Click here for a description of the Invisible Children’s Project

The Invisible Children’s Project: A Family-Centered Intervention for Parents with Mental Illness

Beth Hinden, Ph.D.

Kathleen Biebel, M.S.

Joanne Nicholson, Ph.D.

Liz Mehnert, CSW

Mental Health Association in Orange County, Inc.

20 Walker Street

Goshen, NY 10924

and

Center for Mental Health Services Research

Department of Psychiatry

University of Massachusetts Medical School

Prepared for the Center for Mental Health Services

Substance Abuse and Mental Health Services Administration

Office of Policy, Planning and Administration

5600 Fishers Lane, Room 17C-02

Rockville, MD 20857

SUBMITTED: April 15, 2002

ACKNOWLEDGEMENTS

The Mental Health Association in Orange County, Inc. (MHA) is a not-for-profit organization providing an array of services to the mentally ill, developmentally disabled, sexual assault victims and their family members. The agency focus is on education, advocacy and training for the community through direct service programs, support groups, information and referral services, 24-crisis services, outreach efforts and a cross systems approach to services.

The Invisible Children’s Project, (ICP) a program of MHA was developed to address the needs of, and gap in services for parents with mental illness and their children. In addition to providing direct services to parents and children, ICP aspires to create systems change on a local, state and national level. ICP receives funding from the New York State Office of Mental Health, Orange County Department of Mental Health, Orange County United Way, Mental Health Association in New York State, National Mental Health Association, Orange County Department of Health, Jewish Family Services in Orange County, Eli Lilly, Solomon Smith and Barney and private donations. ICP also benefits from the ongoing support of Chris Ashman, Commissioner of the Orange County Department of Mental Health and James Bopp, Executive Director of Middletown Psychiatric Center, both of whom have collaborated on the project since its origins.

Many individuals have contributed to the success of this study. Judith Katz-Leavy, Senior Policy Analyst at the Center for Mental Health Services of the Substance Abuse Mental Health Services Administration (SAMHSA), was pivotal in the initial conceptualization of the study and has continued to provide support and consultation. Lucinda Sloan Mallen, former Executive Director of MHA and founder of ICP, also participated in the initial conceptualization and has offered on-going support and consultation. Pat Shea, Project Officer at SAMHSA, provided needed guidance throughout the process. Numerous MHA agency and ICP staff significantly contributed to this study. These include Michael Bassett, ICP Program Coordinator, Monique Boniello, ICP Case Manager, Maryanne Quirk, File Extractor, Linda Norman, MHA Division Director, Nadia Allen, MHA Executive Director, and Cindy Urbin, ICP Case Manager. This team’s commitment and dedication to providing innovative and high quality service is unsurpassed in the field of mental health. Their passion for making a difference in the lives of parents with mental illness and their children is extraordinary, and greatly appreciated and respected.

MHA’s partners in this study, The Program for Parenting Well at the Center for Mental Health Services Research (CMHSR) at the University of Massachusetts Medical School (UMMS) is a multi-disciplinary group of parents and professionals committed to understanding the experiences of parents with mental illness and their families, and developing resources to meet their needs. The Program for Parenting Well receives on-going funding and support from their colleagues and partners at the Massachusetts Department of Mental Health and the UMMS Department of Psychiatry. This study could not have been completed without the dedication, commitment and expertise of the Parenting Well staff. A special thanks goes to Heather DiGiovanni, Stanley Scholar Intern at CMHSR, for her participation in data collection and management.

The Orange County Department of Social Services (DSS) is responsible for providing social services for children and families. Services include but are not limited to child protective and preventive services, foster care, residential treatment, group homes, childcare, youth advocacy services, home monitoring, respite and parent aide services. DSS administration provided critical information on service costs for individual families participating in this study, and agreed to time consuming interviews with DSS case workers that had worked with family participants. Specifically, we are grateful to Margaret Kirshner, Commissioner, Elizabeth Mustion, Supervisor, Connie Antona, Director of Services, Nicole Disiglio and Mike Milano, Youth Advocates, Bill Jolly, Director of Youth Advocacy Program, Margot Mitchell, Supervisor, and Beth Gold, Debbie Pazola, Jeff Schmidtt, Case Workers, for their generous assistance with this study.

Finally, our greatest thanks go to the parents and children living with mental illness that agreed to participate in this study. Parents invited us into their homes and into their hearts. In lengthy conversations about experiences prior to and since involvement with ICP, parents shared profoundly moving stories about their struggles and successes as parents with mental illness. We are particularly grateful to Sharon Butler, who agreed to join the evaluation team as Parent Consultant. Sharon acted as a voice for all parents. Her input into the development and implementation of this study has been invaluable.

EXECUTIVE SUMMARY AND RECOMMENDATIONS

Millions of adults in the United States are affected by mental illness. The majority of these adults are, or will become parents (Nicholson, Biebel, Hinden, Henry & Stier, 2001). Despite the prevalence of parenthood among adults with mental illness, and the potential for negative effects on some children, there are very few programs or services available to meet the needs of parents and their children. In addition, available services have not been rigorously evaluated. Little is known about what is helpful for families, or effective with respect to enhancing family and family member functioning as well as quality of life.

The Invisible Children’s Project

The Invisible Children’s Project (ICP) in Orange County, New York, a nationally recognized program for parents with mental illness, is one of very few programs available to families in which a parent has a mental illness. ICP provides home-based, family-centered case management services. The program is founded upon the assumption that mental illness does not preclude good parenting, and that all parents want to be the best parents they can be. The family rather than the individual is the unit of service. ICP emphasizes access to and coordination of multiple services to support the safety and functioning of all family members for as long as is necessary.

The majority of referrals to ICP initiate from child welfare authorities at the Department of Social Services (DSS). ICP is often a mandated element in DSS service plans for parents who have lost or are at risk for losing custody of their children. The ability of ICP to address these child safety issues and achieve family preservation with respect to families involved with DSS has never been formally assessed.

The current report describes an evaluation of ICP as it affects families with a history of child welfare involvement. A family study[1] methodology was used to describe ICP services, define key program ingredients, examine family outcomes, and assess costs over time. One hundred percent of the families involved with ICP at the time of the study with a history of DSS involvement (N=8; 50% of ICP families overall) were included in the study. Parents, ICP case managers, and DSS caseworkers were interviewed; ICP files were examined; and service costs were assessed for ICP and DSS services[2] to tell the ICP story.

Key Findings

Services and Key Program Ingredients. Families, ICP case managers, and DSS caseworkers described ICP services as family-centered, strengths-based, and comprehensive. These qualities and practices were reported to be unique when compared with other services received by parents and families, and critical to successful intervention with families in which a parent has a mental illness. Parents, case managers, and caseworkers defined multiple key ingredients based on these qualities. Several key ingredients were common across informants (e.g., families, case managers, caseworkers), while others were more specific to an informant group. Shared and unshared key-ingredients identified across informants are portrayed in Table 1.

Family Outcomes. Families, case managers, and caseworkers agreed that ICP services improved multiple family outcomes, including those prioritized by DSS, i.e., parenting skills and child safety.

Table 1. Shared and non-shared key ingredients across informants

Informant	Key ingredients of ICP case management *
Parent	· Availability of case manager · Strengths-based, non-judgmental approach · Trusting relationship · Emotional Support · Liaison with DSS · Flexible funds to provide concrete support (e.g. utility bills, furniture, holiday presents)
ICP Case Manager	· Availability of case manager · Strengths-based approach · Trusting relationship · Emotional support · Liaison with DSS · Crisis management · Comprehensive services coordination · Referral and access to services · Role modeling
DSS Caseworker	· Availability of case manager · Strengths-based approach · Trusting relationship · Emotional support · Liaison with DSS · Sharing of critical information about family strengths and risks · Mental health expertise and knowledge

* Bold text reflects ingredients identified by all three informants.

Family change over the period of involvement with ICP on eight outcomes targeted by ICP and DSS is portrayed in Figure 1. As can be seen, the majority of families improved or somewhat improved on targeted outcomes, or remained the same over time. None of the families evidenced deterioration on any outcome during their period of involvement with ICP.

Most families evidenced less need for hospitalization while involved with ICP. Four parents had no psychiatric hospitalizations. Two parents were hospitalized briefly, compared to multiple, lengthy psychiatric hospitalizations prior to ICP involvement. Two had not had any hospitalizations prior to ICP involvement and were able to remain hospitalization free.

Many parents showed improved employment outcomes. Three parents achieved full-time employment during their involvement with ICP, two were employed at the time of the interview, five participated in vocational training and supported employment programs, two received GED’s, two completed certificate programs (programs in phlebotomy, nurses’ aid), and one was a full-time student at community college.

With respect to housing, most families received and maintained housing subsidies, moved to more adequate and appropriate housing in safer neighborhoods, and showed increased housing stability.

Families also increased their social support networks. At the time of ICP admission, six of eight families had very limited support from family, friends, and the community. Four parents became engaged or remarried during the period of ICP involvement. Seven families reported new community contacts and supports through work, church, or community events.

Access to and appropriate utilization of medical and mental health care improved for all eight families while involved with ICP. Family members received needed mental health, substance abuse, and/or parenting skills interventions.

With respect to child custody, parents regained custody of children living in DSS placements, and maintained custody for children at risk for removal. Before ICP involvement, eight families were actively involved with the child welfare system: Four families had child protective investigations, two families had open child protective cases, and two families had children in foster care. In addition, three families had or had had children in residential treatment or in psychiatric hospitals. At the time of this study, all children had returned home and were in the custody of their parents. Finally, school attendance improved for 67 % of the children, and child behavior problems decreased for families who had identified them as a problem.

Cost of Services. Case management and childcare/respite services comprised the majority of comparable DSS and ICP costs for families. Service costs increased during their involvement with ICP for most families (88%; n = 7). This increase generally reflected the increased cost of intensive case management services provided by ICP. According to DSS caseworkers, these services were unparalleled by DSS, and absolutely necessary to support DSS goals of family reunification and preservation. Only one family in the study showed decreased costs overall. Five families (63%) showed decreased DSS costs overtime and decreased DSS costs proportionate to total costs. Costs assessed for the current study did not include DSS costs for foster care and residential treatment, because ICP provides no comparable services. However, two children were returned home during the period under study at considerable savings to DSS. In addition, it seems likely that out of home placements were avoided for the remaining families who were at very high risk for losing custody of their children at the time of referral to ICP.

Conclusions

Parents with mental illness and their children who received family-centered case management services through ICP, showed improvement across multiple outcomes. This improvement was consistently reported by parents, ICP case managers, and DSS workers. It is noteworthy that DSS workers stated unequivocally that children were returned home, or maintained in the home as a direct result of ICP involvement. While service costs increased for some families, benefits were great. Parent and agency goals were achieved, and more expensive, disruptive, and potentially damaging out of home placements, e.g., hospitalization and residential care or foster care, were avoided.

Policy Implications and Recommendations

Findings of the current evaluation have important policy implications.

· Family-centered case management services meet the needs of both adults with mental illness who are parents and their children, who may have, or may be at risk of developing psychosocial problems themselves.

· Family case management services require the integration of adult- and child-focused service sectors and systems, e.g., mental health, child welfare, public health, housing, educational/vocational services, early intervention, etc.

· Organizational, administrative, and financial mechanisms must support and facilitate the coordination and integration of adult and child services, and the collaboration of direct service providers.

· Providers from all service sectors need to be educated about the prevalence of parenthood among adults with mental illness, their goals, strengths and challenges in caring for children, and the benefits of appropriate and adequate supports and services for all family members.

· Providers must be encouraged to consider the strengths and resources, needs and goals of clients as family members, in the context of family life, rather than as individuals living in isolation.

· The number of families assigned to a provider must allow the provider to be accessible and supportive to family members, sometimes as often as daily. Provider availability and dependability are essential for parents with mental illness to establish meaningful and useful relationships.

· Flexible funds must be available to allow for the purchase of appropriate formal and informal (e.g. summer camp) services for all family members regardless of agency or service system affiliation; and to support families during times of financial crisis.

· Programs and services need to be documented and manualized to allow for rigorous evaluation with respect to specific and meaningful outcomes, and to facilitate the development of evidence-based practices for families in which a parent has a mental illness. Replication of successful programs is needed to evaluate practices in different communities and with diverse samples of parents and families. Technical and financial assistance for programs will be necessary to support such development and evaluation.

INTRODUCTION

Millions of adults in the United States are affected by mental illness. The majority of these adults are, or will become parents (Nicholson, Biebel, Hinden, Henry & Stier, 2001). Despite the number of parents with mental illness, mental health systems are generally designed to provide services for individuals. These systems are not prepared to support individuals in their role as parents, and not well prepared for working with families. Adults and children are funneled into separate, categorically funded service systems that cannot provide a cohesive family plan. As a result, there are gaps in available services, and there are very few places that parents with mental illness can obtain the services they need for themselves and their children.

The Invisible Children’s Project

The Invisible Children’s Project (ICP) in Orange County, New York is one of very few programs available to parents with a serious mental illness. ICP is nationally recognized as an innovator in services for families. ICP provides family case management for families in which a parent has mental illness. Case management services are intentionally home-based, and emphasize access to and coordination of multiple, comprehensive services for all family members.

ICP is part of a private, not-for-profit agency, Mental Health Association (MHA) in Goshen, New York. ICP was founded in 1994 on the principles that parents want to be the best parents they can be, and the act of parenting is a significant, and potentially healing role for adults with mental illness. ICP embraces a family-strengths/family-centered case management model, where ICP staff and families work together to assess strengths and determine needs. With these principles in the forefront, ICP strives to empower parents to create a safe and nurturing environment for their children, while supporting efforts to keep the family unit together. More specifically, ICP is built on the assumptions that parents have strengths, parents may require services from multiple systems, children are usually better off with their parents, families need and deserve support, mental illness is not the cause of good or bad parenting, enhanced parenting leads to enhanced child development, and dependable, consistent relationships are therapeutic.

ICP services include 24-hour family case management; referrals to community resources; advocacy with schools, child welfare agencies, and courts; family crisis planning; respite childcare; access to financial assistance; parenting education; pregnancy and post-partum education, children’s art therapy, 24-hour Helpline; and supported housing. Most ICP services are provided in families’ homes, and clinical services are provided via consultants and community-based providers. ICP staff stress the importance of creating meaningful relationships with families, built on trust and mutual respect.

ICP’s primary funding comes from the New York State Office of Mental Health, with additional support from HUD, the United Way, local fund-raising, and state reinvestment money. However, since ICP serves families rather than individual clients, flexible funding is required for costs not covered by traditional adult mental health funding streams. MHA covers the difference between ICP’s funding and the true costs of serving ICP families.

ICP and the Department of Social Services

Since its beginning in 1994, ICP has served over 150 families. The majority of these families were referred by the Department of Social Services (DSS) as a result of child safety concerns. The ability of ICP to address these child safety issues and achieve family preservation with respect to families involved with DSS has never been formally assessed. Using a “family-study” methodology, the current study provides such an assessment. The primary goals of the current study were to describe and document ICP practices, and examine the relationship of these practices to meaningful outcomes including family functioning, DSS involvement, and service costs. ICP practices and their relationship to outcomes will be explored from the perspective of multiple informants or stakeholders: Parents, DSS workers, and ICP case managers.

METHODS

Study Participants

Families were chosen for inclusion based on three criteria:

1) Currently receiving ICP services

2) Receiving ICP services for at least one year at the time of the study (November 1, 2000)

3) History of DSS involvement either prior to or during time of ICP involvement

A total of eight families met these criteria. The parent who was originally referred to ICP was recruited for participation in the study. At least one parent from all eight families agreed to participate. Thus, the current study represents the entire population as defined by inclusion criteria. Six of the parents interviewed were mothers and one was a father. In one family, two parents (mother and stepfather) were interviewed together because, although the mother was the original ICP client, the stepfather had been referred to ICP during the course of the family’s involvement with ICP.

Parent Participants. Parents ranged in age from 26 to 40 years. Six parents were Caucasian and three were African American. Five parents had primary diagnoses of Major Depression, one with psychotic features, one parent had a diagnosis of Bipolar Disorder, one had a diagnosis of Schizoaffective Disorder, and one had a diagnosis of Adjustment Disorder with features of anxiety and depression. Two parents had secondary diagnoses of Borderline Personality Disorder, and one parent had Mental Retardation. Seven parents had histories of substance abuse, and six had histories of suicide attempts.

There were 16 children and two grandchildren currently living with parents interviewed for this study. Several families had additional children who were grown or were being raised by other family members or foster parents. Children (including grandchildren) living at home (N=18) ranged in age from 2 to 14 years. Ten of the children living with their parents had mental health diagnoses of their own, and five had histories of psychiatric hospitalization or residential treatment for emotional and behavioral problems. Among the 18 children currently living with their parents, 14 had a history of DSS involvement at the time of referral to ICP. The remaining four children were born or came into ICP after referral to DSS.

Child Participants. Although parents are the family member referred for ICP services, ICP provides family case management that includes assessment of children’s needs, and referral to and coordination of necessary services to address these needs. In order to better describe the families participating in the study, and the complex needs often addressed by ICP, two standardized instruments on child adjustment were administered. These instruments were collected only on those children who had a history of DSS involvement at the time of referral to ICP (N = 14). Instruments were administered by ICP case managers.

Child Adjustment Measures

The Behavioral and Emotional Rating Scale (BERS; Epstein & Sharma, 1998) is a standardized measure of child strengths. The BERS includes 52 questions that ask parents to identify strengths across five dimensions: 1) Interpersonal Strengths represents the child’s ability to control emotions in a social setting; 2) Family Involvement reflects the child’s participation in the family and his or her relationships to other family members; 3) School Competence is a measure of the child’s functioning in school; 4) Intrapersonal Strengths represents the child’s sense of confidence in his or her abilities and accomplishments; and 5) Affective Strengths is the child’s ability to express emotions appropriately and to accept affection from others. The BERS also creates a score for a “Strengths Quotient” which provides an overall assessment of child strengths.

Figure 2 portrays the number of children out of the total of 14 assessed that showed average or better than average strengths across the five dimensions and the Strengths Quotient. Half of the children were reported to show average or better strengths for emotional expression and ability to give and receive affection (Affective Strengths). Almost half of the children showed strengths for Family Involvement, Intrapersonal Strengths, and School Competence. Interpersonal Strengths were less prevalent among this group of children, with only three of the 14 showing average or better than average strengths on this dimension. Five children had average or better than average Strengths Quotients.

The Child Behavior Checklist (CBCL; Achenbach, 1991) is a checklist of emotional and behavioral problems completed by parents about their children. Scoring of the instrument creates scores for four competency subscales, eight “narrow-band” problem syndromes, and two “broad-band” problem syndromes. A Total Problems Score is also created. Competency subscales reflect Activities/Involvement, Social Competence, School Competence, and Total Competence. The narrow-band syndromes reflect Social Withdrawal, Somatic Complaints, Anxiety/Depression, Social Problems, Thought Problems, Attention Problems, Delinquent Behavior, and Aggressive Behavior. The broad-band syndromes reflect total scores for Internalizing Problems (e.g., Social Withdrawal, Somatic Complaints, Anxiety/Depression), and Externalizing Problems (Delinquent Behavior, Aggressive Behavior). Scores on each of these scales can be compared to other children of the same age and gender to determine if a child is showing clinical, borderline clinical, or non-clinical levels of competency or problems.[3]

Parents’ reports on the CBCL revealed that children involved with ICP showed both competency and symptoms. As illustrated in Figure 3, eleven children (79%) showed clinically low levels of Total Competence. However, fewer children showed clinically low levels of Activity/Involvement, Social Competence, and School Competence. Figure 4 illustrates the range of narrow-band behavioral and emotional problems of children receiving family-centered case management from ICP. Clinical levels of Somatic Complaints were least frequently reported, while Thought Problems, Attention Problems, and difficulties with Delinquency and Aggressive behavior were more common. Clinical levels of Social Withdrawal, Anxiety/Depression and Social Problems were evidenced by either half or nearly half of the children. When broad-band syndromes (Internalizing and Externalizing Problems) and Total Problems were examined (see Figure 5), most of the children in the study were reported to have borderline clinical or clinical levels, indicating a substantial degree of child mental health issues among the families referred to ICP.

The Invisible Children’s Project: Family-Centered Case Management

ICP provides comprehensive case management services to parents with mental illness and their children. Parents qualifying for public sector mental health services are referred to ICP by a variety of other providers, including case managers working for the New York State Office of Mental Health, mental health clinicians, and DSS case workers. Parents are enrolled into the program as space becomes available. Enrollment priority is given to families representing the highest risk for loss of child custody. Case managers[4] develop service plans related to explicit goals for all family members. Case managers facilitate access to services defined in the plan, and provide ongoing coordination of services received by all family members, and support communication between all service providers involved. ICP case managers maintain regular contact with families, and are available by pager for crisis management 24 hours per day, seven days a week. In a time of crisis, parents can call the Emergency Helpline at MHA, the parent agency for ICP, and ask the Helpline worker to contact their case manager. The program currently has two full-time case managers, one of whom is also Program Coordinator. The Coordinator works with six families, and the case manager works with twelve families. ICP case managers have a Bachelors degree and a minimum of two years experience in direct human services.

ICP case management is comprehensive and fundamentally flexible in an effort to be responsive to specific and changing family needs. ICP relies on a “whatever it takes” approach, and as a result case managers wear many hats. Case managers provide education and referral, but are also available to transport parents and accompany them to important appointments if needed to assure parent attendance. Provision of emotional support is also a central function of ICP case managers. The development of a trusting and supportive relationship between ICP case managers and all family members is a critical component of ICP case management. Availability and reliability are considered necessary in order to promote trust among families who have often felt unsupported and sometimes betrayed by professionals in the past. Contact with families is therefore highly intensive when needed. ICP case managers are available for daily contact by phone or in person, and in times of crisis may speak with parents multiple times in a single day. During times of stability, phone contact may be weekly and in-home visits bi-weekly.

These values on relationship and the capacity to provide comprehensive and intensive services distinguish ICP from less comprehensive case management programs in general and from DSS services in particular. Table 2 illustrates some of the differences with respect to comprehensiveness in case management between DSS and ICP, and makes evident that one unit of service has very different implications across the two agencies.

ICP case management is family-centered. Family-centeredness reflects practices that are strengths-based, collaborative, and respectful of family “voice and choice” about both needs and goals (Allen et al., 1995). ICP assumes that parents want to be the best parents they can be, and that mental illness is not a determinant of parenting ability. The parenting role is valued, and the goals and needs of the entire family are considered in the creation of a service plan. These values and principles provide the foundation from which case managers work with families, and are believed to be related to positive outcomes for ICP participants.

Family-Centered Measure

The Family Centered Behavior Scale (FCBS; Allen, Petr, & Brown, 1995) was used to assess the presence of family-centered qualities in ICP services from the perspective of parents participating in the current study. The FCBS includes 26 items that assess whether ICP case managers behaved in a family-centered, strength’s based manner when providing support and services to families. The FCBS asks respondents to rate the frequency of family centered behaviors in interaction with their ICP case manager on a 5-point scale (1=never; 5 = always). For the current study, an overall Family Centeredness score was calculated for each family by averaging across all 26 items. The FCBS was administered to parents by researchers as part of a longer interview (Parent Interview; see below). ICP case managers were not present for the administration, and parents were assured that individual responses would not be shared with ICP staff, nor affect their services in anyway.

As can be seen in Figure 6, all eight families reported that ICP case managers exhibited family-centered behavior “most of the time” (score = 4) or “always” (score=5). Average overall scores ranged from 4.15 to 5.00 on a scale of 1 to 5. The mean score across families was 4.75, with a standard deviation of .26, indicating that the parents in the families involved in this study felt respected and treated in a strengths-based, culturally competent manner “almost always.”

Procedures

Interviews. Interviews were constructed for the current study to gather information from parents, ICP case managers, and DSS case workers. Interviews included questions related to ICP practices and family outcomes, and were informed by a collaborative process between research staff, program staff and administrators, and an ICP family representative. Over the course of several meetings and structured conversations, program staff and the participating family member defined critical risk factors, and related areas of functioning that are targeted by ICP. These areas of functioning were defined as common “critical outcomes” and were specifically assessed through interviews and file extraction.
Table 2. Comparison of ICP and DSS case management services

	ICP	DSS
Focus of Service	Case management services provided for the entire family. Focus is on all meeting family needs through referral, linkage, support and advocacy.	Services provided for identified parent and child(ren). Focus is on child safety through referral to mandated services and home monitoring.
Family Contact	Minimum contact is two times a month in home. Actual minimum contact is once weekly in-home.	Minimum contact is once monthly face to face. Actual contact is one time monthly.
Availability	Case manager available 24-hours per day, seven days a week via Crisis Helpline at parent agency.	Caseworker available Monday to Friday, 9 A.M to 5 P.M. Emergency line available for child safety concerns, but does not access family case worker.
Caseload	On average, full-time ICP case managers carry a caseload of 12 families.	On average, full-time DSS caseworkers carry a caseload of 20 families.
Service Coordination	ICP case manager coordinates multiple services for all family members. ICP maintains regular contact with other providers and facilitates provider and interagency communication and conflict resolution, and convenes interagency meetings as needed.	Caseworkers provide referral to services, but do not coordinate services.
Advocacy/Support · *Legal Advocacy* · *Educational Advocacy*	Case managers advocate for appropriate services, forge relationships with other providers when needed, and accompany parents to school, court, and DSS meetings to provide support and to advocate for appropriate services and supports. Case managers make referrals to and maintain contact with professional legal advocates. Case managers make referrals and facilitate relationships with professional educational advocates for children receiving special education or in need of evaluation for school placement. Case managers attend IEP meetings, incorporate child services and needs into overall family service plan, and provide transportation if needed.	Caseworkers do not generally provide direct advocacy services.
Housing	Subsidized HUD housing available for six families. Referral to Section 8 and other supported housing programs in the community. Case manager assists parent with completion of application and other requirements.	Caseworkers provide referral to Section 8 and other supported housing programs in the community.
Flexible Funds	Case managers have access to flexible funds to address critical or clinically relevant needs. These can include payment of rent and utility bills to avoid eviction or discontinuation of services, purchase of home furnishing, and additional funding for school clothing and activities, birthday and holiday gifts, and recreational activities.	DSS does not provide flexible funding to cover concrete needs.