners, specifically,
Community Living Toronto, Family Service Toronto, Toronto Central LHIN and
YouthLink, are committed to working together in a seamless way providing you
with a clear point of contact for all the services you are receiving and to creating a
Coordinated Service Plan that identifies what is important to your family.
How our system works together to deliver
Coordinated Service Planning
The Core Service Partners also have agreements in place with broader system
organizations including hospitals, schools, and a wide range of social service
agencies to partner together in taking a team approach to your child’s care. This
collaborative approach across many providers is intended to:
▶ Reduce the need for you, the family, to tell your story over and over
▶ Keep the family and child at the centre of developing a meaningful plan
▶ Share relevant information amongst team members in a secure and
confidential way
▶ Help families by making them away of services and supports in their
community
▶ Support smoother transitions such as into school or moving to adulthood
Referring for Coordinated Services
Families and service providers including physicians can make a referral to
Coordinated Service Planning by calling Surrey Place at (416)925-5141.
A service provider may make a referral on your behalf aer discussions with you
by sending the Service Provider referral form to Surrey Place Centre
Referrals for Coordinated Service Planning will be reviewed and families will be
provided with the most appropriate level of service. Depending on the needs
identified there may be a wait for services.
The Coordinated Service Planning Process
The diagram bellow hows the full cycle of Coordinated Service Planning. The
descriptions are linked to the picture by number.
THE COORDINATED SERVICE PLANNING CYCLE
INTAKE (1 and 2)
The process begins at intake at Surrey Place where a “service navigator” will
work with you to identify the intensity and urgency of your child and family’s
needs. They will use a screening interview to identify your family’s needs to
determine what service would be most helpful and appropriate. There may be a
wait for services.
You will be asked to identify the service providers currently working with your
child and who should be included in your Child and Family Team. You will be
asked for permission (your consent) for these professionals to share information
and use your child’s shared electronic record. Other team members may
have completed a variety of assessments that provide important background
information. All team members are encouraged to review the information stored in
the shared record and minimize the need for the family to repeat their information.
STRENGTH NEEDS IDENTIFIED (3)
The Navigator and the family will complete the Child and Adolescent Needs and
Strengths service planning tool, or CANS for short. The tool helps to identify the
areas to focus on and what strengths to build on from the family’s perspective.
The results are shared with other team members and lay the foundation for the
development of a coordinated plan. .
The following is a link to more information about the CANS tool https://
praedfoundation.org/tools/the-child-and-adolescent-needs-and-strengths-cans/
Information from the CANS is recorded in the shared record and is available to all
the team members using the shared record. The assessment and results can be
printed o if you would like a copy.
ASSIGNING A COORDINATOR (4)
Depending on the outcome of the intake and strength/needs assessment,
a Service Planning Coordinator may be identified from amongst those
professionals who are currently working with you, or a new Service Planning
Coordinator may be assigned to you from one of the Core Service Delivery
Partner agencies.
GOALS SET AND PRIORITIZED (5 and 6)
Your family’s priorities are at the centre of your child’s coordinated service plan.
They form the common framework that all team members use to set goals and
develop treatment plans. Your family’s priorities will determine the direction and
focus of your child’s coordinated service plan for the next 6 to 12 months.
Your service planning coordinator will meet with you (either face-to-face or over
the telephone) and assist you to create priority statements that the team will
base their goals on. These statements will be documented in your child’s shared
record for all team members to review and use. This helps to ensure everyone is
focused on what is important to the family.
In preparation for meeting with the Service Planning Coordinator it would be
good for you to spend some time thinking about what changes you would like to
see for your child and family over the next 6 to 12 months … the areas where you
would like your family and your team to put their energy and focus. You might
gather reports and contact information for any other professionals working with
your child and family, as well as any written information that you would like to
share with the professionals on your Child and Family Team.
When you meet with the Coordinator, you will identify the changes you would like
to see and the Coordinator will help you turn these into priority statements. This
discussion may help identify other areas of concern where new referrals might be
helpful.
At the end of this meeting you will identify the team members that need to
participate and start work on setting a meeting date that works at least for key
team members.
COORDINATED SERVICE PLANNING TEAM MEETING (7)
The first team meeting will bring you, your child and your entire team of service
providers together. The purpose of the meeting is to work together to develop
goals and plans that are meaningful to you and your child and focused on your
family and child’s strengths, needs and priorities. This approach puts your family
and child at the center of the process. You and your child are the most important
members of the team.
This meeting is dierent from most conferences where professionals typically
share their individual clinical findings. In the coordinated service planning
process team members are encouraged to read up on clinical assessments and
understand each other’s role ahead of the meeting in order to make maximum
use of the planning time. By sharing and reviewing information before the
meeting, team members come to the meeting prepared to work together with
you and your child. The SPC will assist team members to have access to the
information they need prior to coming to the meeting.
Coordinated service planning meetings are usually held at least once per year but
may be more frequent depending on what is happening in the child and family’s
life and the progress being made.
IMPLEMENTING AND MONITORING THE COORDINATED
SERVICE PLAN (8 AND9)
Aer the planning meeting and the goals and activities have been agreed on, you
and your team members will work on the various tasks and activities as outlined
in the plan. Team members will document their interactions and activities in
the shared record. Your service planning coordinator will review notes made in
your child’s record and communicate with you and individual team members to
make sure the plan is on track. Your SPC will contact you regularly to check on
things however if you have any concerns or questions or there are changes that
may impact your plan and your child’s progress then notify your service planning
coordinator. You should speak with them at least every few months to discuss
progress made and identify any new issues or concerns.
