Ten Principles of High-Fidelity Wraparound
WE CELEBRATE THE UNIQUE IDENTITY, STRENGTHS, AND CULTURE OF EACH CHILD AND FAMILY.
Contributed by Dan Lotz, Care Manager Supervisor, PEP Connections
For over 30 years PEP Connections has helped young people with serious mental and behavioral health needs remain in their homes and communities by delivering a care coordination service using a high-fidelity wraparound approach. Wraparound, as it is often called, is a community-based service that uses a collaborative team-based management approach. The High-Fidelity Wraparound (HFW) model, a specific approach to providing wraparound, uses 10 key principles to build a family’s ability to meet their child’s complex needs.
Today, Ohio is poised to make HFW available to young people throughout the state by way of OhioRISE, a newly developed, specialized Medicaid managed care program. With PEP’s long history in this space, we thought it might be helpful to share some insights to serve as a guide for those interested in learning more about the wraparound framework.
The Ten Principles of Wraparound Defined
The implementation of HFW at PEP is framed by the National Wraparound Initiative’s, “Ten Principles of the Wraparound Process.” At PEP, this is how that looks.
1. Family Voice and Choice
Family voice and choice means that all team and treatment decisions are centered on preferences of the youth and family. This includes everything from who will participate on the team to what phrasing is used in the treatment plan. It includes things like the location and time of appointments and meetings and whether specific modalities of treatment will be used. This principle is essential to fostering a sense of safety, trust, and empowerment necessary to ensure that the family feels ownership of their treatment.
Example: A family may prefer treatment options that do not include psychiatric medication. While this may not be the approach the provider would recommend, this principle insists that a child and family’s lived experience, culture, and preferences are the guiding authority behind all decisions for that young person. As a result, this preference would be respected.
This principle challenges us to honor the team as the primary venue for critical decision making. The team process ensures not only that we are considering multiple sources of input but also that we are holding each other accountable to the wraparound values and commitments. If a crisis or emergency arises before a scheduled team meeting, we may call an emergency team meeting to process the concerns together.
Example: We uphold this principle when we defer to the team for deciding on whether to make a referral for a more intensive form of counseling, when planning for an upcoming juvenile court hearing, or to introduce a new resource for respite.
3. Natural Supports
The inclusion of natural supports is a critical layer to assure the team includes individuals who the family trusts. It’s also essential to ensuring our efforts will be culturally responsive and respectful to the family system. Another reason natural supports are one of the 10 principles of wraparound is because they ensure that treatment will be sustainable since these supports continue after our services conclude. Efforts to include these supports are active and intentional; however, it is the wraparound facilitator’s role to ensure these contributors feel valued and empowered to play meaningful roles on the treatment team.
Example: Natural supports can be anyone meaningful in the young person’s life such as extended family, a deacon from the family’s church, a neighbor, a coach, or a teen client’s close friend. We’ve even included a parent’s cousin living in Chicago and a child’s adult sibling living in North Carolina.
The treatment team, made up of both formal and natural supports, collaborate to develop, implement, monitor, and evaluate the treatment plan goals. A wraparound treatment plan — or Plan of Care — incorporates the strengths, needs, culture, and vision identified by the family and team collectively, and is driven by the team process.
Examples: Collaboration may include supporting an extended family member with the coaching and resources they need to become an effective emergency respite provider for the child; developing multi-disciplinary interventions with CCBDD staff to address co-occurring treatment needs; or partnering with a Probation Officer to advocate for court decisions which best empower the family and support treatment needs.
5. Community Based
The wraparound principal of community-based treatment focuses on establishing support for the least-restrictive, most inclusive setting possible for the young person. In addition to promoting accessibility, this principle reinforces sustainability beyond the formal wraparound process by creating and reinforcing connections that can become the child and family’s ongoing network of support. To be effective, the facilitator must be highly familiar with the diverse assets, resources, and systems of the communities they serve.
We often work with the family and team to create comprehensive, community-based alternatives to higher levels of care. To do so, we develop the structure and routines where the child can receive the most appropriate treatment to safely remain in their home and community settings. We incorporate whatever supports and resources may be needed. These plans often require the use of our flexible funding for the services and resources needed to develop these individualized plans.
6. Culturally Competent
To establish the trust of the family and natural supports, it is essential that we embrace culturally competent care. Identifying the family’s unique strengths, beliefs, traditions, and expressed social identity is imperative, as is recognizing and affirming the family’s lived experience and understanding the journey and historical trauma of their identified cultural groups. The wraparound facilitator should actively explore these elements of culture, incorporating the information gathered directly into the language of the treatment plan.
Culturally competent practice involves maintaining an approach of curiosity and appreciation of cultural differences and identities found throughout our communities and partnering with local cultural networks and organizations whenever possible. It also involves using the “Strengths, Needs, Culture & Vision Discovery” wraparound tool to identify cultural strengths and values to be used in treatment planning, including those relevant to family roles, shared beliefs, and spiritual influences.
A central hallmark of the wraparound model is that treatment is individualized. With a fully-appreciative exploration of strengths, needs, culture and vision – and active and inclusive team-building and identification of natural supports – treatment will be entirely unique to each family. Therefore, no two teams, treatment plans, or even safety plans should EVER look alike. Families should be able to recognize their quotes, language, and values captured into all treatment tools and documents.
The team’s creativity with this approach will result in many unique interventions, action-steps, and strategies of empowerment, such as: using flexible funding to enroll a child in martial arts programming to learn techniques to promote mindfulness and impulse-control; helping a teen client use features on their own smartphone to develop a personalized safety plan for anger management; funding enrollment in cultural dance and drumming programming to support healthy self-esteem development; and incentivizing the use of exercise equipment in the home to promote somatosensory self-regulation.
The 10 principles of wraparound – and in fact, all aspects of wraparound – should be inherently strengths based. The team should actively identify and document strengths of the child, family, and support system throughout treatment. This ongoing “strength-spotting” is a signature responsibility of the wraparound facilitator, as strengths should be recognized at every opportunity, especially during team meetings and updating of the treatment plan. It is imperative that we use this strengths-focus to frame the family’s journey throughout all system advocacy and navigation
Example: Successes during treatment, such as the resolution of crises, are seen as strengths. For instance, in successfully de-escalating a stressful or explosive situation in the home, the episode may reveal family strengths of effective safety planning, problem-solving, and accessing of their natural supports—and these identified strengths can then be built into future treatment planning
9. Unconditional Care
Unconditional Care refers to the wraparound team’s obligation to persist in their efforts toward plan of care goals until the family and team agree that the formal wraparound support is no longer needed. Wraparound services should not terminate due to limited progress or temporary placement disruptions, and there is no identified time-limit to wraparound services. The family and team collectively determine when transition-planning is appropriate.
This principle is demonstrated when we support the team in brainstorming new ways to break through challenging barriers to progress, or when we extend our final transition phase of wraparound treatment to create opportunities to ensure the parent feels more confident about the gains they have made.
Finally, the 10 principles of the wraparound require the process to be Outcome-Based. Goals and objectives in the plan of care are how the team defines its “mission” as it works collaboratively toward the family’s “vision.” Ongoing evaluation of progress includes input from both formal and natural supports, meaningful measurement of capacity-building, and celebrations of success. The wraparound process creates a framework for efficient and accountable action-steps and fine-tuning of interventions and strategies, which ensures the team-based process remains focused and productive.
Meaningful measurement of outcomes and progress may include successful collaboration with the school to assess a child’s needs and develop the supports to preserve her classroom placement; reduction or elimination of psychiatric emergency room visits; or helping a teen client to secure and maintain a summer job.
Upholding and implementing these 10 principles of wraparound requires active and intentional efforts to remain accountable to this philosophy of care. At PEP we remain enthusiastic in our use of this approach. We celebrate the unique identity, strengths, and culture of each child and family, while engaging and appreciating each community as a source of healing and opportunity. We look forward to Ohio’s expanded access to this incredibly effective and powerful approach to care, and to the healing, confidence, and hope it will bring to many more families.