CAR Family Care Plan (FCP) Pilot Program

This grant award will have an initial period of performance starting in FY27 (11/01/2026 (or upon execution of the agreement) through 06/30/2029). A budget should be submitted for FY27 only.
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DESCRIPTION

Services of Provider are focused on:

1. Preventing substitute care placement for children reported as neglected due to substance exposure by assisting parents prior to the birth of a child. Provider will perform timely Family Care Plan Services and associated care coordination to facilitate referrals to supports and services to reduce the need for substitute care.
2. Promoting family reunification by educating frontline health care providers and support staff to assist parents in developing a Family Care Plan that works for the child and family to promote parent engagement in treatment and therefore reduce the time to reunification after an infant’s birth;
3. Stabilizing foster care placements by ensuring a Family Care Plan is in place for an appropriate caregiver prior to an infant’s birth, reducing foster care disruption and transitions; and
4. Ensuring the safety, permanency, and wellbeing of children by providing supports to caregivers and reducing the need for substitute care.
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PROOGRAM DETAILS

The Family Care Plan (FCP) Pilot Program aims to ensure the safety and well-being of an infant with prenatal substance exposure and the pregnant person by addressing the health and substance use disorder treatment needs of both the infant and the affected family or caregiver.

Provider staff must be available to eligible clients during normal business hours of operation, Monday through Friday.

• Provider will identify pregnant and post-partum persons with a history of substance use or substance use disorder as eligible clients through the administration of a verbal 5Ps screening (https://ilpqc.org/wp-content/docs/toolkits/MNO-OB/5Ps-Screening-Tool-and-Follow-Up-Questions.pdf).

• Provider will offer Family Care Plan services to all eligible clients.

• If the client accepts the Family Care Plan service, a member of the Provider’s direct service staff will meet with the client for at least 1 hour, at least once per week for the first month. The initial meeting will occur in person at the Provider’s office, the client’s home, or another safe location of the client’s choosing. Future meetings may be over the phone or virtual if the client prefers.

• The Provider’s direct service staff will assist the client in completing the Family Care Plan/Plan of Safe Care, including:
o identifying strengths and goals
o identifying needs and making recommended referrals
o documenting family and emergency information
o identifying and documenting medical and substance use information

• Provider’s staff will assist in the completion of Family Care Plan/Plan of Safe Care. This includes:
o Initial invitation and explanation of the Family Care Plan/Plan of Safe Care;
o At least 1 hour per week in the first month, and at least 1 hour/month in subsequent months, of appropriate and timely follow-up to support to ensure the Family Care Plan/Plan of Safe Care remains updated per the client’s wishes, with updated medical and referral information. This follow-up may happen direct/face-to-face or by phone/virtual contact.
o Completion of the Family Care Plan/Plan of Safe Care;
o Complete any care coordination activities necessary to facilitate the client’s connection to the referrals requested/recommended and document all referrals to supports/services;
o Document Family Care Plan contacts, services, and referrals.
o Data tracking of each person served;
o Health care or support provider consultation on difficult cases or when additional medical needs are identified;
o Parent education and support;
o Multidisciplinary staffing to coordinate care and referrals to support the patient’s Plan.

• Provider will communicate with any other providers, including Home Visiting, Child Welfare, medical, and substance use treatment/recovery, to maximize the client’s opportunities for engaging in the recovery process.

• Provider will provide feedback to the DCFS Family Care Plans Leadership Team Chair or Co-Chair on the utilization and utility of the form through quarterly reports, surveys, and focus group discussions (1 per quarter for 3 quarters)

• Provider will offer the DCFS-developed survey to every eligible client and reports on survey distribution to eligible clients on a quarterly basis

• Provider supervisor will educate colleagues and staff on best practice standard of care for pregnant and post-partum persons with substance use or substance use disorder. This includes the importance of engaging the parent in treatment and the use of Medication Assisted Recovery (MAR).

Each referral for Family Care Plan Services will be scheduled for the next available appointment with a support person and will occur within two weeks. The length of service can vary depending on each case but may continue until up to 12 months after the infant’s birth. Some of the clients will be discharged with no follow-up needed and others will continue to need follow-up care/support. A Family Care Plan/Plan of Safe Care will be generated for each client and will be distributed in compliance with applicable confidentiality laws to all relevant providers. Provider’s staff will be available to consult with the support provider and with the client to support the completion and utilization of the Family Care Plan/Plan of Safe Care. The Provider will be available for at least 1 hour/week in the first month (and at least 1 hour/month in subsequent months) to meet with the client to complete the Family Care Plan/Plan of Safe Care, issue Provider referrals (including warm hand-offs) to services and supports (including treatment such as MAR), until up to 12 months after the infant is born.
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DEFINITIONS

Medication for Opioid Use Disorder (MOUD): Evidence-based, FDA-approved medication used to treat opioid use disorder. Alternately referred to as Medication-Assisted Recovery (MAR) or Medication-Assisted Treatment (MAT), these medications reduce cravings and withdrawal symptoms without producing euphoria. There are three (3) medications approved by the FDA for the treatment of OUD: buprenorphine, methadone, and naltrexone. It is standard of care to offer medications for opioid use disorder to patients with this disorder as it greatly impacts morbidity and mortality.

Family Care Plan (aka Plan of Safe Care): A document designed to ensure the safety and well-being of an infant with prenatal substance exposure and the pregnant person by addressing the health and substance use disorder treatment needs of both the infant and the affected family or caregiver.

Recovery: A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Recovery is not an end state, but rather a process. Complete symptom remission is neither a prerequisite of recovery nor a necessary outcome of the process. Recovery can have many pathways that may include professional clinical treatment; use of medications; support from families and in schools; faith-based approaches; peer support; and other approaches.

Referral: The act or documentation of directing someone to a different place, person, or resource for information, help, or services. Referrals are a necessary component of Family Care Plans/Plans of Safe Care.

Screening: A validated instrument used when a pregnant person presents, requesting prenatal care to identify those at risk of having a substance use disorder. A positive screen will prompt the clinician to evaluate the patient for a substance use disorder utilizing the DSM-5 criteria for diagnosis. An individual who uses substances may or may not have a use disorder and this can only be determined by an appropriate evaluation. Screening may be part of a formal screening, brief intervention, and referral to treatment (SBIRT) protocol such as that created by the Substance Abuse and Mental Health Services Administration (SAMHSA).

Substance-Affected Newborn: A newborn child who has withdrawal symptoms resulting from prenatal substance exposure or demonstrates physical or behavioral signs that can be attributed to prenatal exposure to substances.
Substance Exposed Newborn: A newborn child who tests positive for substance(s) at birth, or the mother tests positive for substance(s) at the time of delivery or the newborn is identified by a medical practitioner as having been prenatally exposed to substance(s).

Substance Use Disorder: A treatable health condition that affects a person’s brain and behavior, leading to their inability to control their use of substances – including misuse of prescription or over the counter medications, legal substances such as alcohol and cannabis or illegal drugs. Symptoms can be moderate to severe, with addiction being the most severe form of SUD. Opioid Use Disorder (OUD) is one type of SUD.
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REFERRAL AND ADMISSION PROCEDURES

Provider’s direct service staff will identify eligible clients from their existing caseload. If an individual meets eligibility criteria, the Provider will offer Family Care Plan Services to develop a Family Care Plan/Plan of Safe Care with the Client. Otherwise, the Provider will document the reason the client was not offered Family Care Plan Services.

If the client accepts Family Care Plan Services, a member of the Provider’s direct service staff will meet with the client for at least 1 hour, at least once per week for the first month. The initial meeting will occur in person at the Provider’s office, the client’s home, or another safe location of the client’s choosing. Future meetings may be over the phone or virtual if the client prefers.

The Provider’s direct service staff will assist the client in completing the Family Care Plan/Plan of Safe Care, which will include:

Strengths and goals
• Needs and recommended referrals
• Family and emergency information
• Medical and substance use information

The Provider will complete any care coordination activities necessary to facilitate the client’s connection to the referrals requested/recommended.

Provider will offer at least 1 hour per month of follow-up support to ensure the Family Care Plan/Plan of Safe Care remains updated per the client’s wishes, with updated medical and referral information. This follow-up may happen direct/face-to-face or by phone/virtual contact.

Provider will communicate with any other providers, including Home Visiting, Child Welfare, medical, and substance use treatment/recovery, to maximize the client’s opportunities for engaging in the recovery process.
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TREATMENT GOALS/SERVICE PLANS

A Family Care Plan/Plan of Safe Care developed with a supportive, informed support person, can increase engagement in substance use treatment during pregnancy, reducing the incidence of prenatal exposure to substances and minimizing the risk of child welfare system involvement and future risk of child abuse and neglect.
• Goal: Each eligible client will be offered Family Care Plan services to develop a Family Care Plan/Plan of Safe Care.
• Goal: Each eligible client who chooses to participate in Family Care Plan Services will be offered support to complete the Family Care Plan/Plan of Safe Care. That support may occur in person during scheduled appointments, over phone or email, or in the home.
• Goal: All needs identified in the Family Care Plan/Plan of Safe Care will be addressed through a referral and follow-up as needed.
• Goal: Eligible clients will participate in substance use treatment and, if appropriate, MOUD as prescribed by a licensed provider for the duration of their pregnancy and post-partum period.
• Goal: Eligible clients who are already engaged in substance use treatment/recovery process will remain in substance use treatment/recovery through the duration of their pregnancy and post-partum period.
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STAFFING QUALIFICATIONS

DIRECT SERVICE:
Each direct service position must meet the qualifications of at least one of the positions below:
Caseworker:
o Minimum education requirement: Bachelor’s or Master’s degree in social services related field from an accredited institution;
o Licensed Social Worker (LSW) or Licensed Clinical Social Worker (LCSW) preferred;

Physician:
o Licensed by state of Illinois;
o Board certification in Family Medicine, OB-GYN, Pediatrics, or Addiction Medicine preferred;
• Licensed Practical Nurse (LPN) or Registered Nurse (RN);

Peer Support Worker/Community Health Worker:
o Minimum education requirement: High School Diploma or equivalent.
o Lived experience required.
o Certified Recovery Support Specialist (CRSS)/Certified Peer Recovery Specialist (CPRS) preferred.
o Experience working with families and children strongly preferred;

Doula:
o Minimum education requirement: High School Diploma or equivalent.
o Current Doula certification required.

Home Visitor:
o Minimum education requirement: High School Diploma or equivalent.
o Experience working with families and children.

SUPERVISORY:
The program supervisor must meet at least one of the qualifications below:
• Master’s degree in healthcare or social services related field from an accredited institution and at least 5 years of professional experience in the health care or social services related field; or
• Master’s degree in Social Work, Human Services, Early Childhood, or a related social services field from an accredited institution; a state approved, clinical license; and at least 5 years of professional experience in the social services field.

MINIMUM STAFFING EXPECTATIONS
For the program to operate, at a minimum a social worker, medical case coordinator/nursing assistant, or physician must be available for delivery and coordination of the Family Care Plan service.

STAFF DEVELOPMENT
Provider staff must complete one of the following tutorials from the National Center on Substance Abuse and Child Welfare (NCSACW) prior to providing direct services to families:
• Tutorial for Substance Use Disorder Treatment Providers; or
• Tutorial for Child Welfare Professionals; or
• Tutorial for Legal Professionals.
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TARGET POPULATION

DCFS Client Capacity Under DCFS Agreement: TBD
DCFS Client Capacity at Any Given Time: TBD
Agency Client Capacity Under Program: TBD
Agency Client Capacity at Any Given Time: TBD

Average Length of Services: 1 day to 12 months after the initial referral.

Services beyond the program plan service parameters: The Provider must obtain prior authorization from DCFS to serve clients outside of the program plan parameters.

CLIENT: Any person who is pregnant or was pregnant within the past 12 months, who also:
•Reports using substances during their pregnancy; or
•Reports a history of substance use disorder.
A client can also be any infant 0-12 months who is born and identified as being affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure or a fetal alcohol spectrum disorder.

Inclusions:
Any person who is pregnant or was pregnant within the past 12 months, who also:
• Reports using substances during their pregnancy; or
• Reports a history of substance use disorder; or
• Has an infant 0-12 months who is born and identified as being affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure or a fetal alcohol spectrum disorder.

Exclusions:
Children who need primary medical care for conditions unrelated to prenatal exposure to substance use or withdrawal symptoms, and patients who need emergency medical care or hospitalization outside the geographical boundaries of the Provider.
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PROGRAM OUTCOMES AND METRICS

• 80% of eligible patients will develop a Family Care Plan/Plan of Safe Care prior to an infant’s birth
• 50% of infants born and identified as being affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure or a fetal alcohol spectrum disorder will receive at least one service as a result of the Family Care Plan/Plan of Safe Care
• Number of infants for whom a Family Care Plan/Plan of Safe Care was developed after birth; and
• Number of adults and infants for whom a referral was made for appropriate services/supports, based on needs identified in the Family Care Plan/Plan of Safe Care
• 90% of eligible parents who receive a referral based on the Family Care Plan/Plan of Safe Care will participate in at least one service
• 75% of eligible parents who were referred to and participated in substance use treatment remained engaged for at least 9 months
• 5% fewer reports of Allegation 65C to the child abuse hotline in the counties where the pilot occurs
• 5% fewer infants reported to Adverse Pregnancy Outcomes Reporting System (APORS)
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Geographic Area(s): All areas, preference for Northern and Central Regions Federal Assistance Listing: 93.669. Administered by the Illinois Department of Children and Family Services via the Illinois GATA Catalog of State Financial Assistance (CSFA 418-00-3601).