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SECTION 5: DELIVERY OF OAP SERVICES AND SUPPORTS

All OAP services will be delivered in a family-centred approach that promotes the active engagement of parents/caregivers through access to resources and support, informed and transparent decision making and the delivery of flexible and responsive service based on family priorities, strengths and needs. Parents/caregivers will be engaged, oriented, and supported by the Family Support Worker from initial contact throughout their service pathway in the program. Services are planned and captured in each child/youth and family’s OAP Family Service Plan.

For children and youth receiving autism, special needs and/or mental health services concurrently, service providers are encouraged to collaborate with a view to promoting a seamless and coordinated service experience for families.

Flexibility of Service Delivery

Children and youth with ASD vary greatly in terms of their specific skill building needs and the intensity and scope of services required. Within the context of the local service delivery system, different ways of delivering services may be required to best meet the range of needs, including individual and group-based service. Flexibility is required both in terms of the services and supports that are developed and the ways in which they are delivered.

Providers are encouraged to build upon existing partnerships, such as information sharing agreements and service pathways to optimize seamless service delivery for families of children/youth with ASD.

In all areas of the province, OAP services will:

OAP Family Service Plan

A key principle of the OAP is child, youth and family-centred services. As per the OAP Clinical Framework, family-centred care is an approach to planning and delivering care that promotes collaborative partnerships between care providers, children and their families. Family-centred service recognizes that each child, youth and family is unique; that the family is the constant in the child/youth’s life; and that the family has expertise in their child/youth’s abilities, interests and needs. All decisions about supports, behavioural services, and the coordination of services are made in partnership with the family and/or youth and their priorities are at the center of those conversations.

One component of family-centred service is the development of the OAP Family Service Plan.

The OAP Family Service Plan is a living document that changes over time to reflect the shifting priorities of the family, the child’s developmental stage, progress toward goals and objectives and transition planning. The OAP Family Service Plan may include the formation of a Family Team, as described in the OAP Clinical Framework.

The plan will be initiated by the OAP Family Support Worker, who will support the family through its development, revision and delivery of the components illustrated above. Each child/youth and their family will have an OAP Family Service Plan that will be unique to them.

The following sections describe in further detail, the key components of the OAP Family Service Plan.

Family and Children Information (Family Story)

Family Support Workers will follow the comprehensive information collection process outlined in the OAP Clinical Framework that builds the family story. Families will experience a seamless sharing of family and child information as part of the Family Service Planning process; and the Family Support Worker will review and build on key information, about the child/youth and their family, including relevant assessments and reports such as the Individual Education Plan (IEP).

The family story will be updated at a minimum of every six months, or at the progress reviews.

Providers may want to explore the use of a common consent form across the service area where possible and in keeping with requirements under applicable privacy laws. They will be required to seek consent for information sharing at the beginning of the Family Service Planning process and at key decision points to minimize the amount of time consent will need to be sought.

People/ Organization (Family Team)

Inter-professional partnerships and the Family Team are key elements of service delivery in the OAP. OAP providers will work with their partners to ensure they are planning collaboratively and integrating practice and service delivery for children/youth with ASD and their families. The service planning process will include assisting families in navigating and coordinating services for their child/youth. The OAP Clinical Framework focuses on the importance of this collaborative and interdisciplinary approach to service planning; and outlines how the Family Service Plan will be developed, revised, and maintained with input from all relevant professionals and people in the child/youth’s life.

Many children/youth with ASD are active in school, in their communities, with their families and with other services outside of the OAP. They also have natural supports in their life, like friends, community members, caregivers and extended family members. The OAP Family Service Plan will consider the services and supports that those outside of the OAP provide.

When working with children/youth in the OAP who are in school, OAP providers are encouraged to develop, promote and maintain strong partnerships with their local school boards.

The OAP Clinical Framework provides further details regarding how the Family Team is formed should parents/caregivers wish to do so, as well as how the Family Team is engaged and updated on a regular basis.

In some situations, if a child/youth receiving services from the OAP has multiple and/or complex needs, the OAP Family Support Worker may refer the family to the local Coordinating Agency for Coordinated Service Planning under the Special Needs Strategy. In these situations, the OAP Family Support Worker will remain involved with the family and will participate in Coordinated Service Planning.

Family Services and Training

The approach to family services and training in the OAP is driven by a family-centred, child-focused philosophy that promotes collaboration between families and providers. Caregiver involvement is promoted by providing choice and overcoming potential barriers by offering:

Foundational Parent/Caregiver Services

These services include information, workshops, groups and seminars specifically aimed at orienting families who are new to service and providing them with introductory and foundational information about ASD, ABA and how services are provided in the OAP.

Beginning in the Fall of 2017, families who are new to the OAP can expect to be offered foundational parent/caregiver services within six weeks of registration with the OAP.

Needs and Strengths based Parent/Caregiver Services

Evidence based family services and training that are linked to and built upon a parent/ caregiver’s new and applied learning goals will be offered according to the needs and priorities of the families in each service delivery area and may include, but are not limited to:

OAP service providers will expand their current service offerings, and collaborate and partner with each other and other sectors to develop a robust continuum of family services and training to meet the needs of the families in their region.

Example of Consultation and Parent-Mediated Service:

Sophie’s parents identify a need for support with teaching her to independently use the toilet. Their family support worker suggests that they begin by attending a workshop on preparing for toilet training. The workshop covers training methods, child and caregiver readiness, and appropriate data collection methods. A few days after the workshop, the family is provided with a follow-up coaching session to provide additional in-home support. Her parents use the strategies successfully on their own at home and follow up with another coaching session to ask some questions a couple of weeks after the initial coaching session.

OAP service providers will expand their current service offerings, and collaborate and partner with each other and other sectors to develop a robust continuum of Family Services and Training to meet the needs of the families in their region.

Evidence Based Behavioural Services

Evidence based behavioural services, including Applied Behaviour Analysis, in the OAP will be delivered through a strengths based approach that empowers families to develop the skills and knowledge to address needs as they arise. Services will be delivered in a manner that emphasizes and prioritizes the development, maintenance and generalization of functional skills, including those skills that prepare children/youth to more fully benefit from inclusion in typical settings.

A variety of evidence based behavioural services will be offered in the OAP. The timing, duration, intensity and scope of behavioural services will be adapted to meet the individual needs of each child/youth and their family. OAP providers will continue to collaborate with the education sector to support children in building the skills they will need to be ready for school, to participate fully in school and to transition to school as clinically appropriate.

Evidence based behavioural services in the OAP address the following objectives:

The OAP Family Service Plan will include the child/youth’s Behaviour Plan as described in the Clinical Framework. The Behaviour Plan will be created through an assessment process that will involve getting to know the family, the child/youth’s strengths, needs and interests, and contextual/practical factors relevant to the provision of evidence based behavioural services (e.g., language and cultural considerations, transportation, scheduling constraints). The Behaviour Plan will describe the assessment and identified approach to meeting the child/youth’s needs, as developed in collaboration with the family.

Learning new skills and the generalization and maintenance of those skills will be the focus of all aspects of the Behaviour Plan. To support this, services should be delivered in a variety of settings when possible and in a manner that is flexible, taking into account each family’s specific needs.

There will be times when the family is actively working on the development and generalization of new skills and/or managing their child’s challenging behaviour. There will be other times when the family will more exclusively practice those skills in new places, and with new people, including the Family Team. The OAP will provide services and supports for families who are learning new skills as well as those who are generalizing these skills.

Opportunities for learning and generalizing new skills may be delivered in the following formats:

The specific duration, approach, setting and intensity of new learning will be captured in the Behaviour Plan and determined according to:

The Behaviour Plan will be reviewed at least every six months, and will be monitored and evaluated on an ongoing basis. For more information, please refer to the OAP Clinical Framework.

As the identified goal(s) in the Behaviour Plan are attained, the Family Service Plan will be updated to include additional supports and services for the family to apply their learning to real-life situations. The plan may include family services and training and other supports and services delivered through the following modalities:

The Family Support Worker will schedule touch points with the family at least every six months, as noted in the OAP Clinical Framework. When a new need or concern arises, the family, the Behavioural Clinician and the Family Support Worker will discuss the appropriate approach to addressing the need and determine whether a new assessment and a new Behaviour Plan is required, and if so, will facilitate the assessment, at the earliest possible time.

Example: Aamir and Naseem are 3-year-old twins who have just come in to service with the OAP. Based on their individualized assessments and the priorities identified by their family, an OAP Family Service Plan has been developed for each of them.

The Family Service Plans for both boys include opportunities for the family to learn some foundational information and to begin to build their capacity as informed mediators. Both plans include direct teaching, opportunities for generalization and maintenance in their natural environments and training and education for their parents and other caregivers.

Aamir and Naseem’s assessments found some differences in their learning styles, strengths and needs and therefore their Behaviour Plans include different goals and approaches to meeting those goals. Aamir was found to need intensive one-to-one Evidence Based Behavioural Services to increase his rate of overall learning and development. Naseem has some age appropriate skills that he has developed through natural learning opportunities at home and childcare and he was found to need Evidence Based Behavoural Services that focus on building his communication and social skills.

Transition Planning

Transition is a term often used to describe the passage from one stage of life to another or the movement from one environment or setting to another. Times of transition can be especially stressful and challenging for children and youth with ASD and their families. Knowledge regarding information and resources available and advance preparation can help to reduce stress and facilitate a successful transition.

A family may request to withdraw from the OAP with or without transition support services. The removal of a diagnosis of ASD would also warrant an individualized transition plan out of the OAP.

OAP providers will offer a range of transition supports and services to meet the complex and varying transition needs of children and youth with ASD that may evolve over time. As per the OAP Clinical Framework, transition planning will be individualized, planned in advance and achieved in partnership with the OAP provider, family and/or youth, educators and other service providers, as applicable. These services and supports can vary depending on the identified needs of each child and/or youth and their family. Transition planning can encompass educational transitions (e.g., into kindergarten, from elementary school to secondary school), personal transitions (e.g., a move of the family home, changes in family makeup), and transition to adult services (e.g., specialized training, self-advocacy, employment and independent living skills).

Educational Transitions

Partnerships and collaborative planning with OAP providers, families and/or youth, educators and other service providers is instrumental for planning successful transitions to school and maximizing coordination of care and learning.

In the first phase of implementation of the OAP, Connections for Students continues to provide coordinated and seamless transitions to school for school-aged children and youth who are in the former AIP program. Transition planning and process follows the existing Connections for Students. model; however, these children/ youth will continue to receive service from the OAP.

Connections for Students:

As the design of the OAP evolves over the next year, further communication on the future of Connections for Students will be provided.

Transition to Adulthood

As a family and/or youth plan to transition to adulthood, post-secondary education and/or adult services, successful transition planning is achieved through active partnership and collaboration between the OAP providers, the family and/or youth, educators, and other service providers, as applicable. Optimal transition planning is directed by the individual needs, strengths and interests and identified goals of the family and/or youth to promote independence, and improve quality of life.

Youth with ASD and a developmental disability may be involved with Integrated Transition Planning for Young People with Developmental Disabilities (TAY). This initiative is focused on ensuring that young people with developmental disabilities have a single integrated transition plan to support their transition into adulthood. Upon request, starting at age 14, every young person with a developmental disability can get a written plan that helps him/her prepare for adulthood and the transition from youth-centred services and secondary education, to adult community services in a considered and coordinated manner. Local protocols have been developed and lead agencies identified to lead this process locally, and OAP providers are encouraged to collaborate in this process as appropriate.

Clinical Staffing Requirements

During the phased implementation to a new approach to Direct Funding by the end of 2017 and the full launch of the OAP in the spring of 2018, the Clinical Staffing requirements as outlined in the Autism Intervention Program Guidelines (and paraphrased below) will continue to apply to those children/youth who are or will be receiving 20 hours or more of weekly intervention as an interim measure until new clinical staffing requirements are developed.

For full AIP Guidelines, visit: http://www.children.gov.on.ca/htdocs/English/professionals/specialneeds/aip_guidelines.aspx

For all other children/youth receiving evidence based behavioural services from the OAP, the Staff Qualifications outlined in the Guidelines: Applied Behaviour Analysis-based Services and Supports for Children and Youth (and paraphrased below) will apply.

For full ABA Based Services and Supports Guidelines, visit: http://www.children.gov.on.ca/htdocs/English/professionals/specialneeds/guidelines/guidelines-2011.aspx

ABA Professionals with the following qualifications will provide clinical oversight in the assessment, goal setting, development, implementation and evaluation of the Behaviour Plan outlined in the OAP Clinical Framework:

Service providers and professionals with varying levels of training and qualifications may appropriately implement other aspects of the OAP Family Service Plan, depending on the type of service being provided and the child’s or youth’s specific needs. The OAP service provider is responsible for ensuring that:

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