HEALTHY FAMILIES MASSACHUSETTS POLICIES & PROCEDURES

COMMUNITY LINKAGES & REFERRALS

In order to be integrated members in their communities and ensure that services are coordinated and non-duplicative, HEALTHY FAMILIES MASSACHUSETTS (HFM) programs actively collaborate with other home visiting, family support, and service providers for young parents in their catchment areas. These linkages provide a base from which HFM programs receive referrals and to which HFM participants are referred and linked for additional resources toward achieving their goals. HFM community linkages and referrals policies and procedures are divided into the following sections: Collaborations with community linkages, and Referrals to community resources. Rationale Each HFM program is one part of the larger community; it is not and should never be the only source of support for program participants. By providing referrals and encouraging linkages to other agencies, HFM supports participants in developing skills in accessing services in their communities. Relationships fostered between the HFM program and other community agencies models for participants how to make these connections and parallels the connections participants make with each other and their larger community. Research shows that the three major factors contributing to increased risk for child maltreatment are the presence of domestic violence, parental mental health issues, and the presence of substance abusing behaviors. Referrals to address these challenges are key to HFM programs ability to support families and reduce the risks of child abuse and neglect. I. COLLABORATIONS WITH COMMUNITY LINKAGES In order to support the development of linkages between families and community services, HFM programs must develop and maintain a collaborative relationship with a variety of supportive agencies in their catchment area. There is some thought and attention paid to developing linkages that reflect the needs of the service population, which may require that HFM programs create linkages with agencies that they are not historically connected with. These connections may include formal Memoranda of Agreements or more informal agreements that outline referral procedures and other agreements (e.g. staff training agreements, workshops for families, etc). Programs must develop and follow an active protocol to ensure the maintenance and nurturance of these relationships.

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Programs must develop and maintain informal, non-financial collaborations through interagency agreements with supportive agencies across the communities in their contracted catchment areas. These linkages should reflect the needs of the service population as well as that which currently exists within the community. A. HFM programs must have collaborative relationships within the catchment area to the following community programs: Early Intervention (EI) programs and EI Partnerships (MA Department of Public Health); Massachusetts Family Centers (Childrens Trust Fund); Massachusetts Family Networks, Parent-Child Home Program and Community Partnerships for Children (Department of Early Education and Care); Young Parent Support Program and Community Connections (Department of Social Services); and Outreach Services to teen mothers (Department of Transitional Assistance). B. Programs must have links with the appropriate community resources/agencies within the catchment area for training, referrals, and consultations on the following topics: Substance Abuse; Domestic Violence; Mental Health; and HIV/AIDS. If there are not any resources/agencies within the catchment area that focus on these issues, programs must make connections to the reasonably closest resources. NOTE: Please see the HFM TRAINING POLICY for training requirements on these topics. C. Most participants will have an interest in referrals to meet both basic and more complex needs. As such, programs should maintain linkages with the following types of programs so that, depending on a participants needs, appropriate referrals to additional services can be easily made by the program: economic and financial support programs; food and nutrition programs (WIC, local food pantries, etc.); housing assistance programs; school readiness programs (Parent Child Home, Early HeadStart, Headstart, etc.); child care; immigration/interpreter needs; educational resources; job training programs; legal service programs; family support centers; recreational opportunities (e.g. libraries, parks, community centers, etc.);
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substance abuse treatment programs; and domestic violence programs/shelters.

D. Program must develop and maintain relationships for referrals, training, consultation and any other program or participant needs with the relevant organizations within the catchment area. II. REFERRALS TO COMMUNITY RESOURCES In relationship-based work, home visitors may spend time and effort supporting and preparing participants to accept or engage in services from other community providers. This support and preparation is the important work that takes places before home visitors make referrals. Home visitors make referrals by giving participants contact information or agreeing to contact on a participants behalf an agency that could provide a needed or requested service. A. Best Practices in Service Delivery Regarding Referrals Participants always have a say in initiating and accepting referrals to other community services in keeping with the voluntary nature of HFM; Empower participants to be as involved as possible in following up on referrals; Home visitors and participants collaborate to identify needs and resources, initiate and follow up on referrals; and Connect participants to community resources to meet those needs and goals identified through the Family Profile and Individualized Family Support Plan (IFSP) processes. 1. Identifying needs: Home visitors and participants collaborate to identify needs that can be met by resources outside of the program. Over the course of service delivery, there are specific tools that help families articulate their strengths, resources, challenges, and needs, and guide referrals to community resources. Among these tools are the Family Profile and the IFSP; completion of these tools help program participants and home visitors identify ways in which community linkages may augment participant strengths and meet those needs. Home visitors should also use the home visit to discuss and identify needs with participants. Participants then decide if a referral may be sought/made, who will initiate the referral, i.e. the participant or the home visitor, and, finally, give consent to release information between the referral agency and HFM. NOTE: In keeping with the confidential nature of HFM services, HFM programs must obtain written consent from participants authorizing them to share information with other agencies. In instances when participants have initiated referrals on their own or are engaged in other services as part of other programs, home visitors should ask participants about other services and seek a release to follow-up with those agencies.

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2. Identifying resources: Home visitors should identify the available organizations/resources that meet the participant needs. This should follow a discussion with supervisors and/or the home visiting team to ascertain the best match to meet the need. 3. Making a referral: Referral contact information and any additional needed support is given to the participant if s/he will initiate the referral; otherwise, home visitors make the referral. Upon making a referral, home visitors should verify that the agency is able to accept referrals at the time. Home visitors must document in the Participant Data System (PDS) instances when referral sources are unable to accept new referrals, using referral outcome type not accepting referral. Additionally, they will discuss other options in supervision as well as with the participant. B. Follow Up On Referrals

Work on referrals does not end when the referral to other services has been made. Follow-up on referrals is necessary to ensure desired conclusion is reached. Once a referral has been made, home visitors must follow-up on a referral as needed:
When the home visitor takes the lead on making a referral directly to an agency, follow up includes at a minimum, a phone call to the agency and at least one discussion with the participant regarding outcome or next steps. This is particularly important, if the participant will be doing the bulk of follow up contact with the agency after the home visitor initiates the referral. When a participant takes the lead on pursuing a referral, at a minimum, the home visitor must discuss the outcome and next steps with the participant.

Regardless of who initiated the referral: For instances when an agency has refused new referrals, regardless of who initiated the referral, the home visitor must contact the referral agency to find out any additional information (e.g. when the agency will be accepting new referrals) and then convey this to the participant. Additionally, other options to meet the need should be discussed in supervision. In the event that participants opt not to follow-up on referral(s), the home visitor must document this decision in the home visit referral section of the PDS, discuss other options in supervision, and explore with the participant the reasons why and if other referrals may be more appropriate. If a referral agency (due to the nature of the services it provides) can not disclose the family/participant involvement to the HFM program, home visitors must document their nondisclosure in the PDS, discuss it in supervision, and ask the participant if he or she followed through with the referral. Home visitors must discuss with participants any barriers to their accessing referrals, such as: affordable, reliable transportation to access services; linguistic match to community resource in the area and/or need for interpretation services; and unique barriers to the participant and the participants family to accessing referral resources.
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Referrals must be discussed in supervision as a part of regular case review.

C. Documentation of Referrals Referrals, follow-up and their outcome must be documented in participant records as follows. Home visitors must document any referrals in the home visit referral section of the PDS by the tenth of the month following the month in which the referral was made. Home visitors must document their follow up with participants on the progress of referrals, regardless of who initiated the referral, in the appropriate home visit record(s) in the PDS. Home visitors must document the referral outcome in the original referral record in the PDS. Contacts to agencies for referral follow up should be documented in Secondary Activities in PDS Programs must keep a paper copy of any written documentation that accompanies the referral in the participants paper file (such as any applicable referral forms from other agencies). Supervision log documentation must show evidence of discussions about referrals, follow-up, and outcomes during case review.

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