See how Family Driven Teaming is already being used in Pennsylvania!
- High Fidelity Wraparound
- Family Navigator
- Family Driven Care Coordination in Luzerne/Wyoming Counties
- Blair County Case Management
- Diabetes Wraparound Program
Allegheny County
- Allegheny Family Network Joint Planning Team
- Family Resources Joint Planning Team
- Human Services Administration Organization (HSAO) Joint Planning Team
- The Diabetes Wraparound Program
- Family Navigator Pilot Sites funded by the Office of Mental Health and Substance Abuse Services (OMHSAS):
- Allegheny Family Network (AFN)
- Whole Child Wellness Clinic- UPMC Children’s Hospital of Pittsburgh (WCW)
- Serves Western PA
- Youth Move PA
- Serves all of PA: referrals come from The Bradley Center (Residential Treatment Facility in Pittsburgh)
Blair County
- Blair County Case Management
Bucks County
- Child and Family Focus High Fidelity Wraparound
Crawford County
- Family Navigator Pilot Site funded by the Office of Mental Health and Substance Abuse Services (OMHSAS):
- Crawford County Mental Health Awareness program (CHAPS)/Family Children & Community Association (FCCA)
Delaware County
- Child and Family Focus High Fidelity Wraparound
Erie County
- Erie County Care Management High Fidelity Wraparound
Fayette County
- Adelphoi Village High Fidelity Wraparound
Lehigh County
- Pinebrook Family Answers High Fidelity Wraparound
Luzerne-Wyoming Counties
- Luzerne-Wyoming Mental Health and Developmental Services – Family Driven Care Coordination (FDCC)
- Peer Help United Network (PHUN)
- Certified Peer Specialists
- Family Peer Specialists
- Northeast Counseling
- Blended Case Management
- Children’s Service Center
- Blended Case Management
- Partial Hospitalization Family Peer Support
- Fetal Alcohol Spectrum Disorder (FASD) Young Child Wellness Team
- Family Services Association
- Functional Family Therapy
- Truancy Program
- Peer Help United Network (PHUN)
Northampton County
- Pinebrook Family Answers High Fidelity Wraparound
Philadelphia County
- Community Behavioral Health High Fidelity Wraparound
- Family Navigator Pilot Site funded by the Office of Mental Health and Substance Abuse Services (OMHSAS):
- Community Behavioral Health/Philadelphia Family Voices
Venango County
- Mars Home for Youth High Fidelity Wraparound
Washington County
- Family Navigator Pilot Site funded by the Office of Mental Health and Substance Abuse Services (OMHSAS):
- AMI Inc. (Advocate, Mentor, Inspire)
High Fidelity Wraparound
YFTI currently supports High Fidelity Wraparound (HFW), a Family Driven Teaming model operating in many of Pennsylvania’s most populated counties. These teams receive comprehensive YFTI support to ensure consistent model delivery and high‑quality outcomes.
What is High Fidelity Wraparound?
High fidelity wraparound (HFW) is a team-based, collaborative process for developing and implementing individualized plans for youth with complex behavioral health and/or other challenges, and their families. The wraparound process aims to achieve positive outcomes by providing a structured, creative, and individualized team planning process that, compared to traditional treatment planning, results in plans that are more effective and more relevant to the child and family. HFW plans are more holistic than traditional care plans in that they are designed to meet the identified needs of caregivers and siblings and to address a range of life areas and social determinants. Through the team-based planning and implementation process – as well as availability of research-based interventions that can address priority needs of youth and caregivers, HFW aims to develop problem-solving skills and coping skills that will assist the youth and family in becoming self-sufficient.
High Fidelity Wraparound Workforce Roles
The HFW workforce consists of four positions that work in equal partnership:
Coach
Serves as the skill-based teacher and assures that the team is working in fidelity to the model.
Facilitator
Helps the youth, family, and the HFW team to develop their plan and achieve their vision.
Family Support Partner
Uses their lived experience and training to provide direct support to the family.
Youth Support Partner
Uses their lived experience and training to provide direct support to the youth.
Pennsylvania’s HFW model is unique in that the team includes both a youth support partner (YSP) and family support partner (FSP) that function in equal partnership with the facilitator.
Position Descriptions
A Coach in Family Driven Teaming is a professional who provides model-driven leadership to the workforce in their collaborative planning around youth and their family caregivers, ensuring that the services are delivered with fidelity to the model. The Coach is highly skilled in a teaming approach to service delivery having a well-developed leadership framework for supporting the workforce in model-driven practice. They are responsible for onboarding, training, coaching, and providing ongoing model-driven support to the workforce as they hold team meetings where participants prioritize needs, brainstorm strategies that relate to specific goals, and develop concrete, manageable action and crisis plans. The Coach will be supported by a Training and Implementation Coordinator from the Youth and Family Training Institute to ensure that their workforce receives high-quality support in the model.
The Coach position can be full or part-time depending upon the size and scope of the workforce and program needs. A Coach can support more than one program and is not required to be dedicated solely to the Family Driven Teaming model. It is recommended that a full time Coach supports no more than eight workforce members and a half time Coach support up to four.
- Provide overall leadership to their assigned program and workforce using the Family Driven Teaming model.
- Ensure that assigned workforce receive onboarding, training, coaching, and ongoing model-driven support leading to fidelity and family satisfaction in service delivery.
- Complete all requirements to receive a Skill-Based Competency Endorsement from YFTI as a Coach in Family Driven Teaming.
- Partner with YFTI to receive ongoing coaching support as needed.
- Ensure that the workforce completes all requirements to receive a Skill-Based Competency Endorsement from YFTI in Family Driven Teaming in their respective roles.
- Provide data-driven leadership using the Program Fidelity Self-Assessment (PFSA) developed by YFTI.
- Use data from the PFSA to develop Plan Do Study Act cycles for continuous quality improvement.
- Manage referrals ensuring consistent program census.
- Use data to engage funders and other relevant stakeholders in supporting the FDT program.
- Other duties as assigned by their agency/employer.
A Facilitator in Family Driven Teaming is a professional who functions as the team lead in the collaborative planning around youth and their family caregivers, ensuring that their voices, strengths, culture and priorities guide the planning process. They develop and convene a team comprised of the youth and their family caregivers, natural and community supports, and interdisciplinary professionals across child-serving systems using the principles, skills and tools of the Family Driven Teaming Model.
Facilitators require skills in engagement, needs assessment across life domains, team building, meeting facilitation, system navigation, and measurement of progress along with the tools of the model used in planning. Planning requires regular team meetings where participants prioritize needs, brainstorm strategies that relate to specific goals, and develop concrete, manageable action and crisis plans. Youth and family voice and choice guide the planning so that meaningful goals are achieved and the family vision can be attained. The Facilitator teaches the skills of planning to the family throughout the process, so that they feel more confident planning for any new needs or goals that may arise and self-efficacy and independence are achieved.
Caseloads are determined by the complexity of needs of the youth and their level of system involvement. The model is flexible and can be applied across a spectrum of risk levels:
High-Risk youth: Youth with complex needs and involvement in multiple child-serving systems requiring intensive coordination, frequent team meetings, and crisis planning.
- Recommended caseload size: 12–18 youth per Facilitator
- Rationale: Lower caseloads allow Facilitators to provide more individualized attention, manage complex team dynamics, and respond to frequent or acute needs.
Moderate-Risk youth: Youth with moderate needs involved with one or no formal systems but would still benefit from integrated planning, and crisis prevention planning.
- Recommended caseload size: Up to 25 youth per Facilitator
- Rationale: Higher caseloads are manageable due to reduced intensity of coordination and fewer crisis-related interventions.
- Building trust with youth, family caregivers, natural supports and professionals on the team.
- Orienting youth, families and team members to the Family Driven Teaming model.
- Stabilizing immediate crises using the tools of the Family Driven Teaming model.
- Facilitating Family Driven Action Plan and Family Driven Crisis Plan meetings including delegation of tasks, coordination and monitoring of action steps across the team.
- Ensuring family voice and choice are central to all decisions made by the team, organizing information about strengths, needs, and culture into the overall planning process.
- Supporting clear transition planning that leads to increased self-efficacy, sustainable community tenure, and reduced reliance on intensive services.
A Support Partner in Family Driven Teaming is a young adult or family caregiver with lived experience receiving or navigating services in the child-serving systems that provides peer support to youth or family caregivers receiving FDT. They serve as part of the team in the collaborative planning around youth and their family caregivers, ensuring that their voice and choice, strengths, culture and priorities guide the planning process. They support the youth and family caregivers in planning with the team comprised of the Facilitator, natural and community supports, and interdisciplinary professionals across child-serving systems using the principles, skills and tools of the model. Planning requires regular team meetings where participants prioritize needs, brainstorm strategies that relate to specific goals, and develop concrete, manageable action and crisis plans. Support Partners teach the skills of planning to the youth and family caregiver throughout the process, so that they feel more confident planning for any new needs or goals that may arise and self-efficacy and independence are achieved.
Support Partners require skills in engagement, needs assessment, team building, and system navigation, supporting the Facilitator in using the tools of the model in planning. The qualifications for this position can vary depending on the agency, program, and geographic region. Several common requirements and preferred skills are typically sought, primarily lived experience in child-serving systems. These qualifications combine educational, experiential, and personal qualities that equip the Support Partner to effectively support the youth and their family caregiver in navigating the complexities of mental health services.
Caseloads can vary depending on the complexity of needs of the youth and their family caregiver.
- Recommended caseload size: Up to 25 youth per Support Partner. Each Support Partner can be paired with either one or two Facilitators based on Facilitator caseload size which is determined by the risk level and planning needs of the youth.
- Rationale: Support Partners have fewer administrative duties related to the model than Facilitators, allowing for higher caseloads.
- Building trust with youth, family caregivers, natural supports and professionals on the team.
- Orienting youth and family caregivers to the Family Driven Teaming model and providing support across the four phases.
- Gather information about voice and choice, needs and culture to inform crisis and action planning.
- Providing support during crisis.
- Supporting the full participation of youth and family caregiver in Family Driven Action Plan and Family Driven Crisis Plan meetings.
- Ensuring family voice and choice are central to all decisions made by the team, supporting the youth and family in communicating information about strengths, needs, and culture into the overall planning process.
- Actively support the use of natural and community supports as ongoing team members.
- Supporting clear transition planning that leads to increased self-efficacy, sustainable community tenure, and reduced reliance on intensive services.
Funding High Fidelity Wraparound
The primary funding for HFW in Pennsylvania is authority under federal Medicaid rules (42 CFR 438.208) that guides how managed care entities provide coordination and continuity of care. Most of the youth receiving HFW are eligible for Medicaid because they meet the standard of having a disability as a result of their complex behavioral health disorder. Medicaid requires a comprehensive assessment as well as a treatment or service plan developed in conjunction with the person being served and any provider involved in the service. Pennsylvania refers to this as the joint planning team and applies it to high fidelity wraparound.
The joint planning team process is treated as an administrative cost (like case management) for youth and families that are eligible for Medicaid Managed Care because it is a planning process and not a medical service. However, cost savings are expected to be realized through decreased out-of-home placement, decreased hospitalization, and a more appropriate use of available community-based services. Counties that are able to demonstrate cost effectiveness are able to have those costs included in their capitation rates. Some counties also use funds from the county children and youth agencies to pay for HFW teams to work with youth involved in the child welfare system. Other counties are using Medicaid reinvestment funds that counties and the Behavioral Health Managed Care Organizations control, while other counties are paying for HFW through county needs-based budget funds.
Impact Across the State
The HFW sites supported by YFTI contribute to show improved youth and family outcomes statewide. Benefits associated with HFW implementation include:
The primary aim of the Family Navigator program is to provide short-term, individualized support to children, youth, and young adults (CYYA) and family caregivers seeking mental health services and resources to meet the needs of their CYYA. This support could be given in a single phone call or could be offered up to six months, helping navigate the complex systems that serve CYYA with serious emotional disturbance (SED) or serious mental illness (SMI).
The Family Navigator program seeks to:
- Promote Early Access: Supporting CYYA and family caregivers in reducing barriers to access with mental health services and resources.
- Enhance Engagement: Encouraging active participation from both the CYYA and family caregivers in developing Family Driven Action Plans.
- Improve Coordination: Streamlining communication and collaboration between service providers and systems through integrated planning.
- Optimize Treatment: Tailoring connections to mental health interventions to meet the unique needs of each CYYA and family.
Impact
Allegheny Family Network
Proposal Overview: Allegheny Family Network (AFN) is a “Family Run” non-profit organization serving Allegheny County for over 15 years. AFN will develop a Family Navigator division under its complement of peer to peer, education and advocacy programming.
AMI, Inc. of Washington-Greene Counties
Proposal Overview: Advocate, Mentor, Inspire (AMI) is a peer-run non-profit mental health organization focused on strengths-based, recovery-focused services that intends to develop a Family Navigator program that will promote early access, engagement, coordination, and optimization of mental health treatment and services for youth and young adults experiencing symptoms of mental health problems, while supporting their family caregivers.
Community Behavioral Health/Philadelphia Family Voices
Proposal Overview: Community Behavioral Health (CBH) is a not-for-profit 501c (3) corporation that is the Behavioral Health Managed Care Organization (BH-MCO) for Philadelphia’s Medicaid population and Philadelphia Family Voices (PFV) is Philadelphia’s formalized family support agency. They have partnered to address existing gaps to establish Family Navigators connected to children’s psychiatric Crisis Response Centers (CRC) and Behavioral Health Urgent Care Centers (UCC) located throughout Philadelphia County.
Crawford County Mental Health Awareness Program (CHAPS)
Program Overview: The Crawford County Mental Health Awareness Program (CHAPS), is a non-profit, consumer-driven organization that was founded in 1988 and Family Children & Community Association (FCCA) is a non-profit 501(c)(3) community organization originally established in 1951 that will partner to develop a Family Navigator program to serve family caregivers and youth in a site-based as well as community-based rural setting.
Whole Child Wellness Clinic – UPMC Children’s Hospital of Pittsburgh
Program Overview: The UPMC Children’s Hospital of Pittsburgh is a non-profit hospital founded in 1883 and consistently ranked as one of the top pediatric hospitals in the nation. The Whole Child Wellness Clinic (WCWC) provides combined physical and behavioral health care in a medical and behavioral health care home model for families. There are pediatricians, psychiatrists, therapists, nursing, care coordination and family peers working together to support the family. The WCWC, the first of its kind in the country, offers a holistic approach to behavioral health and a “one-stop-shop” of coordinated care that treats a child’s physical and mental health all in one location and helps with navigating the system overall.
Youth MOVE PA
Program Overview: Youth MOVE PA is a non-profit statewide youth & young adult advocacy organization that is a program of the Pennsylvania Mental Health Consumers’ Association (PMHCA). They will build a “Youth Empowered” Family Navigator program that provides youth and their families with the tools, resources, and support necessary to ensure a smooth transition from the RTF setting to their home environment.
Family Driven Care Coordination in Luzerne/Wyoming Counties
Luzerne and Wyoming Counties are implementing Family Driven Teaming into a model called Family Driven Care Coordination. This model is one of the ways Family Driven Teaming can inform a variety of staffing structures and levels of care, based on the needs of the local community. Through funding awarded through the Substance Abuse and Mental Health Services Administration “Project Linking Actions for Unmet Needs in Children’s Health (Project LAUNCH)” and the “Children’s Mental Health Initiative,” Luzerne-Wyoming Counties Mental Health and Developmental Services is focused on providing Family Driven Care Coordination for youth ages birth to fifteen and their families. Family Driven Teaming informs their blended case management, family peers, Early Intervention and other care coordination programming. Both counties are strengthening collaboration, improving service alignment, and ensuring families lead their own planning process.
A Family Driven Approach
Luzerne and Wyoming Counties have adopted a model that integrates Family Driven Teaming principles and phases into practice.
This approach ensures that every plan developed with families reflects:
- Their identified needs
- Their cultural values and strengths
- Their vision for the future
Blended case managers, family peers and their professional partners work across systems to create plans that are more collaborative, reflecting the perspectives of all team members, guided by youth and family voice.
A Team-Based, Wraparound-Informed Structure
Luzerne and Wyoming Counties use team‑based meetings to promote agreement in planning efforts. These meetings:
- Bring together natural supports, professionals, and county partners
- Rely on strengths‑based discussion and coordinated problem‑solving
- Follow structured Family Driven Teaming meeting planning practices
The result is an approach that feels consistent, supportive, and aligned for families navigating multiple systems.
Centering Family Voice and Choice
In both counties, Family Driven Care Coordination ensures families are not passive recipients of services — they lead the planning process. Teams:
- Invite natural supports chosen by the family
- Ensure the family’s priorities drive decision‑making
- Build trusting relationships that support ongoing engagement
This empowers families while improving the quality and relevance of the plans created.
The Impact for Families in Luzerne and Wyoming Counties
Integrating Family Driven Care Coordination into local service providers has begun transforming the family experience by providing:
- Clearer, more coordinated support across programs and providers
- Greater empowerment, as families lead planning and goal‑setting
- Stronger natural support networks that remain beyond formal services
- Improved engagement due to relationship‑based practice
- Plans that reflect family priorities, not system mandates
Together, these counties are demonstrating how Family Driven Care Coordination can enhance collaboration and create meaningful, sustainable outcomes for families
Blair County Case Management
Blair County is one of Pennsylvania’s early adopters implementing the Wraparound-informed practice of Family Driven Teaming into its Case Management program. By implementing Family Driven Teaming principles into their existing service structure, Blair County is strengthening coordination, elevating voice and choice, and improving outcomes for clients of all ages across the lifespan with complex needs.
A Blended Case Management Model
Blair County has incorporated Family Driven Teaming principles and the four phases of the process into a blended case management model, ensuring that case managers use a team‑based, strengths‑focused, and individual/family‑driven planning approach with everyone they serve.
This model supports individuals and their families across the lifespan that may be involved in child or adult serving systems while ensuring the individual’s/family’s priorities remain at the center of decision‑making.
Building Collaborative Teams
Using a Family Driven Teaming approach, Blair County Case Management helps build teams that include:
Natural supports (relatives, friends, neighbors, community members)
System partners from key agencies
Case managers trained to facilitate family‑driven planning
These teams work together to identify needs, set goals, plan supports, and monitor progress through team-based collaborative methods.
Embedding Wraparound-Informed Practice
Blair County’s Case Management program draws on Wraparound‑informed practice, including:
This ensures that case management is not simply a service referral model, but a guided team planning process built around individual/family leadership and long‑term sustainability.
What Family Driven Teaming Means for Blair County
By embedding Family‑Driven Teaming into case management, Blair County is helping individuals/families experience:
This approach positions individuals and families as leaders in their own planning and ensures they have the skills, support, and confidence to navigate challenges long after formal involvement ends.
The Diabetes Wraparound Program
The Diabetes Wraparound Program Pilot was a collaboration between the Division of Pediatric Endocrinology and Diabetes at UPMC Children’s Hospital of Pittsburgh and the Youth and Family Training Institute.
The Beginning – Recognizing a Need
Youth with type 1 diabetes (T1D) represented a vulnerable population. Many youth were not achieving glycemic targets like HbA1c, which is important in managing diabetes and reducing the risk of complications. Youth and young adults with T1D were about twice as likely to be diagnosed with a psychiatric disorder, especially affecting eating, mood, and anxiety. Depressive symptoms, diabetes-related distress, and family conflict raised some teens’ risk for poorer diabetes management and control.
Adapting High Fidelity Wraparound for Type 1 Diabetes
For youth with T1D and their families, multi-system involvement was needed.
- Child and family needs were complex
- There were overlapping problem areas
- Families may have had challenges meeting basic needs in other areas of life
- Each of the child serving systems was in separate silos (school, insurance companies, medical team, etc.)
The pilot program created a peer-based team planning process, with emphasis on lived experience, sharing stories and empathy, and with families deciding what their goals were. Peer supports met with youth and the parent/caregiver weekly, with integrated family, friends, and professionals in monthly meetings with concrete plans and actions steps.
Impact in Care
At the time of discharge from the pilot program, difficulties managing diabetes while at school decreased and youth knowledge of their insulin to carbohydrate ratios increased. Youth also showed improvement in their willingness to share about their diabetes management overall and with their parents. Check out some of the other study results below!
Additional Information
Check out this article from UPMC Physician Resources for more information about the pilot program.
The Diabetes Wraparound Program continued after the completion of the pilot program. It is available to support families in the Endocrinology Clinic at UPMC Children’s Hospital of Pittsburgh. For more information about the program, contact the UPMC Children’s Division of Pediatric Endocrinology at 412-692-3294 or visit their webpage.