Service Delivery,
Policy, Procedure, and
Resource Manual
Washington State Wraparound with Intensive Services (WISe) is a range of
services designed to provide behavioral health services and support to
individuals twenty years of age or younger, and the individual’s family. WISe
provides intensive behavioral health in home and community settings to youth
who are Apple Health eligible under WAC 182-505-0210 and meet medical
necessity criteria for WISe.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 2
Introduction ................................................................................................................................................................. 5
Section 1: Foundational requirements ...................................................................................................................... 6
Objective .................................................................................................................................................................. 6
What is different about WISe? ............................................................................................................................ 6
Agency infrastructure .............................................................................................................................................. 7
Federal and state requirements ......................................................................................................................... 7
WISe-specific requirements ................................................................................................................................ 8
Service array ........................................................................................................................................................ 9
Staffing ............................................................................................................................................................... 10
Child and Adolescent Needs and Strengths (CANS) ........................................................................................ 10
CANS (Child and Adolescent Needs and Strenghts) and BHAS (Behavioral Health Assessment Solution) 11
Highlighted staffing requirements ................................................................................................................... 11
Community oversight and Cross-system collaboration ................................................................................. 11
Documentation .................................................................................................................................................. 12
WISe agency website ......................................................................................................................................... 13
WISe access protocol ............................................................................................................................................. 13
Identification ..................................................................................................................................................... 14
Referrals ............................................................................................................................................................. 15
WISe screening ................................................................................................................................................... 16
Interest list monitoring ..................................................................................................................................... 16
WISe intake......................................................................................................................................................... 17
WISe service requirements ................................................................................................................................... 18
Culturally and Linguistically Appropriate Services (CLAS)............................................................................. 18
Providing intensive care coordination and services using a wraparound approach ................................... 18
Intensive care coordination .............................................................................................................................. 18
WISe document considerations ........................................................................................................................ 19
Phases of WISe (Practice model) .......................................................................................................................... 19
Engagement ....................................................................................................................................................... 20
Assessing ............................................................................................................................................................ 21
Teaming .............................................................................................................................................................. 22
Service planning and implementation ............................................................................................................ 23
Monitoring and adapting .................................................................................................................................. 25
Service implemenation/Service array ................................................................................................................. 26
Intensive services provided in home and community settings ..................................................................... 26
Direct services include, but are limited to ....................................................................................................... 26
Crisis planning and delivery.............................................................................................................................. 27
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 3
A crisis prevention and response plan (A Crisis Plan) ..................................................................................... 28
Crisis response actions ...................................................................................................................................... 28
Services .............................................................................................................................................................. 29
Documentation considerations ........................................................................................................................ 29
Crisis delivery ..................................................................................................................................................... 29
Crisis services within transition phase ............................................................................................................ 30
Additional information on transition phase .................................................................................................... 31
Guidance on team functioning and facilitation of WISe ..................................................................................... 31
The approach ..................................................................................................................................................... 31
WISe team meeting facilitation components and team structure ................................................................ 31
Facilitate introductions and review agenda .................................................................................................... 32
Set ground rules................................................................................................................................................. 32
Review the youth and family vision statement(s)........................................................................................... 32
Construct a team mission statement and review team mission .................................................................... 32
Develop a list of strengths and review strenghts ............................................................................................ 32
Develop a list of needs and review curent needs ............................................................................................ 33
Prioritize needs .................................................................................................................................................. 33
Develop outcome statements for prioritized needs ....................................................................................... 34
Brainstrom strategies ........................................................................................................................................ 34
Assign action steps ............................................................................................................................................ 34
Summarize and agree on the plan ................................................................................................................... 34
Schedule the next team meeting ..................................................................................................................... 34
Principles evidenced in practice....................................................................................................................... 35
WISe training and coaching framework ........................................................................................................... 36
WISe practitioner training and coaching framework ..................................................................................... 36
Training and coaching framework ................................................................................................................... 36
Practitioner training and coaching .................................................................................................................. 37
Enhanced tratining sessions offered ................................................................................................................ 37
WISe coaching onsite and virtual sessions ...................................................................................................... 37
WISe training and coaching framework ........................................................................................................... 38
Training and coaching plans ............................................................................................................................. 39
Orientation ......................................................................................................................................................... 39
Client rights ............................................................................................................................................................ 40
Decisions and dispute resolution ..................................................................................................................... 40
Reaching consensus on a child and family team (CFT) ................................................................................... 40
If the CFT can reach agreement on a a plan..................................................................................................... 40
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 4
How to file a grievance ...................................................................................................................................... 40
Right to appeal a denial, termination, reduction, or suspension of services ............................................... 41
Types of appeals ................................................................................................................................................ 42
How do I file an appeal ...................................................................................................................................... 43
Determination .................................................................................................................................................... 43
How to request an administrative (fair) hearing ............................................................................................. 43
Continuing services during the appeal ............................................................................................................ 44
Help for youth, families, and caregivers .......................................................................................................... 44
Governance and coordination .............................................................................................................................. 44
Developing regional linkages to the goverance structure ............................................................................. 48
Center of Parent Excellence .............................................................................................................................. 49
Quality plan ............................................................................................................................................................ 49
Background ........................................................................................................................................................ 49
Components ....................................................................................................................................................... 49
Quality infrastructure........................................................................................................................................ 49
Quality Improvement Review Tool (QIRT) ....................................................................................................... 50
WISe Fee for Service .............................................................................................................................................. 50
Overview of Apple Health for individuals non in Managed Care or Fee for Services (FFS) .......................... 50
Participation as a WISe Fee for Service (FFS) provider ................................................................................... 50
WISe innovations when service individuals non in Managed Care (FFS program) ....................................... 51
WISe FFS referrral list ........................................................................................................................................ 51
Section 2: Specialty teams and guidance ................................................................................................................ 52
A. BRS and WISe concurrently ........................................................................................................................ 52
B. WISe and American Indian and Alaska Native youth and their family .................................................... 55
C. Partnering with Transition Age Youth (TAY) in WISe ................................................................................. 57
D. WISe Birth through Five (B-5) ..................................................................................................................... 59
E. Intellectural or Developmental Disabilities Including Autism Spectrum Disorder and WISe ................ 61
F. Partnering with youth and families experiencing homelessness ............................................................ 62
Section 3: Background and additonal information ................................................................................................. 64
A. Background: T.R. settlement agreement .................................................................................................. 64
B. WISe terminology, definitions, and roles .................................................................................................. 65
C. Service array and coding ............................................................................................................................. 72
D. WISe Attestion(s) for Managed Care plans and Tribal Behavioral Health ............................................... 73
E. Washington’s CANS algorithm .................................................................................................................... 75
F. WISe example templates ............................................................................................................................. 75
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 5
Introduction to the WISe service delivery, policy,
procedure, and resource manual
The WISe service delivery, policy, procedure, and resource manual, commonly referred to as “The WISe Manual”
is arranged in three sections:
• Foundational Requirements
• Specialty Teams and Guidance
• Background and Additional Information.
The first section, Foundational Requirements, covers general information and requirements needed for WISe
agencies to provide WISe. It also includes information on the WISe practice model, service requirements,
training, and other foundational information such as client rights and the quality plan.
The second section, Specialty Teams and Guidance, provides information to WISe teams who are partnering
with youth and families where the WISe model may need slight adjustments to have the best opportunity for
youth and family success. While WISe is already individualized, there are times when specific approaches can be
used from the start of services to help with outreach, increase engagement and improve outcomes for youth and
families.
Finally, the third section is background and Additional Information. Here you can find historical information on
the T.R. Settlement Agreement, sample forms, the CANS algorithm, and information on encountering WISe
services.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 6
Section 1: Foundational requirements
Washington State’s Wraparound with Intensive Services (WISe) is based on System of Care (SOC) values and is a
range of services designed to provide behavioral health services and support to individuals twenty years of age or
younger, (herein referred to as “youth”) and the individual’s family. SOC values are family-driven and youth-
guided, community-based and culturally and linguistically appropriate. The goal of WISe is for eligible youth to
live and thrive in their homes and communities, as well as to avoid or reduce costly and disruptive out-of-home
placements while receiving behavioral health treatment services.
The purpose of this manual is to create consistency across Washington State’s service delivery system for those
providing intensive in-home and community-based behavioral health services to eligible youth. The WISe
service delivery model is intended to be individualized and tailored with room for flexibility, creativity, and
youth and family voice and choice.
The manual will assist the community behavioral health system and allied agencies, as well as other formal,
informal, and natural supports with the identification of eligible youth and provision of WISe. It is intended to
provide an understanding of the required infrastructure, expectations, and the Practice Model of WISe.
This manual is a living document and will be reviewed annually. The most current version of the manual will be
posted on our Children’s Behavioral Health website.
Objective
This manual provides guidelines to ensure consistency in the goals, principles, service delivery, and quality of
WISe across the state. The WISe service delivery model, utilizes the Washington State Children’s Behavioral
Health Principles (previously named the Mental Health Principles), to:
• Promote recovery, increase resiliency, and reduce the impact of behavioral health symptoms on youth
and families.
• Keep youth safe, at home, in the community, and making successful progress in school.
• Promote youth development, maximizing their potential to grow into healthy and independent adults.
The Washington State Children’s Behavioral Health Principles guide the implementation of WISe and provide
the foundation for the practice model and clinical delivery of intensive services. More information on these
principles can be found online.
What is different about WISe?
Focus on youth and family voice utilizing a strength-based approach
The WISe provider intentionally seeks out youth and family voices, choices, and preferences during all phases of
the process, including planning, delivery, transition, and evaluation of services. Supports and services are
delivered in a way that honors youth-guided and family-driven care. Together, the WISe provider, youth, and
family plan for the delivery services and supports in a manner that identifies, builds on, and enhances the
capabilities, knowledge, skills, and assets of the youth and family, their community, and other team members.
Primary setting
WISe is intended to be provided in the home and in community locations, and at times and locations that ensure
meaningful participation of youth, family members, and natural supports. Telehealth is also an option for
service delivery and should be guided by youth and family choice (in Section 3, Part D, Service Array and
Coding). WISe is tailored for youth with intensive and complex behavioral health needs. Assessment, treatment,
and support services are provided in the youth and family’s natural setting, where needs, strengths, and
challenges present themselves (such as the home, school, and community).
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 7
Flexible and creative services
WISe is intended to be provided in timely, creative, individualized, and flexible ways. Those served through WISe
tend to come into services with complex needs and involved histories. This approach must provide unique
methods of support, as many of the youth and families served have found traditional behavioral health care
unable to meet their needs. Others remain at risk of more restrictive care, even after receiving traditional
behavioral health services.
Involvement of Family Partners and Youth Partners (Certified Peer Counselors) is Essential
Family Partners and/or Youth Partners who have lived experience must be a part of the team. They must be
meaningfully involved in the provision of WISe. The Family Partner and/or Youth Partner are equal team
members with the Care Coordinator and Mental Health Therapist. The Family Partner and/or Youth Partner meet
with the youth and/or family on a regular basis to provide support in addressing the needs of the youth and
family, as defined in the Cross System Care Plan (CSCP). Youth Partners and Family Partners should be educated
in how to utilize the Child Adolescent Needs and Strengths (CANS) results to support and educate the youth and
family and are encouraged to be certified in CANS. The role of a Youth Partner and Family Partner are distinct
and separate roles. See Appendix B for more detailed information related to the Youth Partner and Family
Partner roles.
Agency infrastructure
Wraparound with Intensive Services (WISe) utilizes a range of outpatient behavioral health service components
in a way that is individualized, intensive, coordinated, comprehensive, culturally relevant, and home and
community based. WISe is for youth who are experiencing behavioral health symptoms that disrupt or interfere
with their functioning in family, school, vocation, with peers or in their community.
WISe team members demonstrate a high level of flexibility and accessibility by working at times and locations
that ensure meaningful participation of family members, youth, and natural supports, including evenings and
weekends. WISe also provides access to crisis response 24 hours a day, seven days a week, by individuals who
know the youth and family’s needs and circumstances, as well as their current crisis plan. The service array
includes intensive care coordination, intensive treatment and support services, and mobile crisis outreach
services. The service array is provided in home and community settings and based on the individual’s needs and
a plan developed using a wraparound process by a Child and Family Team (CFT).. WISe was designed to be
comprehensive and may change through the course of treatment based on the needs of the youth and family.
Service intensity averages must be at least 10.5 hours monthly at the agency level. Care is integrated in a
way that ensures youth are served in the most natural, least restrictive environment. The intended outcomes are
individualized to the goals identified and prioritized by each youth and family. Potential areas to include in goal
setting can include:
• Increased safety, stabilization, school success, and community integration
• Support to ensure that youth and families can live successfully in their homes and communities
• Gathering information and resources to support youth and families to make informed decisions
regarding their care and with a goal of avoiding hospitalizations and out-of-home placements
whenever possible
Federal and State requirements
This section outlines the infrastructure requirements an agency must have in place to be eligible for
consideration as a WISe provider. The services provided under WISe are Medicaid state plan funded services,
and therefore require agencies to meet all applicable federal standards related to the provision of behavioral
health services covered under the Medicaid state plan. Agencies interested in becoming a WISe provider must
hold a current Behavioral Health Agency License, issued by the Department of Health.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 8
In order to be paid for providing WISe, approved agencies need a contract with a Managed Care Organization
(MCO) or a Fee for Service (FFS) contract with HCA. Ideally, approved WISe agencies will have both types of
contracts. Additionally, agencies must be certified to provide, or have sub-contracts or Memorandums of
Understanding (MOUs) in place, to provide services listed under:
• WAC 246-341-0737 Outpatient intervention, assessment, and treatment
• WAC 246-341-0700 Behavioral Health Support
• WAC 246-341-0901 Behavioral Health Outpatient Crisis Observation and Intervention
Which includes such services as:
• Individual treatment services
• Family therapy services
• Case management services
• Psychiatric medication services
• Crisis mental health services—Outreach services
• Recovery support—Peer support services (for example peer counseling)
The list above is intended to direct the minimum certification requirements. Agencies need to follow all WACs
and certification requirements for the services they are providing. If an agency provides other services,
additional certification standards may apply. The monitoring of these requirements will continue to be
completed by the Department of Health’s Licensing and Certification staff. More information can be found on
the Department of Health website.
WISe-specific requirements
Adherence to WISe, outlined below, will be reviewed by the WISe agency, the associated MCO, and DBHR
according to the WISe Quality Plan. In accordance with WAC 182-501-0215, HCA, MCOs and WISe provider
agencies must comply with the WISe Quality Plan. Agencies interested in becoming a WISe provider must meet
standards related to:
1. Access
2. Practice model
3. Service array
4. Staffing
5. Community oversight and cross-system collaboration
6. Documentation
Access and Practice Model (items one and two) will be discussed in detail in subsequent chapters, beginning on
pages 13 and 19. The requirements for items three through six in the list above are as follows.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 9
Service array
Agencies providing WISe must have the capacity to provide a wide array of intensive, therapeutic, home and
community-based services within the agency, or through sub-contracts or an MOU. WISe agencies will provide
each participating youth and their parent/caregiver and family or support network with a Child and Family Team
(CFT) and at a minimum, access to these services:
1. Intake Evaluation
2. Intensive Care Coordination
3. Intensive Services
4. 24/7 Crisis Intervention and Stabilization Services
5. Peer Support
The WISe service array must be provided and encountered as described in the most recent versions of the
Integrated Managed Care or IMC Service Encounter Reporting Instructions (SERI)
, and for WISe Fee for Service,
Part 2 of the Mental Health Service Billing Guide or the Tribal Health Billing Guide or the Tribal Billing Guide
within the subsections of the Provider billing guides and fee schedules.
Behavioral health services offered to youth and families that are participating in WISe should typically be
provided by staff employed at a WISe-qualified agency and provided in accordance with applicable sections of
WAC 246-341. However, services and supports are not limited to only those provided by the WISe agency. The
CFT has the responsibility to identify needs consistent with youth and family voice, and develop strategies to
meet these needs, including referral and coordination with other services and systems. When the CFT
determines a core component of WISe should be provided by another agency that is not WISe certified, (for
example youth would prefer to remain with their current therapist based on specialized treatment needs, and
the therapist is not at the WISe agency), the CFT has the responsibility to coordinate with the youth’s MCO and
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 10
obtain MCO approval. Other needed services and supports (such as substance use disorder treatment or Applied
Behavioral Analysis), including those provided by system partner agencies, are to be outlined in the single Cross
System Care Plan (CSCP) that is developed and monitored by the CFT. This includes any medically necessary
services covered under EPSDT (Early and Periodic Screening, Diagnostic and Treatment) and identified on the
Individual Service Plan, which would also be linked to the CSCP and coordinated through the WISe team.
Note: See the WISe Service Requirements Section for further information on services.
Staffing
WISe provider agencies must have sufficient WISe qualified staff to:
• Manage the monthly caseload target identified by the MCO
• For WISe FFS manage monthly caseload target identified by DBHR
• Deliver or coordinate all medically necessary behavioral health services, including but not limited to,
intensive services, substance use, Applied Behavioral Analysis, psychiatric consultation/medication
management.
• Provide each youth/family served with:
o Mental health therapies (i.e., family, individual treatment, etc.).
o Care coordination.
o Peer counseling through Family Partner and/or Youth Partner who are certified peer
counselors.
Note: Descriptions and responsibilities for staff that provide each of these services are outlined in
Section 1, Part F, Guidance on Team Functioning and Facilitation of WISe.
• Provide clinical supervision and support in participation for ongoing training and coaching with the
WISe- Workforce Collaborative (see Section 3 for the framework).
• Have psychiatric consultation available to each team.
• Maintain an average caseload size per Care Coordinator of 10 or fewer participants, with a maximum of
15 at any given time, for each Care Coordinator.
• Provide 24/7 mobile crisis intervention (see Section 4 for details) to youth and families, preferably
through staff that are known to the youth and family.
• Meet timelines for completing WISe CANS (Child and Adolescent Needs and Strengths)
CANS
The CANS is a way to organize and capture needs and strengths of an individual, and family. It is also a
communication tool that is used by all the systems involved with the youth and family to help them
communicate, set priorities, and identify strategies.
A CANS information sheet is available online to help youth and families become more familiar with CANS and
how it is used in WISe.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 11
In WISe, the Full CANS assessments are used for care planning, and outcome measurement. The Full CANS
assessments that are completed during the individual’s time in WISe, are not used for continued eligibility
determination or as a factor for determining payment. Full CANS should be completed in a timely manner,
though WISe youth and families often have complicating factors that may make meeting timelines challenging.
Timelines for WISe CANS:
• CANS screen completed and entered into BHAS within 14 days of referral, to determine if WISe would
be a good fit for the individual
• Initial Full CANS within approximately 30 days of WISe enrollment, considered late after 45 days and
• Re-occurring Full CANS approximately every 90 to 105 days while the youth is enrolled in WISe,
considered late if completed after 105 days
Note, the first re-occurring Full CANS is completed 90 to 105 days after the Initial Full CANS is
completed.
• ALL CANS screens and Full CANS include entering the information into the Behavioral Health
Assessment Solution (BHAS, the online CANS data repository).
• A discharge Full CANS when WISe services end. If it is not possible to complete a separate Full CANS for
discharge, the last Full CANS may be converted to a discharge CANS
CANS and BHAS (Behavioral Health Assessment Solution)
All CANS Screens and Full CANS must be entered into BHAS. Reports are available in BHAS to assist MCOs and
WISe agencies in monitoring timeliness of CANS. Additional information on using BHAS to monitor CANS
timeliness will be available as it is developed on the provider page of the WISe website.
Highlighted staffing requirements
• All staff on the WISe team must be an Agency Affiliated Counselor (AAC) unless they have another
appropriately designated license with DOH (LICSW, LMHC, LMFT, etc.)
o Applications for AAC must be submitted to DOH within 30 days of hire
• To become a certified peer counselor the following steps are required when not already certified
o Complete the online CPC prerequisite modules
o Submit certificate of completion of online modules and application to DBHR
o Only approved applicants will be invited to a state CPC training
o Individuals will be required to pass an exam at the end of the training
o For more details on this process visit the HCA Peer support website
o Integrated managed care guidance on Medicaid reimbursable peer services, July 2021
Community oversight and Cross-system collaboration
WISe provider agencies are required to collaborate and include other child serving system partners such as child
welfare, juvenile justice, education system, developmental disabilities support, (hereafter referred to as system
partners) on the development of the cross-system care plan and CFTs, and as indicated by youth and family
choice. The agency is to work with the youth, family and system partners to develop a single Cross System Care
Plan (CSCP) for the youth and family. The CSCP can encompass the individual service plan requirements and will
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 12
likely include a variety of other activities. Medicaid services must be prescribed clearly, according to Medicaid
documentation standards, regardless of whether the individual service plan is incorporated into the CSCP or a
separate document.
The MCOs will work within their local communities to invite diverse representation and establish appropriate
communication channels for engaging family, youth, and local community representatives in the Regional
Family, Youth, System Partner Round Tables (FYSPRTs) to inform local policy-making and program planning.
Section 1, part I describes the requirements to identify regional processes on how MCOs coordinate and
participate in the governance structure.
Documentation
WISe provider agencies must maintain the following administrative documentation, in addition to that required
for Behavioral Health Agency licensing:
• Quality Plan
• Monitoring to ensure WISe teams meet monthly caseload benchmark
• Monitoring to ensure WISe agency is meeting monthly service intensity benchmark
• Child and Family Team requirements (Cross System Care Plan {CSCP}, plan reviews, progress, revisions,
CFT meeting sign-in sheets, and CFT minutes)
• WISe provider agencies must maintain the following documentation for each WISe-qualified provider’s
personnel file:
o Required WISe trainings
o Coaching
o Supervision
o Agency Affiliated Counselor registration or another individual professional licensure (LMHC,
LICSW, LMFT, etc.) in accordance with Department of Health rules and/or
o Certified Peer Counselor as outlined by HCA/DBHR
In addition to documentation requirements for behavioral health agencies, and compliance with Medicaid
regulation, WISe provider agencies must ensure the following WISe-specific documentation can be found in
each individual’s record:
• A copy of all CANS screens and assessments completed.
• Reason for discharge from WISe, which should be based on successful achievement of goals outlined in
the CSCP, youth and family choice to discharge from services, or other documented reason
o Length of treatment in WISe is not a set time period. It is based on medical necessity and allows
for up to six months of transition time into a lower level of care.
• If the youth has been out of WISe for more than 6 months a new CANS screen must be completed. If it has
been less than 6 months since the youth discharged from WISe, no new CANS screen is needed. A Full
CANS should be completed within 30 to 45 days of a youth’s first WISe service regardless of provider to
assist with care planning.
• Cross System Care Plan (CSCP) (note: see the WISe Manual Resources section of the HCA website for
core elements and a sample format), including revisions and updates.
o The CSCP must address the needs found within the Individual Service Plan (ISP) or could
include all required elements of the ISP within the CSCP.
o Expected outcomes/transition activities and transition/discharge criteria will be clearly defined
in the CSCP or contained in a Transition Plan.
• All necessary Releases of Information
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 13
• Crisis/Safety Plan (may also be known at some providers as a Wellness Plan or Support Plan.)
• CFT meeting notes:
o CFT meetings should occur as frequently as needed, based on needs intensity of the youth and
family. Meetings should be held every 30 days at a minimum, or more often if youth and
family needs indicate.
o Notes should include a list of attendees (the youth and/or family are required to be present for
a meeting to be considered a CFT). Participation of young children will be decided upon the
CFT, as appropriate.
o A record that notes shared with all members of the CFT, with a signed release of information,
within a week of each meeting that reflects the voice of family and youth.
WISe agency website
The following information should be included on the website for each WISe agency:
• General information about WISe
• Information regarding eligibility for WISe
• Direction on how to make a referral for WISe
Note: Agencies must not require an intake or application be completed in order to have a WISe
screen. Also, the ability to complete the CANS screen over the phone must be an option.
• Helpful, but optional, to have a Link to the HCA WISe website.
WISe access protocol
This section provides uniform standards on the administrative practices and procedures for providing access to
WISe and its services. WISe providers, WISe providers approved for Fee for Service (FFS) and Managed Care Plans
(MCOs) will utilize the protocols of this section to meet the requirements related to:
• The identification of youth who may qualify/benefit from WISe.
• The WISe referral process.
• The components of the WISe Screening and Intake Process.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 14
Identification
Child-serving systems, such as Department of Children, Youth & Families (DCYF), Department of Social and
Health Services (DSHS), Health Care Authority (HCA), school personnel, county and community providers, and
Tribal service providers, mobile crisis teams (including youth mobile rapid response crisis teams) and MCO’s
assist in the identification and referral of youth who might benefit from WISe. Consideration for referral begins
with youth who are Apple Health eligible for coverage under WAC 182-505-0210, age 20 or younger, and who
have complex behavioral health needs. Other indicators to consider for a WISe referral may include, but are not
limited to:
1. Youth with involvement in multiple child-serving systems (e.g., child welfare, mental health, juvenile
justice, developmental disabilities, special education, substance use disorder treatment).
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 15
2. Youth for whom more restrictive services have been requested, such as psychiatric hospitalizations,
residential placement or foster care placement, due to behavioral health challenges.
3. Youth at risk of school failure and/or who have experienced significant and repeated disciplinary issues
at school due to behavioral health challenges.
4. Youth who have been significantly impacted by childhood or adolescent trauma.
5. Youth prescribed multiple or high dosages of psychotropic medications for mental/behavioral health
challenges.
6. Youth with a history of detentions, arrests, or other referrals to law enforcement due to behaviors that
result from behavioral health challenges.
7. Youth exhibiting risk factors such as suicidal ideation, danger to self or others, behaviors due to
mental/behavioral health challenges.
8. Youth whose family requests support in meeting the youth’s behavioral health challenges.
Referrals
Anyone can make a referral for a WISe screen, including the youth and family. All Apple Health youth who are
eligible for coverage under WAC 182-505-0210, age 20 or younger, who might benefit from WISe should be
referred for a WISe Screen.
A referral for a WISe screen must be made for youth who are eligible for Apple Health coverage under WAC 182-
505-0210 in the following circumstances:
1. When a youth is referred to Behavioral Rehabilitation Services (BRS).
2. While a youth is enrolled in BRS services only (not BRS and WISe concurrently): no less frequently than
every six months, and during discharge planning.
3. Prior to a youth discharging from CLIP.
a. Managed Care Organization staff are responsible for making the referral for their enrollee to a
WISe agency at least 30 days prior to discharge
4. Prior to a youth discharging from a psychiatric hospital.
5. When a step-down request has been made from institutional or group care.
6. When a youth receives crisis intervention or stabilization services, and there are past and/or current
functional indicators of need for intensive behavioral health services.
If a youth is currently receiving Apple Health behavioral health services a referral for a WISe Screen can be
completed in the following ways:
• The current outpatient provider can complete the CANS screen, if they are also an approved WISe
provider or
• The current provider that is not an approved WISe agency, can make a referral to an approved WISe
provider agency that will complete the CANS Screening.
• If a youth does not meet the CANS algorithm, clinical judgment may be used to continue with a
referral to WISe. Note that for children under the age of 6, there is no algorithm, and the decision is
made on clinical judgment.
If a youth is not currently receiving Medicaid behavioral health services, a referral to WISe can be most easily
completed by contacting the WISe referral contacts for each Managed Care Plans (MCP) contracted WISe
provider or county Fee for Service providers.
In addition, requests for assistance with referrals for a WISe screen may be made directly to an MCO or any
contracted WISe provider.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 16
WISe screening
Anyone can make a referral for a WISe screen and all referrals should result in a WISe screening, regardless of
referral source. A WISe screen must be completed and entered into BHAS within 14 calendar days of
receiving a referral for the screen to be considered “on time.” A WISe screen is not considered to be
complete until entered into BHAS. WISe screens are available at WISe agencies and the option to complete the
screen over the phone will be offered when that option is more convenient.
A referral form can be offered but must not be required to complete a WISe screen. A mental health intake must
not be required to be completed to do the WISe screen. Anyone can request a screen for a youth that is eligible
for Apple Health coverage under WAC 182-505-0210 and is age 20 or younger.
All WISe screens will include:
1. Information gathering that utilizes the information provided by the referral source (i.e. the youth, a
family member, a system partner, and/or an informal or natural support). Additional information may
be gathered from the youth and family directly and others who have been involved with the family
(including extended family and natural supports) and/or other service providers working with the youth
and family.
2. Completion of the Child Adolescent Needs and Strengths (CANS) Screen, which consists of a subset of
26 questions, pulled from the Full CANS. The CANS screen must be completed by a CANS-certified
screener. For more information on how to become CANS-certified see Transformational Collaborative
Outcomes Management Training (TCOM Training).
Note: Training materials, related to how to enter CANS into BHAS are available. For children age 5
and younger, WISe providers will use the CANS Birth - 5.
3. Entering the CANS Screen into the Behavioral Health Assessment Solution (BHAS) which will apply the
CANS algorithm (for individuals over the age of 5) to determine whether the youth would benefit from
WISe.
• The CANS Screen should be entered into BHAS prior to MCO notification. Make sure to follow
MCO timeframes around notifications of WISe eligibility status.
Note: There are differences in screening requirements and BHAS entry for youth enrolled, being
referred to or discharging from BRS services. Please see WISe and BRS section for more detailed
information.
Interest List Monitoring
The BHAS “Closed Pending Enrollment” status is currently in place to demonstrate that a youth is eligible for
WISe and is not yet enrolled.
MCOs and Providers need to ensure this list is timely, up to date, and accurate to track to understand capacity
needs and how long it takes people to get into WISe. It is critical that screens are entered into BHAS on time and
that the screens are accurately categorized as ‘closed pending’ when the youth is on the interest list.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 17
BHAS “Closed Pending” lists are required to be reviewed regularly by MCO’s and Providers. Instruction on the
process are included on the WISe Interest List Quality Improvement and Monitoring information sheet.
Note: Per existing requirements, MCOs and/or WISe providers are responsible for providing
information and access to crisis services to the youth and/or family, while they await the WISe
screen and intake. For youth who have expressed interest in WISe and have completed a CANS
screen with a result of “WISe recommended” or clinical override into WISe but are not actively
enrolled in WISe are considered to be on the WISe interest list.
Children and youth should be placed on the interest list as soon as the CANS screen show WISe is
recommended or it is determined the CANS screen outcome will be overridden regardless of
mental health intake completion. This is not considered a waitlist and children and youth must
be offered and receive state plan services . Waitlists are not allowed by Medicaid.
WISe intake
For any youth who is not currently enrolled in Medicaid for behavioral health services, in addition to the
WISe screen, the following intake eligibility determinations must be made:
1. Establish Medicaid eligibility. The WISe service delivery model is a collection of Medicaid mental health
state plan services and can only serve youth age 20 and younger and eligible for Apple Health coverage
under WAC 182-505-0210.
2. Establish that the youth meets qualifying medical necessity criteria. All youth who meet the CANS
algorithm and have a mental health diagnosis will be determined to meet WISe level of care. If a youth
does not meet the CANs algorithm or if the child is less than 6 years old, clinical judgment may be used
to continue with a referral to WISe if indicated. Indicate in BHAS comment section the reason youth is
being offered entry into WISe.
All youth, ages 6 through 20, who meet the CANS algorithm and are eligible for Apple Health coverage under
WAC 182-505-0210, and qualifying criteria noted above will be offered entry to WISe. For those children under 6
years of age, this decision shall be made based on information from the CANS Screen and clinical judgment.
*Note: See access protocol updates for non-MCO beneficiaries (i.e. AI/AN beneficiaries getting FFS
WISe)
For youth who are determined eligible for WISe, this is when initial engagement to begin planning, facilitating,
and coordinating services will occur. Initial engagement can be done by any WISe Practitioner and is typically
done by a Care Coordinator and Youth Partner and/or Family Partner (depending on the youth and family’s
preference). WISe may be accepted or declined by any youth who has achieved the age of consent, 13 years and
older. If a youth is reluctant to engage in WISe, a parent may work with their WISe provider to request Family
Initiated Treatment as a time limited opportunity to engage the WISe team with a youth who meets medical
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 18
necessity and their family. More information on FIT services can be found online at the HCA FIT website with
information for both providers and parents and family members.
Youth who are not eligible for Apple Health coverage under WAC 182-505-0210 or do not meet intake eligibility
requirements will be referred to other community resources, including their health care plan for behavioral
health services. All youth receiving or eligible for Medicaid behavioral health services and enrolled in a Managed
Care Plan, but who do not meet the CANS algorithm, will be notified of their rights of grievances and appeals by
the MCO. Youth and families will also be referred to other services, which could include relevant behavioral
health community services and/or care coordination through the individual’s MCO. In addition, agencies must
follow MCO notification timelines when youth are determined not eligible for WISe.
WISe service requirements
Culturally and Linguistically Appropriate Services (CLAS)
Agencies are required to promote access to and delivery of culturally and linguistically appropriate services to
all youth and families. More information about the CLAS standards can be found on the U.S. Department of
Health and Human Services website.
Providing Intensive Care Coordination and Services using a Wraparound
Approach
WISe is intended to operationalize the system of care (SOC) values in service delivery to eligible, youth, and their
families with complex behavioral health needs. WISe is best implemented through the support of a statewide
system of care to the fullest extent feasible. It is delivered using a wraparound approach, to improve
collaboration among child-serving agencies. It focuses on the individual strengths and needs of each
participating youth and family.
Once screened eligible for WISe, youth and families participating will have access to a wide array of services and
supports to address their specifically identified needs. Although the intensive care coordination and services
available under WISe are funded by Medicaid and state dollars (see section 3 for more information on reporting),
the WISe service model is intended to draw in other resources through teaming with formal, informal and
natural supports and programs that are offered in a variety of settings (home, community, school, etc.). For
more information and a definition of formal, informal and natural supports, see Section 3 subpart C: WISe
Terminology, Definitions and Roles.
Intensive Care Coordination
Intensive Care Coordination is a service that facilitates assessment of, care planning for, and coordination and
monitoring of services and supports, through the phases below.
While WISe is a team-based approach, it is typically the role of a Care Coordinator to facilitate and coordinate
services and supports. This includes facilitating and coordinating all services and supports identified in the
Cross System Care Plan. This intensive coordination continues through each of the phases of WISe as described
on the following pages (adapted from the nationally recognized Wraparound phases). Other WISe Practitioners*
should be partnering to most effectively meet the needs of the youth and family.
* WISe Practitioners– a term used to describe the collection of WISe-certified staff roles, required
for each team (the Care Coordinator, the Family Partner and/or Youth Partner, and the Mental
Health Therapist)
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 19
WISe documentation considerations
WISe is a collaborative process. When considering how to document services provided, it is important to note
the youth/family/team response to the WISe practitioner’s actions in addition to what the WISe practitioners are
doing. In the following section about the phases of WISe, general documentation considerations are listed for
each phase. However, WISe phases are not always clear and distinct, and are often not linear. Documentation
considerations listed for one phase may also be relevant to other phases as well. Clear and descriptive
documentation is also important for the Quality Improvement Review Tool (QIRT), see page 51 in the WISe
Manual for information on the QIRT and the Quality Plan. The complete WISe Quality Plan can be found at the
HCA website online.
Phases of WISe (Practice model)
There are six phases in WISe: Engagement, Assessing, Teaming, Service Planning and Implementation,
Monitoring and Adapting, and Transition. This section will expand more on the goals and tasks of each phase.
Below you will see a visual representation of a WISe episode as it moves through each phase.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 20
Engagement
In the engagement phase, the groundwork for trust and shared vision among the youth, family, and WISe team
members is established, so people are prepared to come to meetings and collaborate. The tone is set for
teamwork and team interactions that are consistent with the Washington State Children’s Behavioral Health
Principles, particularly through the initial conversations about strengths, needs, and culture.
In addition, this phase begins to shift the youth and family’s orientation to one in which they understand they are
an integral part of the process and their preferences are prioritized. Initial engagement should be completed
relatively quickly (within 1-2 weeks if possible), so that the team can begin meeting and establish ownership of
the process as soon as possible. However, elements of the engagement phase will be implemented in conjunction
with other phases.
When a youth is coming into WISe from another program or placement (i.e., CLIP, BRS, an inpatient
hospitalization, SUD residential or a juvenile justice facility), this phase is especially important, to begin before
the youth discharges the program or placement, to assist in successfully transitioning youth back into to the
community.
Note: Contact the youth’s MCO to develop a plan for contacting the youth prior to discharge from a
program or placement.
Goals/purpose
• To address pressing needs and concerns, prior to forming a Child and Family Team when necessary,
so the youth, family and team can give their attention to the WISe process.
• To explore the results of the CANS and the individual’s and family’s strengths, needs, culture, and
vision, and develop a youth and family narrative that will serve as the starting point for planning.
• To orient the youth and family to the WISe process.
• To gain the participation of team members who care about and can aid the youth and family,
• To set the stage for their active and collaborative participation on the team.
• To ensure that the necessary procedures are undertaken so the team is prepared to begin an effective
WISe process.
Essential steps
• To lay the groundwork for trust and shared vision among the youth, family and WISe team.
• To establish rapport and build commitment to the WISe process through warmth, optimism, humor,
and identification of strengths.
• The WISe Practitioner(s) meet with the youth and family to explain the WISe process, and how it differs
from traditional care.
• The WISe Practitioner(s) obtains consent for services.
• The WISe Practitioner(s) discuss with the youth and family the events, circumstances, and moments
that brought the youth and family to WISe.
• The WISe Practitioner(s) obtain the youth and family perspective on where they have been), where they
are presently (including listening for both their expressed needs and strengths), and where they would
like to go in the future.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 21
• The WISe Practitioner(s) discuss the youth’s and family’s view of crises, and develops a written plan to
stabilize dangerous or harmful situations immediately.
• The WISe Practitioner(s) ensure the youth and family understand any system mandates (if applicable)
and ethical issues.
Note: For services under this phase of the intervention to be Medicaid compliant, an initial
Individual Service Plan, under the direction of a Mental Health Professional, must be in place that
directs the ongoing assessment and team development of services.
Documentation considerations
• Capture the steps taken by the WISe team and the outcome of those efforts to create a genuine
understanding of WISe, their content, duration and intended outcome, and the roles of key persons
involved in WISe.
• Describe the process to identify barriers to participating in WISe and how these barriers were
addressed.
• Accurately capture all encounterable contacts with the youth and family to clearly indicate the intensity
of contact between all WISe practitioners and the youth and family in the first 30 days. See information
in Section 3, Part C, WISe Service Array and Coding.
Assessing
In this continuation of the engagement phase, the WISe Practitioners expand the discussion with the youth and
family to add context to their involvement in WISe. The WISe Practitioners (Care Coordinator, Family Peer, Youth
Peer and Mental Health Therapist) help the youth and family to understand that their input is central to the WISe
process, and that their perspectives and preferences at all phases of care planning and implementation will be
prioritized. This includes helping the youth and family understand and incorporate any legal mandates into their
plan. The WISe Practitioners also listen to the youth and family’s perspective for information about the youth’s
and family’s strengths, needs, culture, and natural supports. A WISe Practitioner completes and reviews the
results of the Full CANS (to be completed within 30 to 45 days of enrollment into WISe) with the youth and family,
and determines how to present this information to the team.
Goals/Purpose
• To continue meeting and engaging to further understand the youth and family’s story and context.
• To begin initial documentation of strengths, needs, and natural supports (including CANS scores and
other information obtained).
• To complete a youth and family approved narrative.
Essential Steps
• The WISe Practitioner(s) complete a strengths discovery and a list of strengths for all family members.
• The WISe Practitioner(s) discuss and list existing and potential natural supports.
• The WISe Practitioner(s) with the youth and family complete a list of potential team members.
• The WISe Practitioner(s) summarize the youth and family context, strengths, needs, vision for the
future, and supports.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 22
• The WISe Practitioner(s) determine with the youth and family how the CANS information will be
provided to the team.
• All Full CANS must be completed in collaboration with the youth and family. Results of the Full CANS
must be shared with the youth and family.
Documentation Considerations
• Document that the initial Full CANS is completed and entered into BHAS within 30 to 45 days of WISe
enrollment.
Note: For data entry and as referred to in the Service Encounter Reporting Instructions (SERI),
using a U8 modifier indicates the youth is enrolled and receiving WISe. The date of WISe
enrollment is the first use of U8 modifier. The first U8 modifier entered should be the first
encounterable/billable WISe service provided for the youth and/or family in order to maintain a
consistent timeframe for tracking the ‘full CANS timeliness’. That date needs to be entered into
BHAS to track this time.
• The results of the Full CANS have been reviewed with the youth/family and their feedback is solicited
and changes incorporated into the final written version before the Full CANS is entered into BHAS.
• Clear indication in BHAS or individual’s record that a meaningful discussion of strengths and culture
across family members and integration of that discussion into the formulation of the youth’s needs and
strengths.
• Does the Full CANS indicate need for psychiatric consultation? If yes, document conversation around
this need with the youth and/or family and the outcome.
Teaming
In this continuation of engagement and building on the assessing phase, the WISe Practitioners help the youth
and family identify, and reach out to persons who should be part of the WISe Child and Family Team (CFT). The
team is essential to successful planning and intervention and creation of the Cross System Care Plan (CSCP). See
service planning and implementation for more details on the CSCP.
Goals/Purpose
• To identify who the youth and family want as part of their team. Periodic check-ins should occur to
continue to identify and engage supports as the child and family team evolves.
• To engage others who are involved in the youth and family’s life to collaboratively support the youth
and family and ensure all involved individuals are aware of the youth and family’s mission and vision.
• To explain the team process to potential team members and elicit commitment to the process from
team members.
• To make necessary meeting arrangements.
Essential Steps
• The WISe Practitioner(s) explain WISe to potential team members, eliciting their perspectives, and
working to get their commitment to participate in the team process.
• The WISe Practitioner(s) invite potential team members to join the team process.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 23
• The WISe Practitioner(s) partner and orient team members to the WISe process and team meeting
structure.
• The CFT members help to create the team meeting agenda, provide input about the meeting logistics
and provide comfort for youth and family.
• The CFT will include the youth, parents/caregivers (see definitions in Appendix B), relevant family
members, and natural and community supports. For further guidance on teaming with transition age
youth, see Appendix O, Partnering with Transition Age Youth in WISe
• The CFT is expected to meet with sufficient regularity (every 30 days, at a minimum), as indicated in
the CSCP, to monitor and promote progress on goals as indicated in the CSCP and maintain clear and
coordinated communication.
The CFT reviews the interventions and action items and adjusts these accordingly, using the
outcomes/indicators associated with each priority need, included in the CSCP.
• Practitioner guides the team in evaluating whether selected strategies are promoting improved health
and wellness for the youth, and successfully assisting in meeting the youth and family’s identified
needs.
• The CFT works together to resolve differences regarding service recommendations, with particular
attention to the preferences of the youth and family.
• The CFT has a process to resolve disputes and arrive at a mutually agreed upon approach for moving
forward with services.
• The WISe Practitioner(s) are expected to check in with team members on progress made on assigned
tasks between meetings.
• The WISe Practitioner(s) set a time, date, and location for the team meeting that is convenient to the
youth and family and considers the safety of all the team members.
Documentation Considerations
• To ensure a comprehensive CSCP, representatives from all domains where there is an identified need
are contacted and their input solicited for the CSCP where there is an identified need in the CANS. For
example, for an identified need in the school setting, input from a representative from the school
should be included in the CSCP, or for a need regarding housing stability, a representative from that
area should be contacted for possible input into the CSCP.
Note: Input for the CFT can be obtained in multiple ways. A specific representative does not need
to be physically present at a CFT meeting to incorporate their input into the plan.
• Be mindful of identifying any legal mandates or systems, which need to be included in the CSCP
planning process.
Service Planning and Implementation
During this phase, team trust and mutual respect are built while the team creates an initial Cross System Care
Plan using a high-quality planning process that reflects the Washington State Children’s Behavioral Health
Principles. Youth and families should feel that they are heard, that the needs chosen are ones they want to work
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 24
on, and that the options, strategies, and interventions chosen are going to capitalize on the strengths of the
youth and family. The team also reviews and expands the crisis plan to reflect proactive and graduated
strategies to prevent crisis, or to respond to them in the most effective and least restrictive manner.
The initial CSCP should be completed during one or two meetings that take place within 1-2 weeks. The rapid
time frame is intended to promote team cohesion and shared responsibility toward achieving the team’s
mission or overarching goal, as identified on the CSCP.
Goals/Purpose
• To create a CSCP using a facilitated process that elicits multiple perspectives and builds trust and
shared vision among team members, with an ever-present focus that the youth and family drive the
plan.
• To base care planning on needs and identified strengths, as indicated on the CANS.
• To establish a team mission that guides the planning direction and builds cohesion in the work of the
team members and empowers the youth and their family.
• To establish a set of prioritized needs, including the strategies to meet them, and to determine
expected outcomes.
• To identify team tasks and roles, and document commitments and timelines.
• To establish ground rules to guide team meetings.
• To identify potential barriers and crises, prioritize according to seriousness and likelihood of occurrence,
and create an effective and well-specified crisis prevention and response plan.
Essential Steps
• The WISe Practitioner(s) meet with the youth and family and develops a list of possible needs of the
family prior to the team meeting, based on the results of the Full CANS assessment, which is completed
and shared with the youth and family.
• The WISe Practitioner(s) convene one or more team meetings to discuss and obtain agreement on the
elements of the CSCP.
• In the CFT meeting, the youth and family’s vision for their future is presented.
• The CFT discusses and sets ground rules to guide the meetings.
• The CFT reviews and expands the list of strengths for the youth and family.
• The CFT creates a mission that details a collaborative goal describing what needs to happen prior to
transition from WISe.
• The CFT reviews the list of needs and agrees which to prioritize in the CSCP, respecting and including
the preferences and priorities of the youth and family.
• The CFT brainstorms an array of strategies to meet these needs, and then prioritizes strategies for each
need including the use of natural supports and intensive services.
• CFT members agree upon assignments, or action steps, around implementing the strategies including
follow up on action items/assignments.
• The CFT evaluates the crisis plan and adapts as necessary.
• The work of the team is documented and distributed among team members.
• The CFT monitors youth and family goals and objectives to highlight when progress is being made and
when youth and family are ready to transition out of WISe.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 25
Note: See the Cross System Care Plan example in Appendix H
Documentation Considerations
• The CSCP reflects the youth and family’s priorities, as well as including needs and strengths identified in
the initial Full CANS, and any decisions to defer addressing lower priority needs.
o For example, there are 10 needs rated 2 or 3 on the Full CANS. In the CFT meeting together, the
youth, family, and the team identify the top 3 to address now. The CSCP indicates which needs
were chosen for action and which have been deferred to be addressed in the future.
• The CSCP contains a manageable number of SMART (Specific, Measurable, Achievable, Relevant, Time
bound) goals.
• At least one of the CSCP goals involves a strength area to develop, or the use of an already identified
strength to enhance.
• CSCP is updated when a new Full CANS is completed.
• The role of each team member is clear.
• Tasks are clearly assigned and updated at each CFT.
Monitoring and Adapting
During this phase, the CSCP is implemented, progress and successes are continually reviewed, and changes are
made to the plan and then implemented, all the while maintaining or building team cohesiveness and mutual
respect. The activities of this phase are repeated until the team’s mission is achieved.
Goals/Purpose
• To implement the CSCP, monitor completion of action steps, strategies, success in meeting needs and
achieving outcomes.
• To use a facilitated team process to ensure that the plan is continually revisited and updated to re-
spond to the successes of initial strategies and the need for new strategies.
• To maintain awareness of team members’ satisfaction and concurrence to the process, and take steps
to maintain or build team cohesiveness and trust.
Essential Steps
• The CFT continues to meet as necessary to address youth and family needs – at minimum, every 30 days
to evaluate progress towards meeting needs and the effectiveness of indicated strategies.
• The CFT collects data to determine the effectiveness of strategies, then adds, subtracts and modifies
strategies to create the most effective mix of services and supports.
• The CFT evaluates whether there is progress towards the designated outcomes.
• The CFT adds members, as necessary and appropriate, and strives to create a mix of formal, informal,
and natural supports.
• The CFT celebrates successes and adds to strengths as they are identified.
• Full CANS assessments are administered and entered into BHAS every 90 to 105 days to help track
progress, and to catch emerging needs and make changes to the plan as necessary.
• The WISe Practitioner(s) maintain ongoing communication outside of the team meetings to continue
engagement and ensure that all members’ perspectives are heard.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 26
• As needs are met, continue to prioritize other needs that may have been deferred earlier in the planning
process.
Documentation Considerations
• For each new Full CANS completed, make sure relevant changes or updates have been made to the
CSCP and prioritized.
• Review and incorporate youth and family feedback prior to entering each new Full CANS into BHAS.
• Document completion of CSCP tasks and update CSCP as needed.
• Continue to discuss all strengths and needs with family and team and prioritize based on youth and
family preferences in the CSCP.
• Continue to clearly document participation of, and feedback from, relevant formal, informal, and
system partners.
Service Implementation/Service Array
Intensive Services Provided in Home and Community Settings
Intensive services (“direct services”) are individualized, strength-based services and supports provided in home
and community-based settings. These services are designed to improve mental health symptoms that interfere
with a youth's functioning. Interventions are aimed at promoting health and wellness and helping the youth
build skills necessary for successful functioning in the home and community and improving the family's ability
to help the youth successfully function in the home and community.
Direct services are delivered in accordance with the youth and family’s Individualized Service Plan (ISP), and
coordinated with the Cross System Care Plan, which will contain the appropriate levels of details, to deliver
integrated Wraparound with Intensive Services. The CFT develops goals and objectives for all life domains in
which the youth's mental health symptoms produce impaired functioning (including family life, community life,
education, vocation, and independent living) and identifies the specific interventions that will be implemented
to meet those goals and objectives. The goals and objectives seek to maximize the youth's ability to live and
participate in the community and to function independently by building strengths including social,
communication, behavioral, and basic living skills. WISe Practitioners should engage the youth in home and
community activities where the youth has an opportunity to work towards identified goals and objectives in a
natural setting. Phone contact and consult
ation may be provided as part of the service. For the most up to date
information on telehealth services see the
HCA website.
Direct services include, but are not limited to:
• Educating the youth's family about how the youth’s behavioral health needs may influence behavior, and
how to effectively support the youth.
• Therapeutic services delivered in the youth’s home or community including, but not limited to, therapeutic
interventions such as individual and/or family therapy and strategies or core elements from
evidence/research-based practices (e.g., Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Multi-
Systemic Therapy (MST), Dialectical Behavioral Therapy (DBT), etc.). These services are designed to:
o Improve self-care by addressing behaviors that interfere with daily living tasks.
o Improve self-management of symptoms including self-administration of medications.
o Improve social functioning by developing behavioral health interventions that address social skills
needs and anger management.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 27
o Reduce negative effects of past trauma, using evidence/research- based approaches.
o Reduce negative impact of mental health disorders, such as depression and anxiety, through use of
evidence-/research- based approaches.
o Support the development and maintenance of social support networks, and the use of community
resources.
o Support employment objectives by identifying and addressing behaviors that interfere with seeking
and maintaining a job.
o Support educational objectives through identifying and addressing behaviors that interfere with
succeeding in an academic program.
o Support independent living objectives, by identifying and addressing behaviors that interfere with
seeking and maintaining housing and living independently.
• Coordination of other services such as:
o Personal care hours
o Applied Behavior Analysis (ABA) Therapy
o Other needed supports as identified by the WISe team
Settings: Direct services will be provided in any setting where the youth is located, including the home, schools,
recreational settings, childcare centers, and other community settings wherever and whenever needed,
including evenings and weekends.
Avai
lability: Direct services will be available in the amount, duration, and scope necessary to address the
medically necessary identified needs.
Providers: Non-clinical direct services are typically provided by paraprofessionals under clinical supervision.
Certified peer counselors, which include a Family Partner and/or a Youth Partner, may provide direct services.
Clinical treatment services are provided by a qualified mental health therapist, rather than a paraprofessional.
Paraprofessionals and Family Partner and/or Youth Partners may provide a follow-on “care extension” role for
clinical services (e.g., to provide support to caregivers’ efforts to manage behavior, support to youth’s skill
building to develop emotional regulation skills, etc.).
Notification: The full array of WISe services may be provided, as medically necessary, once the
MCO is notified by a provider of WISe enrollment. Make sure to follow the MCO process and
procedures for notification.
Crisis Planning and Delivery
All Community Behavioral Health Agencies have general requirements around crisis response and suicide
prevention, and all WISe agencies must maintain appropriate crisis certification by DOH. In addition to these
required expectations, there are additional expectations specific to the WISe process.
If you are not familiar with, or want to review some of the general BHA agency crisis de-escalation and suicide
prevention training requirements, those can be found at:
• RCW 49.19.020 Workplace violence plan
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 28
• RCW 49.19.030 Violence prevention training
• Marty Smith Trainings
• RCW 43.70.442
The rest of this section will focus specifically on requirements for WISe crisis planning and delivery. Effective
crisis planning is a critical component of an effective care plan. Steps in WISe crisis planning include:
• Help youth and family define what crisis means to them
• Help youth and family identify what leads to crisis
• Help youth and family understand the crisis cycle
• Help youth and family understand when they would reach out for additional support, i.e. call 911 if
youth reports an overdose or medical emergency
A Crisis Prevention and Response Plan (A Crisis Plan) should include the
following elements:
• Types of crisis
• Crisis identification and prevention steps, including CFT members’ roles related to proactive
interventions to minimize the occurrence and severity of crises.
• Crisis response actions to address severity of crisis situation
• Legal mandates and community safety
• Clear behavioral benchmarks that change over time to reflect progress, and changes in the
youth/family’s expectations.
• A post crisis process for evaluating the crisis plan for what worked and what part or parts of the crisis
plan could be updated after a crisis occurs. WISe requires:
o Scheduling a team meeting within three days following a crisis.
o Agreement from the team to make no major decisions until at least 72 hours after a crisis has
passed
o Planning relies on support people who will not escalate a crisis.
o Coordination of services between out-of-home provider and the CFT.
o Crisis plans are modified as needed based on the changing situation of the family and child and
understanding of when outside supports such as calling 911 or accessing an emergency
department may be needed to assist with crisis response. This should be an identified step on
the WISe crisis plan to address an imminent safety need. There may be times where supports
are beyond the scope of the WISe team and natural supports.
• Information related to assessed safety risks and a plan to manage risks identified (i.e. restricting access
to medications, sharps or other objects of concern, limiting access to upper floors, increasing
supervision).
Crisis Response Actions
• 24/7 response
• Formal and natural supports
• Respite/back up care as determined by the cross-system care plan. Respite is not a state plan service,
but may be available through natural supports or other programs.
• Potential precipitating events and methods
• Successful strategies that have worked in the past
• Strengths-based strategies that ensure safety
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 29
Services include
• Crisis planning that, based on the youth’s history and needs:
o Anticipates the types of crises that may occur.
o Identifies potential precipitating events and methods to reduce or eliminate.
o Includes coordination with tribal crisis plan when appropriate
o Establishes individualized responsive strategies by caregivers and members of the youth’s
team, including natural supports, to minimize crisis and ensure safety.
• Stabilization of crisis by reducing or eliminating immediate stressors and providing counseling to assist
in de-escalating behaviors and interactions.
• Referral and coordination with:
o Services and supports necessary to continue stabilization or prevent future crises.
o Any current providers and team members including a care coordinator, mental health
therapist, youth partner, family partner, family members, primary care practitioners, tribal
agencies or school personnel or others working with the youth and family
• Crisis follow-up services (stabilization services) provided periodically to:
o Ensure continued safety and delivery of services necessary to prevent future crises.
o Coordinate services between the out-of-home provider (if the youth is placed out of home)
and the youth’s treatment team to facilitate a plan for rapid return home.
• Tools and resources available to manage potential risks.
Documentation Considerations
• A crisis prevention and response plan is completed and available to all CFT members and crisis-
specific supports.
• All items in the Risk Behavior Domain rated 3 in the initial Full CANS are addressed in the Crisis Plan
and included in the CSCP with details as appropriate.
• The Crisis Prevention and Response plan is updated regularly.
• The Crisis Plan actively addresses early intervention and identification and has tiered action steps that
match with clearly identified roles before, during and after a crisis.
• The crisis plan indicates the CFT team will meet within 14 days of crisis resolution to review the crisis
plan and update as needed.
Crisis Delivery
Crisis services are provided to support the youth and family and may include crisis planning and prevention
services, telephone support, as well as face-to-face interventions.
Settings: WISe crisis services are typically provided at the location where the crisis occurs, including the home
or any other setting where the youth is naturally located, including schools, recreational settings, childcare
centers, and other community settings.
Availability: WISe mobile crisis and stabilization services are available 24 hours a day, 7 days a week, 365 days a
year.
Providers: Each WISe provider agency must have capacity to respond to destabilizing events whenever the need
arises. Individuals who know the youth and family’s needs and circumstances, as well as their current crisis plan,
will respond to the crisis and are preferably drawn from the team. Crisis responders may partner with others
outside the team if necessary, and when it is written into the crisis plan.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 30
Note: At the time of this update, Washington State is undergoing a system wide change in how
crisis and stabilization services are provided for everyone in the state. These changes will not alter
the 24/7 WISe crisis and stabilization requirements. A communication pathway will need to be
established between WISe providers and crisis teams to ensure a clear understanding of the roles
of each and how they will refer or partner when individuals enrolled in WISe are in crisis.
Individuals enrolled in WISe who are experiencing a crisis may be contacted initially by a Mobile
Rapid Response Crisis Team (MRRCT) including a Mobile Response and Stabilization Team (MRSS).
The MRRCT and MRSS team should be made aware the youth is enrolled in WISe with the goal of a
warm handoff to the WISe team for continued support.
Crisis Services within Transition Phase
• Update the crisis plan to meet the needs of the youth and family as they transition out of WISe
• Rehearse response to crisis and create linkage to post-WISe crisis resources
• New team members need to reflect post-transition strategies, services and supports
• Discuss responses to potential future situations
• Negotiate the nature of each team member’s post-WISe participation with the youth and family
Crisis drills should be practiced during the transition phase
Transition to a lower level of care occurs after the CSCP has been implemented and modified over time, and the
right set of interventions have been successfully delivered to produce desired outcomes and the team’s mission
has been achieved. The goal of this phase is to identify an “end date,” which supports rather than abandons the
family, and assists them with moving into a life free from system interference.
Goals/Purpose
• To plan a purposeful transition out of WISe in a way that is consistent with the principles, and that
supports the youth and family in maintaining the positive outcomes achieved in the WISe process.
• To ensure that the transition out of WISe is conducted in a way that celebrates successes and frames
transition proactively and positively.
• To ensure that the family is continuing to experience success after WISe and to provide support if
necessary.
Essential Steps
• The CFT creates strategies within the CSCP for a purposeful exit out of WISe to a mix of possible formal
and natural supports in the community (and, if appropriate, to services and supports in the adult
system). At the same time, it is important to note that focus on transition is continual during the WISe
process, and the preparation for transition is apparent even during the initial engagement activities.
• The CFT creates a post-WISe crisis plan that includes action steps, specific responsibilities, and
communication protocols. Planning may include rehearsing responses to crises and creating linkage to
post-WISe crisis resources.
• New members may be added to the team to reflect identified post-transition strategies, services, and
supports. The team discusses responses to potential future situations, including crises, and negotiates
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 31
the nature of each team member’s post-WISe participation with the team/youth and family. CFT
meetings reduce in frequency and ultimately cease.
• The WISe Practitioner(s) guide the CFT in creating a document that describes the strengths of the youth,
family, and team members, and lessons learned about strategies that worked well and those that did
not work so well. The CFT prepares/reviews necessary final reports (e.g., to court or participating
providers).
• The CFT is encouraged to create and/or participate in a culturally appropriate “commencement”
celebration that is meaningful, to the youth, family, and team, and that recognizes their
accomplishments.
Documentation considerations
• Formal transition plan developed when the team agrees that is appropriate
• Evidence of transition planning is found in CFT meeting notes,
• Transition plan includes input from formal providers, natural supports, family and youth
CFTs use the CANS to monitor for an increase of strengths and a reduction of needs. The CFT, using clinical
judgment and supervision, will determine the beginning of the transition window, and prepare for the youth and
family to transition out of WISe. The timing of transition is determined by the CFT and outlined in the CSCP. Up
to six months of transition are allowed under the WISe model. Upon discharge from WISe, a Full CANS (coded as
discharge) must be completed and entered into BHAS.
Additional information on the transition phase
• Transitioning out of WISe should be discussed with the team from the beginning.
• Crisis drills should be practiced, and the youth and family should be confident they know what to do if
things go poorly.
• The youth and family should be able to articulate how to access services in the future.
• The youth and family should have a way to connect with other youth and families who have been
through the WISe process.
• The youth and family's concerns should be considered in the transition planning.
• The youth and family should have a list of team members’ contact information, to include phone
numbers and email addresses, who they can contact if needed.
• The youth and family should have written documents that describe their strengths and
accomplishments.
• The youth and family should be offered a formal opportunity to celebrate their successful transition
from WISe.
Guidance on team functioning and facilitation of WISe
The approach
The WISe approach in the state of Washington will strive toward quality and consistency of practice within the
Washington States Children’s Behavioral Health Principles.
WISe team meeting facilitation components and team structure
Each team meeting must include the following facilitation components:
• The youth and/or a family must be present for a meeting to occur.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 32
• Team meetings are held at times to ensure meaningful participation of family members, youth and
natural supports. Participation of young children will be decided upon by the CFT, as appropriate.
• A Family Partner and/or Youth Partner will be available to all family and youth.
Facilitate introductions and review agenda
• Allow the youth and family to introduce themselves first. Consider having other team members include
their role (formal supports) or how they know the youth and family (informal/natural supports).
• Bring a copy of a written agenda for everyone or write it on easel paper for everyone to see. The agenda
should be an outline of the facilitation components listed here so that everyone can begin to learn the
process.
Set ground rules (sometimes referred to as comfort agreement) or review
ground rules
• A discussion about ground rules to refer to during difficult times should take place at the first meeting.
• “Ground Rules” is not a common term and may need to be explained.
o Examples include: cell phone ringer off, one person talks at a time, use respectful language
when talking about concerns and needs, be on time, etc.
Review the youth and family vision statement(s)
• The WISe Practitioners should talk with the youth and family about their vision(s) before the first team
meeting and help them express this vision(s) to the rest of the team.
o Generally, there should be one collective vision for the youth and family. However, there are
times that the youth may have a separate vision than the family.
• The language used by the youth and family should be preserved in the final vision statement.
• The family vision is created and owned by the family, is an expression of their voice and choice, and is
used as a touchstone to ensure team activities align with the family’s preferred future. Team members
may, however, need clarification as to the implications.
• All team members should be given a written copy of the final vision statement and should be reviewed
by the team regularly.
Construct a team mission statement and review team mission
• The team should formulate a mission statement, stated as if it is true today, that is focused on what
they need to accomplish during their time together and how they will know when they are done.
• All team members should add to the mission statement.
• Consider recording major themes and edit final statement as an independent activity.
• All team members should be given a written copy of the final mission statement and it shall be reviewed
by the team regularly.
Develop a list of strengths and review strengths
• The WISe Practitioners should talk with the youth and family about their strengths prior to the first
team meeting and help them list their strengths for the team.
• The WISe Practitioners should prompt all CFT members prior to the first CFT to come prepared with a
list of strengths about the youth and family.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 33
• The initial list of strengths should come from the youth, family and the CANS, and then all team
members should add to these strengths.
• Maintain a written list of strengths and add to these at each team meeting. The list should also include
successes including the family’s history of solution finding.
• At the first team meeting, members may be focused on descriptive and contextual strengths. As the
team gets to know each other, WISe Practitioners can assist the team in formulating functional
strengths to use in the plan of care.
• Avoid going back-and-forth between strengths and needs. Finish the strengths list before moving on.
Develop a list of needs and review current needs
• The WISe practitioners should talk with the youth and family about their needs, as indicated on the
CANS, and help them list these at the first team meeting.
• Team members should state all concerns or identified problems in needs language: “I need…, we
need…, they need…, etc.”
• Needs are not services*. Team members should be redirected to state the real need(s).
• Avoid going back-and-forth between strengths and needs. Complete strengths before identifying needs.
• During the brainstorming of needs, avoid organizing the list of needs by person.
Note: See further information about needs vs services on pg. 73
Prioritize needs
• Facilitate a discussion with the team about which needs should be prioritized (including those domains
with 2’s or 3’s on the CANS) to work on over the next 30/60/90 days.
• Typically, teams work better with less than 5 needs prioritized at one time.
• Avoid a numeric ranking of each need by importance.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 34
Develop outcome statements for prioritized
needs
• Teams may need a lot of guidance with this at first.
• Use the SMART test.
• Avoid wasting time with specific wording at the team meeting.
You can rewrite the statements after the team meeting and
revisit the final statement for group approval.
Brainstorm strategies
• Brainstorm multiple strategies for one outcome statement at a
time.
• Devise strategies to help achieve each desired objective.
• Encourage the youth and family to select which strategies they
think would work best for them and fit with the culture of their
family.
• Include strategies that draw from the strengths of the youth and
family.
Assign action steps
• Each selected strategy includes specific action steps and should
be assigned to a specific team member(s) keeping the
individual’s strengths and abilities in mind. When appropriate,
all team members are given action steps for the strategy that
will help achieve the outcome statement and meet the need.
Summarize and agree on the plan
• The meeting facilitator summarizes the entire plan for the team
and solicits feedback about missing components or needs.
• Following the team meeting, the Cross System Care Plan is
documented and given to each member of the team.
Schedule the next team meeting
• The next team meeting is scheduled while all team members are
present.
• Meetings will be scheduled at least once every month
When developing outcome
statements for prioritized
needs, remember the
SMART test.
Specific
Linked to a rate,
number, percentage, or
frequency
Measurable
Has a reliable process to
measure progress
toward the achievement
of the goal, objective, or
outcome
Achievable
It can be done with a
reasonable amount of
effort
Relevant
The objective is
consistent with the
overall goal
Time-Bound
Has a start/finish date
clearly stated and
defined SMART goal
criteria developed by
George T. Doran
SMART GOALS
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 35
A note regarding “needs are not services” from EnRoute, the WISe Workforce Collaborative:
It is very common for people to say, “he needs therapy” or “she needs residential treatment.”
When we do this, we fail to articulate what the real underlying need is. A common way to untangle
this is to ask what the actual need(s) the person we are referencing has that they were hoping the
stated service was going to address.
For example:
Service: Therapy
Possible Needs: Someone to talk to, understand my behavior, and learn strategies to control my anger etc.…
Service: Residential Treatment
Possible Needs: Safety, structure, stability etc.…
Services are the chosen intervention or strategy to address a need. Not the need itself. When we don’t
distinguish the two, we interrupt the creative, individualized planning and focus on the one stated intervention.
If we focus on the need, there are possible multiple ways to meet the need that include formal, informal or
natural supports. Also, getting a service doesn’t mean your need is met.
In order to get a true needs statement, take the service that has been suggested and plug it into any or all of the
following questions.
What is it you hope to get out of ______?
How will _____help you?
What type of concerns do you want _____to address
What does the child/youth/family need help with that _____will address?
Principals evidenced in practice
The 10 Washington State Children’s Behavioral Health Principals are the guide to practice-level decision-
making.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 36
WISe training and coaching framework
WISe practitioner training and coaching framework
WISe training and coaching is an ongoing contractual requirement. The WISe case rate includes cost
reimbursement for participation in training and coaching. The case rate is based on the expectation that newly
hired WISe staff will engage in 100 hours of training and coaching during their first year. The case rate supports
80 hours of training and coaching for each WISe practitioner each year after completion of their first year in
WISe.
On-going training and coaching support staff working in a highly intense service structure, with the goal of
retaining WISe practitioners to provide continuity of care for youth and families. The training framework also
provides authority and accountability at the provider level for onboarding new staff for interested WISe
providers. The WISe training and coaching framework requires role specific trainings and coaching sessions. The
framework is also linked to TCOM processes and outcomes identified in the Quality Plan. The work to improve
training and coaching will be informed by multiple perspectives of the system.
WISe training and coaching is facilitated by the WISe Workforce Collaborative and informed by the annual WISe
Youth and Parent/Caregiver Survey; Quality Improvement Reviews, quarterly BHAS reports; WISe Data
Dashboards; WISe Service Characteristics reports; feedback from the statewide FYSPRT; feedback from WISe
practitioners.
The WISe Workforce Collaborative wants to hear from providers about training and coaching needs to continue
expanding and improving WISe training and coaching content, curriculum and offerings.
Training and coaching framework
System Level: Technical assistance for WISe is available at each level of the system. DBHR works in partnership
with Managed Care Plan (MCP) staff and allied Child and Family Serving Systems through the work of the WISe
Workforce Collaborative. Convening WISe community trainings and webinars for system initiatives is a function
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 37
of the Workforce Collaborative. MCP staff also collect feedback from their contracted WISe provider network. An
example of this work is the BRS and WISe webinar series.
Requirements: Representatives from all MCPs participate in the WISe Training Advisory Group to assist in
providing input and guidance for the annual training schedule and review of updating curriculum. WISe leads
are encouraged to participate in the on-going provider coaching calls. These sessions may be offered in person
or virtually and facilitated by the WISe Workforce Collaborative contractor.
Practitioner training and coaching
The WISe Workforce Collaborative is the training and coaching hub for WISe practitioners across the state. The
Collaborative provides WISe training for new practitioners as well as additional on-going training and coaching.
Requirements: Participation in the state sponsored trainings and coaching sessions offered through the WISe
Workforce Collaborative are a requirement of WISe agency staff. When onboarding new WISe practitioners,
agencies must document completion of the following set of trainings:
• WISe Introductory Skills with Foundations of Crisis/Safety Planning, (2 days)
o Note: If a region or a WISe agency has an approved training plan, see additional information
under the section, Regional/Agency training plan.
• Crisis and Safety Planning, (1 day)
• Certified Peer Counselor (CPC) training (5 days in person or HCA approved virtual course) for those hired
in peer support roles.
o Note: See section 2 of the WISe manual for additional information.
• CANS online certification
• CANS/WISe Integration (2 days)
Enhanced training sessions offered include:
• WISe Intermediate Training – Care Coordinators, Youth Partners, Family Partners, and Clinicians (2
days)
• Bridging the Gap to Culturally Specific Practices in WISe, led by BIPOC trainers (2 days)
• WISe and Indian Health Care Providers Training, led by American Indian or Alaska Native Trainers (2
days)
• WISe Supervisors (2 day)
• WISe Data to Practice trainings (times vary)
WISe coaching onsite and virtual sessions may include:
• CANS - virtual coaching
• Mental Health Therapists
• Supervisors of Youth and Family Peers
• Youth and Family Peers Supervisors of Care Coordinators
• Care Coordinators
Representatives from the WISe providers participate in the WISe Training Advisory Group to assist in providing
input and guidance for annual training and review for updating curriculum.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 38
WISe training and coaching framework
New staff – Orientation and
onboarding (one-time trainings)
Intermediate trainings (one-
time trainings and on-going)
Coaching (on-going)
• 32 hours of live training + 14
hours of eLearning content
for
all new WISe staff
36 hours of training + avg 6 hours of
eLearning for
Youth and Family
Peers
– if not certified at time of
hire
12-18 hours required training per
role
on the WISe team, annually.
• 8-16 hours of coaching calls
annually, based on coaching plan
Onboarding and Orientation
for all new staff includes:
• WISe Introductory eLearning
Modules & Exam (avg 6 hours)
• CANS eLearning Modules and
Certification (avg 8 hours)
• WISe Introductory Skills &
Crisis/Safety Planning (2-days)
• CANS/WISe Integration training
(2-days)
Required Intermediate Trainings
for all WISe team members
• Intermediate Practice Skills (2-
days)
• Crisis/Safety Planning (1-day)*
o 12-18 hours
On-going coaching calls
Topics and staff to attend are based on the
region or agency coaching plan.
Call: 1-2 hours a month, up to 8 calls
annually, based on need.
Certified Peer Counselor (CPC)
Training
- for WISe Youth and Family
Peers
Certified Peer Counselor (CPC)
eLearning modules and live training
for those hired in peer support
roles.
Supervisors & Coaches:
WISe Supervisors training (2-day)-
Crisis/Safety Planning (1-day)
16 hours
Coaching:
Up to 4 sessions a year per region based
on needs of the region/agency, the
coaching plan, and Quality Review
outcomes.
Who attends the particular coaching depends on
topic, coaching needs, and coaching plan.
WISe agencies are required to have lead staff participate in WISe coaching sessions. Agencies will partner
with the WISe Workforce Collaborative, which serves under the direction of DBHR as their primary resource for
ongoing technical assistance related to training and coaching for WISe practitioners. WISe agencies will:
• Develop annual coaching plans
• Be accountable to the training and coaching plans
• Participate in coaching calls offered by the WISe Workforce Collaborative.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 39
Training and coaching plans
Agencies are encouraged to design an onboarding system to prepare their staff with sufficient knowledge and
skills for their work with youth and families. WISe agencies (approved by an MCO) qualify once they have
attended a WISe “Train the Trainer” session and have a training plan approved by DBHR and the WISe Workforce
Collaborative. Technical assistance from the WISe Workforce Collaborative on completing a regional agency
WISe onboarding plan is available. Regions and/or agencies must provide documentation of their individualized
onboarding processes to the WISe Workforce Collaborative as a part of their overall training and coaching plans.
Once approved and to maintain qualifications as a regional or agency WISe onboarding training site, DBHR staff
and the WISe Workforce Collaborative will observe one training annually to assure that the training is aligned
with the state approved curriculum.
Orientation
The following activities are required to orient WISe practitioners in all roles. Agencies must document
completion of these activities as indicated below:
• Staff must be provided with their own copy of the WISe manual. Staff must also review the Behavioral
Health Assessment System (BHAS) manual.
• Staff must review the Regional Family, Youth, System Partner Round Table (FYSPRT) manual.
• Staff must review the WISe Due Process brochure.
• Staff must review the Quality Plan
• Staff must complete the WISe Overview Modules 1-6 and the self-test
o Completion of items above must be noted on a WISe orientation checklist.
Training: WISe practitioners must participate in the required trainings in the “Practitioner Training and
Coaching” section noted above unless a region or an agency has an approved training plan.
DBHR will offer “train the trainer sessions” to agencies interested in managing the WISe orientation and
onboarding of new staff. MCPs or WISe agencies may also develop a regional training plan to provide the
WISe Introductory Skills Training and a portion of the required two-day CANS training.
Regional or Agency Training Plans are reviewed and approved by the DBHR WISe lead and the WISe
Workforce Collaborative. WISe agencies must have approval from an MCP to submit a training plan. To
WISe supervisors and coaches will continue to provide on-going support to WISe practitioners. Coaching
that is already happening at the regional level and/or agency should link to the WISe Coaching requirement
to assist with further support of the WISe supervisors and practitioners. The statewide goal is for WISe
practitioners to receive ongoing, competency-based coaching to facilitate skill development relevant to
their role.
To support this work:
• WISe agencies should identify one or more seasoned staff who can provide mentoring to newly hired
staff. Trainees should have the opportunity to see good practice performed, either live or via video, in
real or simulated situations.
• WISe practitioners should have regular, ongoing coaching with their supervisor or coach.
• WISe supervisors and coaches will participate in WISe Collaborative-facilitated coaching calls.
Supervision: WISe practitioners must receive regular, ongoing supervision by qualified agency staff as
required by their licensing body (Documentation requirements determined by provider).
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 40
Client rights
Decisions and dispute resolution
This section is intended to explain the decision-making and appeal procedures for youth, parent/caregiver (for
youth under 13) seeking or receiving WISe. This section of this manual does not alter any Medicaid or due
process rights contained in state or federal law. A WISe information sheet with information on client rights
can be found at the HCA website.
Reaching consensus on a CFT
Youth participating in WISe are entitled to any services on the Medicaid behavioral health service array that are
necessary to correct or ameliorate a mental health condition. These include services needed to build on
strengths that reduce, eliminate, or improve a mental health condition, as well as services needed to maintain
functioning or prevent the condition from worsening.
CFT members should use the WISe planning model described and the Washington State Children’s Behavioral
Health Principles when developing the Cross System Care Plan to reach consensus on the services and supports
necessary to reach the youth’s best possible functional level. The team should also adhere to the needs and
strengths identified with the CANS and utilize the preferred strategies expressed by the youth and family.
Although the CANS assessment is not the sole measure of youth functioning, the CANS assessment will be
utilized to evaluate the progress of the youth in reaching their best possible functional level.
The CFT should attempt to reach consensus about what services and supports should be provided, when to
increase or reduce services and supports in frequency or amount, and when to terminate services. If there is
disagreement among CFT members during the care planning process, the WISe Practitioners should help build
agreement among the team to develop a plan for a specified period of time. The impact of the plan can be
assessed and monitored by the CFT and adjusted as necessary.
If the CFT can reach agreement on a plan
• The CFT should meet again within the agreed specified timeframe.
• The CFT should look at the outcomes in relation to the services that were provided.
• Using the decision-making guidelines described above, paying particular attention to the needs and
preferences of the youth and parent(s)/caregiver(s), the care coordinator should help the CFT
determine whether they are able to reach a consensus on continuing with the services or whether to
make changes.
If the CFT cannot reach an agreement on services to be provided on an interim basis, or whether interim
services should continue:
• The Care Coordinator should ensure the youth and family is aware of how to use the grievance process
to notify their MCP of any disagreements they have with specific mental health treatment
recommendations made during the care planning process.
• The team will invite agency administrative or supervisory staff to the next CFT meeting to assist in
finding resolution to the dispute. This process may escalate up the chain of authority until consensus is
reached on the matter. All attempts at finding a solution to a grievance should be made at the lowest
level possible.
How do I file a grievance?
A youth, parent/caregiver (for youth under 13) or their representative can file a complaint on any matter with
which they are dissatisfied. This is called a “grievance.” A grievance is used by a youth, parent/caregiver (for
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 41
youth under 13) or their representative to express dissatisfaction about any matter other than a notice of
adverse benefit determination
1
. A grievance may be filed with the client’s MCP over the phone, or in writing.
Youth or families may also contact the Ombuds
for assistance. If you file a written grievance, you should include:
• Your name
• How to reach you
• A description of the concern or complaint you have
• What you would like to have happen If you are not sure what you would like to happen you can still
file grievance
• Your signature and date of signing
1. When the MCP receives a grievance, they will notify the youth, parent/caregiver (for youth
under 13) or representative to let them know in writing within five (5) business days that a
grievance has been received.
2. The grievance will be reviewed by staff who have not been involved before with the issue(s). If
the grievance is about behavioral health treatment, a health care professional at the MCP who
is familiar with the youth’s condition will review the grievance.
3. The MCP will review the grievance and send a letter of their decision as quickly as the youth’s
health condition requires and no longer than 45 days from the date the MCP receives the
grievance.
Right to appeal a denial, termination, reduction, or suspension of services
WISe enrollees have a right to a specific and detailed written notice and to file an appeal when they disagree
with decisions made by their provider or MCP. The MCP must provide the youth or parent/caregiver (for youth
under 13) with a written Notice of Adverse Benefit Determination, advising them of their right to request an
appeal and to obtain an administrative fair hearing when:
• A youth is screened for WISe and determined not to need or qualify for that service, for any reason.
• A youth or parent/caregiver (for youth under 13) participating in WISe indicates to the MCP and/or
provider agency that there is disagreement with treatment plan recommendations found in the
Individual Service Plan, made during the care planning process.
1
"Adverse benefit determination" means one or more of the following:
(a) The denial or limited authorization of a requested service, including determinations based on the type or level of
service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit;
(b) The reduction, suspension, or termination of a previously authorized service;
(c) The denial, in whole or in part, of payment for a service;
(d) The failure to provide services in a timely manner, as defined by the state;
(e) The failure of a managed care organization (MCO) to act within the time frames provided in 42 C.F.R. Sec.
438.408 (a), (b)(1) and (2) for standard resolution of grievances and appeals; or
(f) For a resident of a rural area with only one MCO, the denial of an enrollee's request to exercise the enrollee's
right to obtain services outside the network under 42 C.F.R. Sec. 438.52 (b)(2)(ii)
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 42
• The MCP denies
2
, terminates
3
, reduces
4
or suspends
5
the authorization of services to the youth that are
included in the Medicaid mental health service array and recommended by the CFT in the Cross System
Care Plan.
An Adverse Benefit Determination is a denial, reduction, termination or suspension of services. The notice to the
youth, parent/caregiver (for youth under 13) and provider must contain:
• An explanation of why the letter was sent
• The reason for the Adverse Benefit Determination
• Client’s right to a second opinion and how to get one; and
• Client’s right to an appeal, an expedited appeal, or administrative (fair) hearing.
These rights are further explained in the Washington Medicaid Behavioral Health Benefits Booklet,
for MCPs.
Types of appeals
Appeals must be made to the MCP. There are two types of appeals a youth, parent/caregiver or designated
representative can file to challenge a denial, termination, reduction or suspension of services: a standard or
expedited appeal. An appeal must be filed within 60 calendar days from the date on the Notice of Adverse
Benefit Determination. An MCP must assist a youth, family/caregiver in filing an appeal, including providing any
interpreter services or other aids they may need. A youth, parent/caregiver or mental health care provider or
other authorized representative acting on the youth parent/caregiver’s behalf and with written consent can ask
for either type of appeal.
• Standard: For a standard appeal with no continued services requested, a decision must be issued by
the MCP within 14 days from the day the MCP received the appeal. The MCP may extend this time up to
14 days based on a request for an extension by the enrollee (youth or family).
• Expedited: An expedited appeal is available to a youth or family member, when the MCP determines or
provider indicates that the youth’s life, health or ability to function could be seriously harmed by
waiting for a standard appeal. An expedited appeal must be decided no later than 72 hours after receipt
of the expedited appeal request.
If the mental health care provider asks for an expedited appeal, or supports the youth or family in
asking for one, and indicates that waiting for a standard appeal could seriously harm the youth’s
health, the MCP will automatically grant an expedited appeal.
6
2
A “denial” is the decision not to offer an intake or a decision by the Managed Care Plan (MCP), or their formal
designee, not to authorize covered medically necessary Medicaid mental health services.
3
A “termination” is a decision by a MCP, or their formal designee, to stop the previously authorized covered
Medicaid mental health services. A decision by a provider to stop or change a covered service (in the
Individualized Service Plan) solely based on clinical judgment is not a termination.
4
A “reduction” of services is the decision by an MCP or their formal designee, to decrease the amount duration or
scope of previously authorized covered Medicaid mental health services. The decision by a provider to decrease or
change a covered service (in the Individualized Service Plan) solely based on his/her clinical judgment is not a
reduction.
5
A “suspension” of services is the decision by a MCP, or their formal designee, to temporarily stop previously
authorized covered Medicaid mental health services. The decision by a provider to temporarily stop or change a
covered service (in the Individualized Service Plan) solely based on his/her clinical judgment is not a suspension.
6
438.410 Expedited resolution of appeals. (a)General rule. Each P, PIHP, and PAHP must establish and maintain
an expedited review process for appeals, when the P, PIHP, or PAHP determines (a request from the enrollee) or
the provider indicates (in making the request on the enrollee's behalf or supporting the enrollee's request) that
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 43
If a youth, parent/caregiver asks for an expedited appeal without support from their mental health
care provider, the MCP will decide if the youth’s health requires one. If the MCP does not agree with
the request, the plan must decide the appeal within standard appeal timeframes.
The MCP may extend this time up to 14 days based on a request by the enrollee (youth or
parent/caregiver) for an extension.
How do I file an appeal?
If the MCP makes an Adverse Benefit Determination involving a youth’s WISe treatment, or the youth is not
considered eligible for WISe from a CANS Screen, the youth is entitled to a Notice of Adverse Benefit
Determination about the decision and the youth’s rights. If the youth, parent/caregiver disagree with the
decision, the youth has a right to file an appeal. To appeal, the youth or parent/caregiver would:
• Contact the MCP by phone at the number provided on the notice, or in writing. The appeal must
include:
o Client name
o Contact number, email or address
o ProviderOne ID
o The service or treatment being appealed
o Information about why the client disagrees with the Adverse Benefit
Determination
1. If the Notice of Adverse Benefit Determination is about services a youth is already receiving, the
youth or parent/caregiver can ask for the services to continue until the appeal is decided. If a
youth or parent/caregiver want to continue to receive benefits a request must be made as follows:
• File the appeal and request benefits continue within 10 calendar days from the date on the
Adverse Benefit Determination or before the termination, reduction, or suspension of
services occurs.
Note: The client may have to pay for the continued services if the appeal is upheld.
How to request an administrative (fair) hearing
In order to request an administrative (fair) hearing, the individual must first receive a Notice of Resolution from
the MCP that decided the appeal. The individual or their representative must request an administrative hearing
within 120 calendar days from the date on the Notice of Resolution. To request a hearing, contact the Office of
Administrative Hearings by phone, fax or in writing at:
Office of Administrative Hearings
P.O. Box 42489
Olympia, WA 98504
Phone: 1-800-583-8271
Fax: (360) 664-8721
(No email correspondence is accepted)
taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health,
or ability to attain, maintain, or regain maximum function.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 44
An Administrative Law judge will look at the evidence provided and decide on whether to grant the appeal. The
judge has 90 days from the date the request was filed to decide. If the judge agrees with the appeal, the MCP must
follow the decision by the judge and authorize or provide the services as fast as the individual’s health condition
requires. An administrative hearing may not be filed regarding
a grievance decision unless the MCP fails to
decide on the grievance within the required time frame. To read all about the administrative hearing process
follow this link
.
Continuing services during the appeal
If a youth is currently receiving services, their services will be continued during the appeal process and state
administrative hearing when:
• The appeal or state administrative hearing request is filed within 10 calendar days from the date the
notification of the resolution was written;
• The appeal involves the reduction, suspension or termination of previously authorized covered
Medicaid mental health services; and
• The youth or family asks for continuing services.
Help for youth, families, and caregivers
If youth, families, or caregivers request help with filing a grievance or appeal, they should be referred to the
Regional Ombudsman.
Below is a list of additional legal or mental health advocates where the youth and family may be referred:
TeamChild
1225 South Weller St., Suite 420
Seattle, WA 98144
Phone: (206) 322-2444
Fax: (206) 381-1742
Email: questions@teamchild.org
Northwest Justice Project
1-888-201-1014
Disability Rights Washington
315 5
th
Avenue S, Suite 850
Seattle, WA 98104
1-800-562-2702 (ask for a “Technical Assistance” appointment)
Fax (206) 957-0729
Governance and coordination
Washington State will maintain a collaborative governance structure that includes families, youth, community,
and youth-serving system partners, as a mechanism for improving behavioral health services and supports as
well as informing the quality of Wraparound with Intensive Services (WISe). A collaborative governance structure
includes youth, family and youth serving system partner (juvenile rehabilitation, child welfare, education, etc.)
voice coming together to ensure coordination, address recurring system gaps and barriers to improve outcomes
for youth and families.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 45
This governance and cross-system collaboration, called the Child, Youth, and Family Behavioral Health
Governance Structure (the Governance Structure) is essential in system change efforts to ensure:
• Collaboration and coordination across child and youth serving systems with youth, family, and
community partners.
• Working to address recurring system gaps and barriers as close to the community as possible.
• Connection to legislative groups to ensure recurring system gaps and barriers elevated by family and
youth are addressed.
• Participation by local system partner representatives (child welfare, juvenile rehabilitation, education,
etc.) in Child and Family Teams (CFTs) when invited by youth and families who are enrolled in WISe and
served by multiple youth and child-serving systems including tribal program partners when
appropriate.
• Coordination of funding sources, to the extent permissible by the state legislature and federal law, to
strengthen inter- and intra-agency collaboration, support improved long-term outcomes, and establish
systems to achieve sustainability of WISe.
• Information sharing about FYSPRT and the governance structure to support cross system learning.
• The development of data-informed quality improvement processes.
• Increased participation of family and youth in all aspects of policy development and decision-making
for WISe and behavioral health services.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 46
The following table provides a brief description of the role and function for each component.
Child, Youth and Family Behavioral Health Governance Structure Component
Descriptions
Regional and local family, youth, system partner round table (FYSPRT)
Role
Required members
Of note
Looks at the full continuum of care,
including WISe quality and service
delivery in the region. Brings
families, youth and youth serving
systems and community together to
address regional challenges and
barriers as identified by the Regional
FYSPRT, Reviews local/regional WISe
data to improve outcomes for
children and youth experiencing
behavioral health challenges.
If not able to resolve or address a
recurring system gap or barrier at
the regional FYSPRT, the Regional
FYSPRT can bring the challenge
forward to the Statewide FYSPRT
with recommendations for how to
address the need.
Families and youth with lived experience
(including past/present WISe youth and
family participants), Tribal and Urban Indian
Health Partners, Behavioral Health -
Administrative Service Organization (BH-
ASO), Managed Care Plan (MCO) staff,
local/regional system partners, and other
community system partners.
Of Note:
• Tri-Led by family and youth
partners with lived
experience (does not need to
be a Certified Peer), and
System Partner from the
membership
• Open Meetings – No
confidential or Protected
Health Information (PHI)
shared. The Regional FYSPRT
is intended to identify themes
around system challenges or
solutions, and provide
recommendations to the
Statewide FYSPRT
• Minimum of 51% youth and
family membership, including
tribal, under represented a
and underserved populations
• Based on how a region
defines their community(ies),
they may select to have more
localized groups (local
FYSPRTs) that connect to
their regional structure, to
better meet the needs of that
region, and address
challenges and barriers as
close to the community as
possible
When part of an individual’s
Cross System Care Plan it is
possible for a WISe practitioner
to attend a FYSPRT meeting with
the individual and/or family and
count it toward service intensity
when part of the youths
individual service plan.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 47
Statewide FYSPRT
Role
Members
Of note
Looks at the full continuum of care,
including WISe quality and service
delivery, across Washington state.
Brings together Regional FYSPRT Tri-
leads and state level youth serving
system representatives (child
welfare, juvenile rehabilitation,
education, etc.) to support the work
of the Regional FYSPRTs. Shares
potential solutions and addresses
recurring system gaps or barriers
identified by regional FYSPRTs that
may require policy
decisions/direction, as well as
reviews statewide data, to improve
outcomes of children, youth and
families experiencing behavioral
health challenges
Regional FYSPRT Tri-leads, state-level system
partners from child and youth serving
systems, tribal and urban Indian health
partners, representatives of the Division of
Behavioral Health and Recovery, and
community partners
•
Tri-Led by Youth, Family, and
System Partner leaders from
the Statewide FYSPRT
membership
• Open Meetings – No
confidential or Protected
Health Information (PHI)
shared. The Statewide
FYSPRT is intended to identify
recurring system gaps and
barriers, share solutions and
provide recommendations to
a youth and young adult
behavioral health focused
legislative work group.
• Statewide FYSPRT
workgroups are utilized as a
means for completing specific
work products, or as a
strategy for making systemic
changes. Representatives
from the Statewide and/or
Regional FYSPRTs will be
invited to participate.
Youth and Young Adult Continuum of Care subgroup of the
Children and Youth Behavioral Health Work Group
Role
Members
Of note
A legislative work group that
receives recommendations from the
Statewide FYSPRT, requests input,
and makes recommendations to the
Children and Youth Behavioral
Health Work Group related to
behavioral health services and WISe
quality and service delivery and to
improve outcomes of children and
youth experiencing behavioral
health challenges.
State child and youth serving agencies,
legislators, health care providers, youth and
parents of children/youth who have received
services, tribes, a FYSPRT representative, and
community partners and organizations
•
Quad-led by legislators, a
family leader and a youth
leader
• A Youth and Young Adult
Continuum of Care Subgroup
member(s) attend Statewide
FYSPRT meetings
• Youth and Young Adult
Continuum of Care Subgroup
meeting notes are posted to
website
• Meetings are open to the
public
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 48
Children and Youth Behavioral Health Work Group (CYBHWG)
Role
Members
Of note
A legislative work group that
receives recommendations from the
Youth and Young Adult Continuum
of Care subgroup, requests input,
and makes policy-level decisions
and recommendations to the
legislature and child, youth, and
family serving agencies.
Recommendations could be related
to behavioral health services and
WISe quality and service delivery to
improve outcomes of children and
youth experiencing behavioral
health challenges
State child and youth serving agencies,
legislators, health care providers, tribes, a
FYSPRT representative, youth and parents
who have received services and community
partners and organizations
• Children and Youth
Behavioral Health Work
Group meeting notes are
posted to website
• Meetings are open to the
public
For more detailed information on the Statewide and Regional FYSPRTs, please refer to the Regional FYSPRT
Manual .
Developing regional linkages to the governance structure
MCOs will work within their local communities to define processes in which local implementation and oversight
of WISe will be achieved and coordinated with the regional and local FYSPRT efforts, and the governance
structure. These processes will differ from the work of Regional and Local FYSPRTs in that they could include
confidential information. The identified processes would describe efforts to:
• Provide collaboration and coordination of care for youth that are eligible for WISe or are participating in
WISe.
• Address recurring system gaps and barriers expressed by a CFT or CFTs. Barriers unresolved through the
identified regional processes should be advanced to the local and/or regional FYSPRT by proposing the
recurring system gap as an agenda item at a future meeting to share and brainstorm solutions.
• Reviewing WISe data at a more local level for continuous quality improvement to problem solve or
identify systemic barriers. This includes areas such as local referents’ understanding of referral
procedures and enrollment criteria, gaining access to WISe in a timely fashion, the array of services and
supports is adequately accessible and of high quality, WISe service utilization (e.g., patterns, attention
to outliers, use of home and community versus restrictive services, patterns by child-serving system
and locality), and local data on outcomes, including: youth, family, and system outcomes.
Note: Although the above types of data and a process for review is largely a state and MCO
function, those groups identified in the regional processes should also have access to information
and use it to solve problems and help improve the local WISe implementation, as is appropriate
per their respective group’s responsibilities.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 49
Center of Parent Excellence
The Center of Parent Excellence (COPE) project was developed as a support to enhance the System of Care
framework. The project is intended to provide a pathway for Washington State parents who are accessing and
navigating the children and youth behavioral health system. The COPE project is staffed by lead parent support
specialists, hired for their lived experience as a parent/caregiver.
Supports provided by COPE is available to CFTs or families. COPE project staff will assist the family and CFTs
when needed for system access and navigation. COPE project will track recurring system gaps and barriers
expressed by a CFT and advance to the local and/or Regional FYSPRT by proposing the recurring system gap as
an agenda item at a future meeting to share and brainstorm solutions.
Quality Plan
The Quality Plan describes the goals, objectives, tools, resources, and processes used by Washington to assess,
manage, and improve the quality of home and community-based intensive mental health services provided
through Wraparound with Intensive Services (WISe). A copy of the WISe Quality Plan can be found on the HCA
website. The WISe quality plan must be used by HCA, MCO’s and WISe agencies per WAC 182-501-0215.
Background
The original WISe Quality Management Plan (QMP), adopted in December 2014, was developed pursuant to the
Commitments set forth in the T.R. v. Birch and Strange Settlement Agreement dated December 19, 2013 (DKT
119-1, paragraphs 18 – 64). The name has been simplified to “Quality Plan” to reflect the focus on the future,
rather than the past, and to better describe the full scope and intent of Washington’s quality planning and
activities. The Quality Plan is periodically reviewed and updated. Future iterations will continue to be informed
and guided by the foundational T.R. principles and goals.
Components
The WISe practice model is built around collaborative goal-setting, individualized, strengths-based, intensive
treatment, provided in the community. The Quality Plan is a key part of efficiently delivering high quality,
effective care to Washington’s children and youth with complex behavioral health needs and their families.
The components of the Quality Plan facilitate both performance benchmarking and adaptation to better meet
the needs of children and youth. Cross-system care coordination, information dissemination, and decision-
making structures allow for consistent and tailored responses to children and youth with complex support
needs.
Quality infrastructure
WISe provider agencies are key partners in assessing, managing, and improving the quality of care. Each WISe
provider agency must participate in a Provider Quality Committee (PQC), as described in the WISe Quality Plan,
section II-C-ii (pp 11-12). PQCs can be internal to a WISe provider agency, or a collaborative group comprising
representatives from multiple WISe provider agencies.
Provider Quality Committees must effectively communicate with “frontline” WISe staff, including care
coordinators, family and youth partners, and mental health therapists. Communicating and collaborating with
staff is a key strategy for identifying not only needed improvements, but also effective quality improvement
strategies and innovative practices. PQCs are required to formally describe their processes for reviewing and
using WISe data, in order to demonstrate that they can meet the quality performance functions required of them
in the WISe quality plan. A PQC "charter document" should lay out expected mechanisms by which the PQC will
document, communicate, and accomplish their quality improvement activities. PQC documentation is required
as part of the WISe attestation process. Each year your WISe provider agency should check to make sure your
PQC documentation is still up to date. If your charter has been amended or updated, please submit the updated
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 50
copy to [email protected] and follow any submission requirements directed by the MCOs with which
your agency is contracted.
Quality Improvement Review Tool (QIRT)
The Quality Improvement Review Tool (QIRT) uses a file review process to assess and provide feedback about
the delivery of WISe. It has a modular format and it is designed to be flexible so WISe provider agencies can use it
as part of their regular WISe quality assurance activities. For example, a WISe supervisor might use the transition
planning submodule of the QIRT Care Coordination section to inform quality improvement activities focused on
improving transitions from WISe to a less intensive level of care. The QIRT also includes an interview module
that is used to gather feedback from youth and families who have participated in WISe. Additionally, HCA uses
the QIRT to conduct external review of WISe.
The QIRT was specifically developed for WISe and many of the QIRT items focus not only on what the WISe
practitioners do, but also the responses of youth and family. This reflects the collaborative nature of WISe.
Because the QIRT is based on a file review process, complete and accurate documentation of the WISe process is
essential.
The two requirements for becoming approved to use the QIRT are 1) completing the QIRT training and 2)
successfully meeting the interrater reliability standard. HCA periodically offers the QIRT training. Please contact
[email protected] if you are interested in more information on the QIRT.
In 2024, HCA is reviewing and updating the QIRT, which will lead to interruptions in the availability of the online
data entry platform (REDCap). During the update process, use of the QIRT is not required. This section will be
updated once the update is complete.
WISe Fee for Service
Overview of Apple Health for individuals non in Managed Care or Fee for
Services (FFS)
Federal law requires state Medicaid programs to enable American Indian/Alaska Native (AI/AN) individuals to opt
into or out of managed care plans. This is to ensure AI/AN persons can access culturally appropriate care from
their Indian Health Care provider. As a result, approximately 60% of AI/AN individuals in Medicaid are enrolled in
Apple Health without a managed care plan (also known as the Apple Health fee-for-service (FFS) program). The
WISe program is available to all individuals in Apple Health FFS who need the service and does not require prior
authorization from either HCA or a managed care plan. There are a limited number of other youth who are not
AI/AN who are also enrolled in FFS.
Participation as a WISe Fee for Service (FFS) provider
HCA encourages all WISe providers to participate in the FFS program to ensure adequate access to WISe for the
estimated 22,500 AI/AN and other youth not enrolled in an Apple Health managed care plan.
WISe payments in the Apple Health FFS program (WISe FFS) allow for services to be unbundled and paid for
separately. WISe FFS also involves a case rate each month for each youth receiving WISe - in addition to
reimbursement for all services provided. WISe FFS providers are required to follow all expectations in the WISe
manual.
To provide WISe FFS, an agency must have a Core Provider Agreement (CPA) with HCA, be an approved WISe
agency, and register through the Provider Entry Portal for Behavioral Health Agencies. HCA staff are available to
provide guidance on the necessary steps to become a WISe FFS agency. The CPA’s terms and conditions
incorporate federal laws, rules and regulations, state laws, rules and regulations, and agency program policies,
provider notices, and provider guides, including the ProviderOne Billing and Resource Guide, and the mental
health services billing guide.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 51
WISe innovations when serving individuals not in Managed Care (FFS
program)
In an effort to support rural WISe FFS providers (or single county WISe FFS providers servicing rural
communities), it may be beneficial to identify additional approaches to ensure success of the youth and family
enrolled in the WISe program. Suggested considerations for WISe FFS providers include:
• Create an innovative Cross System Care Plan. Youth receiving WISe FFS can receive services
concurrently from other Apple Health FFS providers. A WISe Care Coordinator can assist in coordination
of these services and invite other Apple Health FFS staff to participate in Child and Family Teams (CFTs).
• WISe FFS providers are encouraged to be as flexible as possible, particularly in rural counties. For
example, include peers from the youth’s community and actively engage individuals in the CFT already
known to the youth.
• In rural and frontier counties, consider supporting the expansion of WISe business agreements to allow
youth to remain with counselors or peers in their local community who would become an integral part
of the CFT. This would reduce instances of transfer of counselors (which can be a stressor for the child
and family) and reduce travel time for the service provider.
• Expand support for local training of peers and employment of local peers through business agreements
or other means. Tribes often have Certified Peer Counselors on staff or in the community who would be
a better fit for an AI/AN youth enrolled in WISe.
• Develop working relationships to utilize tribal peers or family supports when possible. Peers employed
by the WISe provider who are not part of the tribal community, or the rural community, will likely
struggle to develop trust and be effective.
WISe FFS referral list
For WISe FFS referrals, see the WISe referral fee-for-service provider list
If interested in becoming an Apple Health FFS provider that offers WISe, please contact,
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 52
Section 2: Specialty teams and guidance
A. BRS and WISe Concurrently
Behavior Rehabilitation Services (BRS) and WISe Delivered Concurrently
Washington State Department of Children, Youth and Families (DCYF) contracts for Behavior Rehabilitation
Services (BRS) which is a temporary intensive support and treatment program for children and youth with high-
level complex service needs who are in the care authority of DCYF. BRS is intended to stabilize children and
youth and assist them in achieving their permanent plan.
Both BRS and WISe are intended to:
• Keep children and youth in their own homes with supports to the family.
• Reunify or achieve alternative permanency more quickly.
• Meet the needs of children and youth in family-based care to prevent the need for placement into a more
restrictive setting.
• Reduce length of service by transitioning children and youth to a permanent home or less intensive
service.
The intent of BRS directly aligns with WISe and the state is committed to providing both services together in a
highly coordinated effort by BRS and WISe staff.
WISe Screens and Behavior Rehabilitation Services
A referral for a WISe screen must be made for youth in the following circumstances:
• When a youth is being considered for or referred to Behavioral Rehabilitation Services (BRS);
• Every six months while a youth is receiving BRS only. For youth receiving WISe and BRS concurrently
CANS are completed per WISe timelines; and
• At discharge from BRS if the youth is not enrolled in WISe at that time.
Steps for completing a WISe BRS Screen:
• DCYF or BRS staff are responsible for contacting a WISe agency to request a WISe Screen.
o The list of WISe agencies by county is available on the HCA website under WISe.
• WISe agencies are to complete the CANS screen and enter it into BHAS. Screens must be offered to be
done by phone as well as in person.
o The referral may come from the DCYF staff, BRS staff, or any other person on behalf of a youth
who is Apple Health eligible for coverage under WAC 182-505-0210 aged 20 or younger.
o Note: WISe screens are not considered complete until they are entered into BHAS. WISe staff
have 14 calendar days from the initial contact to complete the screen and enter into BHAS.
• If the youth’s screen is eligible for WISe, but the youth does not plan to enter WISe, WISe staff are to
document the reason a referral is not made to serve the youth concurrently in WISe and BRS into the
comments section of BHAS.
• WISe agencies are to provide DCYF and/or their contracted BRS staff a copy of the WISe screening
results.
• If the BRS screen is “NOT ELIGIBLE,” or a youth in BRS has an “ELIGBLE” screen but is not offered entry
into WISe, they should receive a Notice of Adverse Benefit Determination (NOABD).
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 53
When a child receives BRS and WISe, the WISe provider agency and BRS provider shall coordinate and
collaborate to provide appropriate WISe and BRS services to the youth and family or caregiver.
For DCYF and BRS staff: WISe Screening Solution Communication
If there are complications or delays in receiving a WISe screen from a WISe agency, DCYF and BRS staff are to follow
the steps below:
1) Contact Coordinated Care of Washington at 1-844-354-9876, if:
- The screen is not completed after fourteen (14) calendar days;
- There are any systemic barriers preventing completion of a screen.
If after 72 hours of contacting Coordinated Care of Washington, challenges persist, please do the following:
2) Submit an email to HCA Managed Care Programs with the subject header line “URGENT - WISe Screening
issue” and identify the situation, whether you need an urgent screen or it is a systemic issue and provide
your contact information for follow-up.
BRS Data Entry into BHAS for WISe Staff
There are two unique areas to attend to when entering WISe screens for youth enrolled in BRS:
• Assessment reason
• Referral source
The following screen shots provide an overview of the steps for entering this information:
• The first page is where it asks for the “assessment reason”.
• The drop down menu will force you to choose “initial”.
• Use the comments to further clarify the reason for the assessment, i.e. “BRS 6 month.”
The following screen shots show mock data to demonstrate BHAS functionality.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 54
The next screen will require you to choose a referral source. Use the drop-down menu to indicate whether this is
an initial, rescreen, or discharge.
Then after the diagnosis is input into BHAS, you will choose “BRS and WISe.” A rationale must be given if a youth
in BRS screens eligible for WISe but will not be offered entry into WISe and BRS services concurrently. A Notice of
Adverse Benefit Determination (NOABD) must also be issued to youth who screen eligible but are not offered
entry into WISe. In addition, youth whose screen results in “not eligible” should receive an NOABD
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 55
On-going technical assistance and support is being provided during the phasing in of BRS and WISe by
HCA/DBHR, DCYF, and Coordinated Care of Washington (CCW).
WISe Provider Expectations
• WISe practitioners will review the BRS and WISe Guidance Document
• BRS providers can contact any WISe agency to request a screen and one will be provided
• WISe providers who have contracts for both BRS and WISe will provide services to other BRS providers
when requested. Screens must be completed and entered into BHAS within 14 calendar days to be
considered complete
• WISe teams will collaborate with BRS teams to provide highly coordinated and intensive services for
youth enrolled in BRS.
• WISe teams will participate in provided technical assistance sessions, such as the BRS and WISe
webinars
• Monthly, WISe agencies will report the number of youth receiving WISe and BRS concurrently to the
contracted MCO.
B. WISe and American Indian and Alaska Native Youth and their
Family
HCA/DBHR is pleased to share WISe staff have partnered with Tribal representatives to update the WISe training
curriculum to better support working with American Indian and Alaska Native youth and their families.
HCA/DBHR is hopeful Tribal Behavioral Health agencies will consider the updated training curriculum and WISe
as a service delivery model to include in the array of services they provide.
HCA/DBHR has identified the following resource materials to assist non-native WISe practitioners when working
with American Indian and Alaska Native Youth and their Family
. This resource list below will continue to be
updated in future WISe Manual editions as new resources are identified.
General Information and Map
Washington State is home to 29 federally recognized Indian Tribes. Tribal governments are improving people’s
lives, Indian and non-Indian alike, in all communities from Neah Bay to Usk. More information on Washington
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 56
State Indian Tribes can be found on the Washington Tribes website. More information on Indian Tribes in
Washington State can be found at the following pages:
• Confederated Tribes of the Chehalis Reservation, Oakville
• Confederated Tribes of the Colville Reservation, Nespelem, Inchelium, Keller, Omak, and several other
locations
• Confederated Tribes and Bands of the Yakama Nation, Toppenish
• Cowlitz Indian Tribe, Longview
• Hoh Indian Tribe, Forks
• Jamestown S’Klallam Tribe, Sequim
• Kalispel Indian Community of the Kalispel Reservation, Usk
• Lower Elwha Klallam Tribe, Port Angeles
• Lummi Tribe of the Lummi Reservation, west of Bellingham
• Makah Indian Tribe of the Makah Indian Reservation, Neah Bay
• Muckleshoot Indian Tribe, Auburn
• Nisqually Indian Tribe, Olympia
• Nooksack Indian Tribe of Washington, Deming
• Port Gamble S’Klallam Tribe, Kingston
• Puyallup Tribe of the Puyallup Reservation, Tacoma
• Quileute Tribe of the Quileute Reservation, LaPush
• Quinault Indian Nation, Taholah
• Samish Indian Nation, Anacortes
• Sauk-Suiattle Indian Tribe of Washington, Darrington
• Shoalwater Bay IndianTribe of the Shoalwater Bay Indian Reservation, Tokeland
• Skokomish Indian Tribe , Skokomish
• Snoqualmie Indian Tribe, Snoqualmie
• Spokane Tribe of the Spokane Reservation, Wellpinit
• Squaxin Island Tribe of the Squaxin Island Reservation, Shelton
• Stillaguamish Tribe of Indians of Washington, Arlington
• Suquamish Indian Tribe of the Port Madison Reservation, Suquamish
• Swinomish Indian Tribal Community, LaConner
• Tulalip Tribes of Washington, Tulalip
• Upper Skagit Indian Tribe of Washington, Sedro Woolley
Pulling Together for Wellness Framework
The American Indian Heath Commission for Washington State (AIHC) has the Pulling Together for Wellness
Framework on their website. AIHC is a tribally-driven non-profit organization with a mission of improving health
outcomes for American Indians and Alaska Natives (AI/AN) through a health policy focus at the Washington State
level. AIHC works on behalf of the 29 federally-recognized Indian Tribes and two Urban Indian Health
Organizations (UIHOs) in the state. The AIHC website.
The Substance Abuse and Mental Health Services Administration
(SAMHSA)
The Tribal Training and Technical Assistance (TTA) Center offers training and technical assistance on mental and
substance use disorders, suicide prevention, and mental health promotion using the Strategic Cultural
Framework.
• Link to the site
• TTA Resources
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 57
• TTA Webinars
Department of Children, Youth, and Families
Services are provided to American Indian and Alaska Native youth and children, consistent with the federal
Indian Child Welfare Act (ICWA) and Washington State Indian Child Welfare Act, in the areas of child protective
services, foster care, dependency guardianship, termination of parental rights, and adoption proceedings.
Additional information can be found online
• DCYF Tribal Relations
Health Care Authority
The Office of Tribal Affairs provides support and communication with tribes and tribal-related organizations for
American Indian/Alaskan Native (AI/AN) health care.
Department of Health
The Department of Health (DOH) collaborates with American Indian and Alaska Native youth Tribes, urban
Indian health programs and recognized American Indian Organizations in the development of policies,
agreements, and program implementation that directly affects Native Americans/Alaskan Natives. DOH
maintains a government-to-government relationship with tribes, resulting in partnerships which promotes
effective public health services for Indian people.
C. Partnering with Transition Age Youth in WISe
HCA/DBHR worked with Community Youth Services and Compass Health, WISe agencies specializing in WISe and
Transition Age Youth (TAY), and the WISe Workforce Collaborative to provide additional guidance for
consideration when engaging transition age youth. HCA has also consulted with Students Providing and
Receiving Knowledge (SPARK) to further inform this guidance. Initial information and resources are included in
this WISe Manual update and will continue to be updated as needed.
In the larger context of services for youth in Washington State, Transition Age Youth (TAY) are considered to be
between 16 and 26 years old. For WISe specifically, TAY refers to youth from the ages of 16 – 20 years old. There
is a special focus on building resources for this age range in our overall system of care for multiple reasons.
During this time services for young children are no longer appropriate, but “adult” services don’t quite meet the
needs of transition age youth either. Considerations in this section and future updates will focus on the needs of
transition age youth, resources and considerations related to how WISe may look different with the TAY
population.
WISe and TAY pilot
DBHR worked with Community Youth Services (Mason County and Thurston County), Compass Health
(Whatcom County) and Portland State University to identify strategies focused on reaching and engaging
transition age youth. This pilot focuses on WISe services to transition age youth to determine the supports,
guidance and resources that may be needed to support this population.
Each agency identified one specific WISe TAY team to participate. All core components of WISe outlined in the
manual are required with the agreed upon flexibility of the timing of Team Meetings (not referred to as Child and
Family Team meetings). These teams will work with youth 18 – 20 years old.
For this pilot a required team meeting in the first 30 days has been waived. Based on feedback from 18-20 years
who received WISe, this requirement is too prescriptive.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 58
“Just like other young people in their late teens and early twenties, older youth and young adults
involved in Wraparound expect themselves—and are expected by others—to take more
responsibility for running their own lives. As they do this, they move toward greater self-reliance
and independence from the protection and authority of parents and other caregivers. Young
people over the age of 18 are considered the drivers of their Wraparound process, and they are
expected to make decisions about who will be on the team and what goals to pursue.” -
Wraparound for Older Youth and Young Adults
This work is intended to identify additional guidance on how to best offer WISe for this age group that is
underserved in WISe. The HCA Youth Liaison will guide this work and updates to this section will be made in
future versions.
TAY Consultation
SPARK Peer Learning Center is a career exploration class for youth who are interested in becoming a Certified
Peer Counselor in the State of Washington. They also explore a career path to higher education in social services.
The SPARK program is housed at New Horizons High School in Pasco, WA. Youth also receive interpersonal tools
to use such as social and emotional skills that can be applied to all relationships, personal and professional.
SPARK has partnered with HCA (Washington Health Care Authority) to help build the workforce development of
youth per counselors with an emphasis on WISe in Washington State.
SPARK reviewed the WISe manual for this update and offered the following feedback regarding Youth Peer
Specialists and WISe TAY programs:
• Teams should keep in mind some youth may have had negative experiences with therapy and/or other
systems prior to the referral to WISe
• Youth Partner can be an integral part of crisis prevention and response
• TAY teams often find it is helpful when the Youth Partner has a prominent role in initial engagement and
through each phase of WISe
• Designated WISe teams that partner specifically with transition age youth
• Find ways from the start of services to empower the youth to create their team and who they want on it.
This includes honoring the youth’s definition of who is their family. Team members continue adding
natural and informal supports as directed by the youth.
• Consider having Youth Peer being a liaison with SUD agencies for referral and engagement
• Ensure teams provide consistent outreach and engagement to reach youth outside of formal systems:
o In places youth might be such as homeless shelters, teen centers or libraries
o To build rapport with youth
o To provide tools and resources to youth when needed
• Be mindful of shelter rules around length of stay for youth under 18 years old. In some cases, youth are
only allowed to stay for 72 hours and then must be out of the shelter for 24 hours. Also, once a youth
turn 18, they are no longer allowed to stay at teen shelters
• Being familiar with laws related to TAY and homelessness
• Mindful of activities that can’t be done without parent approval and how that impacts care planning if
the youth’s parents are not a part of the care team.
• Not pushing agency or system agenda on youth. Youth should feel empowered from the start to
create their team, service plan and goals
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 59
Role of Youth Peer on TAY WISe teams
• Prominent in providing outreach and engagement. It is beneficial for Youth Peer to be available
regularly in places where transition age youth are likely to be, and to share information and resources
about WISe education about recovery, it doesn’t happen overnight, and it looks different between
people and cultures.
• Youth Peer is a model of how to maintain and how to handle challenges to recovery.
• Groups with Youth Peers in lead roles such as groups teaching “real life,” “adulting 101” skills can be
helpful, such as
o how to start and maintain a checking account
o budgeting and credit scores
o how to find a place to live
o buying a house vs. renting a house
o how to use the health care system
o how to buy a car
o how to ride the bus
o resume writing
• Assistance with navigating the housing system, if needed, and other services the youth may qualify for
• Continue to offer professional development opportunities for youth peer specialists to expand the YPs
toolbox
Identified family (not always bio family)
Transition age youth may identify others in their lives that they consider family who they want to participate on
their team, even if they are not biologically related to them. The WISe team may also work to bridge the
relationship between the youth and biological family members who may be estranged upon the youth’s request.
“We want them to build their natural supports but then we also want to teach them independence
and how to handle these things.”- Wraparound for Older Youth and Young Adults
D. WISe Birth through Five (B-5)
Children birth through age 5 (B-5) with qualifying mental health conditions are eligible to receive infant-early
childhood mental health services, including through WISe. Because providing infant-early childhood mental
health services can often look and feel different than for older children and youth, additional information about
Infant-Early Childhood Mental Health and WISe B-5 is included below.
Infant-Early Childhood Mental Health
What is infant-early childhood mental health (I-ECMH)? Infant and early childhood mental health includes the
capacities for developing enjoyable, trusting relationships with others; experiencing, communicating, and
managing a range of emotions; and playing and learning. Nurturing relationships with loving, capable,
consistent caregivers provide the context for developing these abilities, which create the foundation for
continued growth and success across childhood and beyond (Cohen & Andujar, 2022).
Can infants and young children have mental health conditions? While positive early childhood experiences
promote strong emotional health, negative experiences can adversely impact brain development, with serious
lifelong consequences. Approximately 20% of young children experience emotional, relational, or behavioral
disturbances (Vasileva et al., 2021). However, when mental health concerns are identified early, there are
services that can redirect the course and place children on a pathway for healthy development. Research
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 60
demonstrates that early prevention and treatment is more beneficial and cost-effective than attempting to treat
emotional difficulties after they become more serious (Oppenheim & Bartlett, 2022).
How are mental health conditions diagnosed in infants and young children? Infants and young children have
unique developmental and relational experiences that must be considered when diagnosing mental health
conditions; because of this, the presenting symptoms of mental health conditions may be different for infants
and young children than older children, youth, and adults. Traditional classification systems designed for older
children and adults (like the DSM 5) often do not tend to reflect these differences.
Because of this, both CMS and SAMHSA recommended that I-ECMH clinicians use the DC:0-5, or the Diagnostic
Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, for the assessment
and diagnosis of children younger than age 6. First published in 1994 and updated in 2016, the DC:0-5 is a system
that was created to provide developmentally specific diagnostic criteria and information about mental health
disorders in infants and young children, considered in relationship to their families, cultures, and communities.
Apple Health mental health professionals are required to use the DC:0-5 for mental health assessment and
diagnosis of children younger than six. Providers can learn more about using the DC:0-5 on HCA’s webpage and
can also find free DC:0-5 training from the IECMH Workforce Collaborative.
What does I-ECMH intervention or treatment for a mental health condition look like? Infant early childhood
mental health treatment is designed to alleviate the distress and suffering of the infant or young child's mental
health problems and support the return to healthy development and behavior, specifically by empowering
parents to build strong caregiver-child relationships. Infant-early childhood mental health treatment is often
dyadic, which means it focuses on the relationship between two things – in this case, the relationship between
the child and the caregiver(s). Providers can learn more about IECMH treatment on HCA’s webpage.
WISE B-5
While WISe B-5 is similar to WISe for older children in many ways, there are a few key considerations for this
specialty area, outlined below.
Several webinars on providing WISe services to children birth through age five
are also available through the WISe Workforce Collaborative via The Bridge, and individualized coaching for
agencies on this topic is available through the WISe Workforce Collaborative.
CANS screening & assessment: When working with children birth through age 5, practitioners should use the
CANS B-5 Screening and Full Assessment, as it addresses the unique developmental considerations of this age
range. Currently, there is no WISe eligibility algorithm for the CANS B-5, so WISe eligibility for the B-5 population
is based on clinical judgment.
Cross-system partners: Key cross-system partners for the B-5 population may be different than for older
children and youth. While children younger than 5 may be enrolled in preschool, they may also attend other
early childhood education or childcare programs, such as Head Start or ECEAP. Other specialized programs for
children birth through five, such as home visiting, early intervention (ESIT), and Early Childhood Intervention
and Prevention Services (ECLIPSE), may also be key partners. Primary care providers (PCPs) play a key role in
the lives of many families of infants and young children, as there at least twelve recommended well child visits
from birth through five years of age. Lastly, programs and services that serve parents/caregivers may be
particularly important partners for working with families of young children; these services could include mental
health or substance abuse disorder treatment, domestic violence or housing insecurity services, or other
economic support systems like TANF, SNAP, WIC, or SSI.
Based on individual need, these potential cross system partners should be considered for participation on a
Child and Family Team (CFT) or at the least coordinated with for care planning. Not all formal supports will be
able to attend CFT’s, but the Care Coordinator should make every effort to include input from them into care
planning.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 61
The “identified client”: One of the defining features of I-ECMH is its focus on relationships; it is common in the
I-ECMH field to hear that “the relationship is the client.” For Medicaid billing purposes, however, a client is
defined as an individual, and for WISe, the client is defined as the child. While much of the work of I-ECMH
treatment may be done with family members, it is important to remember to structure documentation with
Golden Thread principles in mind, such that the “identified client” is the child. For example, interventions that
involve work with family members should be tied back to the child’s diagnosis and child-level outcomes in the
child’s Individual Service Plan (ISP).
Knowledge of developmental milestones: Developmentally appropriate services are important for everyone,
but birth through age 5 is a time of particularly great change and development for children; the brain forms
more than a million neural connections each second in the first years of life (Center for the Developing Child,
2007). It is important for WISe practitioners working with the B – 5 population to be familiar with the
developmental milestones of young children, and to understand the difference between what may be
developmentally appropriate, even if it may still be troubling to the caregiver, and what is out of expectation
with developmental milestones and may need intervention.
E. Intellectual or Developmental Disabilities Including Autism
Spectrum Disorder and WISe
HCA convened an ongoing stakeholder group, to include representatives from Northwest Autism Center, WISe
agencies, DDA, DCYF, MCPs, and families to identify additional guidance and considerations for WISe when
working with individuals who have Intellectual or Developmental Disabilities including Autism Spectrum
Disorder (ASD/IDD). This work began in August 2019 and will continue as needed. Information and resources will
be added and updated in future WISe manual versions as they develop.
Each Child and Family Team (CFT) will be made of relevant partner members who contribute to the overall plan
of care for each youth and family. Not all formal supports will be able to attend CFT’s, but the Care Coordinator
should make every effort to include input from them into care planning. A list is provided below of potential
partners to consider including on a child and family team, but this is not a complete or required list of potential
participants.
Potential Partners to include in the CFT and Cross System Care Plan
• Developmental Disabilities Administration (DDA) staff/Case Mangers
o More information on how to apply for DDA services can be found online at the Developmental
Disabilities Administration website.
• Applied Behavioral Analysis (ABA) therapy provider
o For access and more information on ABA therapy go to ABA therapy go to the HCA website
• Primary Care Provider
• School system and Special Education staff
• Speech Language Pathologist
• Occupational Therapists
• Physical Therapist
Trauma Considerations
People with Intellectual and Developmental Disabilities including Autism Spectrum Disorder experience trauma
at a higher rate than people without disabilities. Children with disabilities are three times more likely to be
victims of physical and/or sexual abuse and 2-3 times more likely to be bullied than children without disabilities
(Crime against People with Disabilities, 2009-2015 - Statistical Tables, 2020). In addition, people with disabilities
have frequent experiences such as people trying to “fix” them, being called names, multiple medical
procedures, and being frequently invalidated by others which can add up over a lifetime.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 62
When completing the CANS, make a special effort to determine what kind of trauma the youth may have
encountered which may be driving behavior. Use plain language to get at these concerns like asking “what kind
of unpleasant or traumatic experiences has the youth experienced, such as bullying, separation from family,
medical trauma, etc.”
Communication
Communication happens in multiple ways, not always exclusively with words-even youth who are non-verbal, or
have limited verbal ability to speak, communicate. It is important to spend time to learn about and make sure
everyone on the team understands the individual and how they express themselves. Spending this time is
crucial to getting accurate assessments and determining the impact of any interventions. WISe teams may need
to come up with creative solutions to ensure they are communicating with the youth in a way that makes sense
for the situation.
Other Considerations
Care coordination will likely be a large focus for teams when working with youth who have an Intellectual or
Developmental Disability including autism spectrum disorder. Families who have not yet accessed auxiliary
services may need assistance in seeking out and learning how to navigate complex systems. Families who are
already accessing these services may need assistance in coordinating the multiple systems and rules they
encounter. WISe teams will need to consider the amount of advocacy skills each family already has, and if
needed, assist them in learning how to increase family’s skills in advocating for themselves and their youth.
F. Partnering with Youth and Families Experiencing
Homelessness
DBHR in partnership with the Office of Homeless Youth, is working to develop best practice and resource
information for WISe teams in partnering with youth and families who are experiencing homelessness. This work
continues at the time of this manual update.
The following information is to help assist WISe agencies in supporting a youth who is experiencing
homelessness. WISe are still applicable to youth who are experiencing homelessness who meet WISe eligibility
criteria. Services may look different for them. Care coordinators and youth peers are vital in this process. Below
is information from HCA and the Office of Homeless youth:
From HCA:
Safe and supportive transition to stable housing for youth ages 16 - 25
From the Office of Homeless youth:
Crisis Residential Centers
Temporary residence, assessment, referrals, and permanency planning services provided in semi-secure and
secure facilities for youth ages 12 through 17 who are in conflict with their family, have run away from home, or
whose health and safety is at risk.
HOPE Centers
Temporary residence, assessment, referrals, and permanency planning services for street youth under the
age of 18.
Independent Youth Housing Program
Rental assistance and case management for eligible youth who have aged out of the state foster care system.
Participants must be between 18 and 23 years old, have been a dependent of the state at any time during the
four-month period preceding his or her 18th birthday, and meet income eligibility. Priority is given to young
adults who were dependents of the state for at least one year.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 63
Street Youth Services
Street Youth Services (SYS) connect youth under the age of 18 to services and resources through street and
community-based outreach. Services can include either directly or through referral drug/alcohol abuse
intervention, crisis intervention, counseling, access to emergency shelter or housing, prevention and education
activities, employment skill building, advocacy, family-focused services, and follow-up support.
Unaccompanied minor services
Young Adult Shelter
Emergency, temporary shelter, assessment, referrals, and permanency planning services for young adults ages
18 through 24.
Young Adult Housing Program
Resources for rent assistance, transitional housing, and case management for young adults ages 18 through 24.
• Please see their website for more resources and information
• Office Of Homeless Youth Provider List
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 64
Section 3: Background and additional information
In September 2021 a joint stipulation to dismiss TR settlement agreement was filed and the settlement
agreement has been satisfied.
A. Background: T.R. Settlement Agreement
Background
T.R. vs. Birch and Strange (formerly known as Quigley and Teeter), a Medicaid lawsuit regarding
intensive children’s mental health services for youth, was filed in November 2009. The lawsuit was
based on federal Early and Periodic Screening, Diagnosis and Treatment (EPSDT) statutes, requiring
states to provide any medically necessary services and treatment to youth, even if the services have
not been provided in the past. Washington State reached a settlement agreement with the
plaintiffs. With this settlement agreement, Washington has committed to build a mental health
system that will bring this law to life for all young Medicaid beneficiaries who need intensive mental
health services in order to grow up healthy in their own homes, schools, and communities.
Who is in the Class (and thus eligible for Wraparound with Intensive
Services)?
All persons under the age of 21 who now or in the future:
1. Meet or would meet the State of Washington’s Title XIX Medicaid financial eligibility criteria;
2. Have a mental illness or condition;
3. Have a functional impairment related to that mental illness or condition, which substantially interferes
with or substantially limits the ability to function in the family, school or community setting; and
4. For whom intensive mental health services provided in the home and community based would address
or improve a mental illness or condition.
Goals
To have a mental health system that will:
a) Identify and screen presumed (assumed to exist or to have existed) class members and link eligible youth to
the WISe program.
b) Communicate to families, youth and stakeholders about the nature and purposes of the WISe program and
services, who is eligible for the program, and how to gain access to the WISe program and services
regardless of the point of entry or referral source.
c) Provide timely statewide mental health services and supports that are sufficient in intensity and scope,
based on available evidence of effectiveness, and are individualized to each Class member’s needs
consistent with the WISe program model and state and federal Medicaid laws and regulations.
d) Deliver high quality WISe services and supports facilitated by a system of continuous quality improvement
that includes tools and measures to provide and improve quality care, transparency, and accountability to
families, youths, and stakeholders.
e) Afford due process to Class members denied services.
f) Coordinate delivery of services and supports among child-serving agencies and providers to Class members
in order to improve the effectiveness of services and improve outcomes for families and youth. Reduce
fragmentation of services for Class members, avoid duplication and waste, and lower costs by improving
collaboration among child-serving agencies
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 65
g) Support workforce development and infrastructure necessary for adequate education, training, coaching
and mentoring of providers, youth and families.
h) Maintain a collaborative governance structure that includes child-serving agencies, youth and families, and
other stakeholders.
i) Minimize hospitalizations and out-of-home placements.
j) Correct or ameliorate mental illness.
k) Reduce mental disability and restore functioning.
l) Keep children safe, at home, and in school making progress; avoid delinquency; promote youth
development; and maximize Class members’ potential to grow into health and independent adults.
m) Use available approaches that have been effective at achieving these outcomes.
B. WISe Terminology, Definitions, and Roles
Definitions
• WISe Interest List: A list of children and youth who have expressed interest in WISe, who have
completed a CANS screen with a result of "WISe recommended" or clinical override into WISe but are
not actively enrolled in WISe. Children and youth should be placed on the interest list as soon as the
CANS screen shows WISe is recommended or it is determined the CANS screen outcome will be
overridden, regardless of mental health intake completion. This is not to be considered a wait list, these
children and youth should be offered and receive state plan services timely. Wait lists are not allowable
by Medicaid.
Phases
• Engagement: Engagement is the process that lays the groundwork for building trusting relationships
and a shared vision among members of the Child and Family Team that includes the family, natural
supports and individuals representing formal support systems in which the youth is involved. Team
members, including the family, are oriented to the WISe process. Discussions about the youth's and
the youth and family's strengths and needs set the stage for collaborative teamwork within the
Washington State Children’s Behavioral Health principles.
• Assessing: Information gathering and assessing needs is the practice of gathering and evaluating
information about the youth and family, which includes gathering and assessing strengths as well
as assessing the underlying needs. Assessing also includes determining the capability, willingness,
and availability of resources for achieving safety, permanence, and well-being of youth.
• Teaming: Teaming is a process that brings together individuals agreed upon by the youth and family
who are committed to them through informal, formal and community support and service
relationships. Where medically necessary and/or with cross system involvement, a formal Child and
Family Team will be used.
• Service Planning and Implementation: Service planning is the practice of tailoring supports and
services unique to each youth and family to address unmet needs. The plan specifies the goals, roles,
strategies, resources, and timeframes for coordinated implementation of supports and services for
the youth, family, and caregivers.
• Monitoring and Adapting: Monitoring and adapting is the practice of evaluating the effectiveness of
the plan, assessing circumstances and resources, and reworking the plan as needed. The team is
responsible for reassessing the needs, applying knowledge gained through ongoing assessments,
and adapting the plan in a timely manner.
• Transition: The successful transition away from formal supports can occur as informal supports are
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 66
in place and providing needed support. Transition to activities and environments consistent with
the principle of treatment at the least restrictive level and the system values of recovery and
resilience.
Roles
Family - people who are committed, “forever” individuals in the identified youth’s life with whom the youth also
recognizes as family; a family is defined by its members, and each family defines itself.
Parent – biological, step or adoptive. If this is not applicable or unclear, the youth should identify who they
consider their parent.
Caregiver – a family member or paid helper who provides direct care for the identified youth.
Youth - the statewide-accepted term to describe children, adolescents, teenagers, and young adults.
Care Coordinator - a formal member of the WISe team who is specially trained to coordinate and facilitate the
WISe process for an individual youth and family and provide advanced care coordination activities within the
phases and activities of WISe. The Care Coordinator is typically the facilitator of the CFT, and ultimately
responsible for leading the team through the phases and activities of WISe both during and outside of the
meetings. The Care Coordinator contributes knowledge and skills related to making sure that the team process
honors each member’s role, responsibility and perspective. The Care Coordinator is qualified by completing the
WISe training, participating in technical assistance, and is involved in ongoing WISe training and coaching
activities. Generally, the Care Coordinator will:
• Facilitate CFT meetings
• Guide the team process
• Be the central point of communication
• Encourage each CFT member to identify their priority concerns, work proactively to minimize areas of
potential conflict, and acknowledge the mandates of others involved in child-serving systems
• Utilize consensus-building techniques to meet the needs of the youth and family
• Establish and sustain an effective team culture by inviting CFT members to propose, discuss, and
accept ground rules for working together
• Engage all CFT members and identify their needs for meeting agency mandates. The Care Coordinator
identifies the strengths and needs of the youth and family, provides CFT members with an overview of
CFT practice, and clarifies their role and responsibilities as a team member in this process
• Increase the “natural supports” in CFT membership and the youth/family’s integration into their
community. This is accomplished by getting to know the family history, culture, and resources, and by
helping the youth and family to identify and engage potential supports. Examples of natural supports
include friends, extended family, neighbors, members of the family’s faith community, co-workers. The
goal is to have more natural and informal supports on the team than formal supports.
• Work with the Youth Partner and/or Family Partner to identify family support, peer support or other
“system” and community resources that can assist the youth and family with exercising their voice in
the CFT process, if needed
• Prepare for meetings:
o Develop a meeting agenda with the youth, family, and other CFT members.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 67
o Schedule meetings at a place/time that is accommodating (comfortable and convenient) to the
youth and family and available to all CFT members
o Prepare visual aids or tools to facilitate the meeting process
o Inform all CFT members of the date, time and location of each meeting
• Contact CFT members who are unable to attend a meeting, in advance, to elicit their input
• Ensure all CFT members receive an updated copy of the CSCP, documentation of progress, CFT meeting
activities, discussions and task assignments within 7 days after the CFT meeting
• Maintain team focus on scope of work for the WISe team and progress/movement toward transition.
• Be sensitive to the needs of team members when working in rural areas where getting members
together physically may be challenging. The Care Coordinator is creative in establishing a team that
may meet via phone or through teleconferencing
• Ensure respect for the input and needs of the youth when forming the team.
• Inform the youth and family of their rights (including Due Process) and obtaining all necessary consents
and releases of information
• Acknowledge and celebrate successes and transitions
It is important to note that the team facilitation may change during the transition phase in order to
allow for family members and/or youth to become facilitators of their own meetings - depending
on what the family and team thinks works best.
The Mental Health Therapist- is a provider and resource for the WISe team. The majority of WISe-enrolled
youth will have clinical needs that may be met at least in part through the efforts of a skilled mental health
therapist. A mental health therapist is a person providing outpatient mental health services (as described in WAC
246-341) to a WISe enrolled youth. While confidentiality of the details of the therapist-client (i.e., family and/or
youth) relationship should be protected, the clinical professionals on the team also must have clearly defined
roles in terms of meeting needs in the plan of care. WISe therapists will provide effective treatment interventions
that build on the youth and family’s strengths, when therapy or some other mental health treatment is outlined
in the Cross System Care Plan. WISe therapists should be encouraged, trained and supported to learn and use
Evidence Based Practices (EBP). More information on reporting EBPs, including the most recent EBP reporting
guide can be found online at the HCA website. The role of the therapist in WISe is expanded upon in “The Role of
the Clinician Employed in a Wraparound Program” which can be found online at the National Wraparound
Initiative website.
The Family Partner - a formal member of the WISe team whose role is to serve the family and help them engage
and actively participate on the team and make informed decisions that drive the WISe process. They are
qualified through their lived, personal experience as the parent of a youth with complex emotional/behavioral
needs, hold a Certified Peer Counselor certification, and have participated in the full WISe training and technical
assistance and is involved in ongoing WISe training activities.
Family Partners have a strong connection to the community and are knowledgeable about resources, services,
and supports for families. The Family Partner’s personal experience raising a youth with emotional, behavioral,
or mental health needs is critical to earning the respect of families and establishing a trusting relationship that is
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 68
valued by the family. The Family Partner can be a mediator, facilitator, or bridge between families and agencies.
Family Partners ensure each family is heard and their individual needs are being addressed and met. The Family
Partner should communicate and educate agency staff on the importance of family voice and choice and other
key aspects of family driven care.
Family Partners should be encouraged and supported to establish and maintain strong connections within the
community. These strong community connections are vital to the Parent Partner role. One way to make sure the
Family Partners maintain strong community connections is through participation in community groups and
functions such as Statewide Family Network events; local, state, and national conferences; and Washington
State Community Connectors. There may also be local parent or advocacy groups not mentioned here which
would be a helpful connection for Family Partners.
The Family Partner has a collaborative relationship with the Care Coordinator, Therapist, and Youth Partner.
Together they establish mechanisms to keep each other informed, make sure the family partner knows when
new families are enrolled in WISe, as well as when and where team meetings will occur, ensure all newly
enrolled families have the opportunity to have support from a newly enrolled families have the opportunity to
have support from a Family Partner, if they choose. The Family Partner and Youth Partner roles are unique and
not interchangeable. In the absence of a Youth Partner, the Family Partner will not fulfill that role. The Family
Partner collaborates with the Care Coordinator to establish the trust and mutual respect necessary for the team
(including the family) to function well. Family Partners should be educated in how to utilize the CANS results to
support and educate the youth and family and are encouraged to be certified in CANS.
The Family Partner will:
• Be a biological/adoptive/step/foster parent, kin, or other “forever” person in the parent role – who has
been the primary caregiver of a youth with emotional or behavioral challenges.
• Be willing to use their own lived experiences to provide hope and peer support to other families
experiencing similar challenges.
• Commit to ensuring that other parents have a voice in the youth’s care and are active participants in the
WISe process.
• Share resources and information in an individualized manner so that families understand the WISe
process and have access to information regarding their child’s care.
• Engage and collaborate with people from diverse backgrounds.
• Maintain a non-judgmental attitude towards youth, families and professionals. Ability to maintain a
stance of appreciation and acceptance of parents, including their choices.
• Certified as a Peer Counselor and have training in WISe when serving as WISe Provider Agency staff.
• Provide consultation to family members as the family learns new skills to support the youth’s treatment
The role of the Family Partner in WISe care coordination is fully spelled out in “How family partners contribute to
the phases and activities of the wraparound process,”
The WISe Practitioner – a term used interchangeably to describe the collection of WISe-certified staff roles,
required for each team (the Care Coordinator, the Family Partner and/or Youth Partner, and the Mental Health
Therapist).
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 69
The Youth Partner – a peer with lived experience as a youth who is an equal member of the WISe team. The role
of the Youth Partner is to partner with youth to help support their engagement and active participation in
making informed decisions to drive the WISe process. The Youth Partner is a mediator, facilitator, and cultural
broker between youth and agencies. A Youth Partner has lived experience in mental health, substance
abuse/recovery, incarceration/juvenile justice, foster care, education, homelessness or identify as LGBTQ+. They
provide support services to youth and young adults in community-based settings. They deliver a wide range of
services to help young people gain control over their lives and create change in their communities. Youth
Partners are role models for competency in recovery (in mental health, addictions etc.) and ongoing coping
skills.
Youth Partners utilize their lived experience and connection to communities and the peer movement to bring
resources and informal supports to the CFT. Youth Partners work in collaboration with the other WISe
Practitioners. Youth Partners ensure each youth is heard and their individual needs are being addressed and
met. The Youth Partner communicates with and educates agency staff on the importance of youth voice and
choice, and the power and benefits of peer involvement- particularly in transition age youth. Youth Partners
serve as peer advocates to help empower youth in gaining the knowledge and skills necessary to be able to
guide and eventually drive their own treatment. Youth Partners should be educated in how to utilize the CANS
results to support and educate the youth and family, and are encouraged to be certified in CANS. Youth Partners
will:
• Be a person with lived experience as a participant in Youth Behavioral Health Services and other
involvement in cross systems.
• Be willing to use their own lived experiences to provide hope and peer support to other youth
experiencing similar challenges.
• Demonstrate leadership experience and diplomacy in resolving conflicts and integrating divergent
perspectives.
• Have knowledge of community resources and supports
• Build relationships with community members and organizations to connect the youth with resources.
• Be able to share resources and information in a developmentally appropriate way to ensure that youth
understand the WISe process and have access to information regarding their care.
• Be committed to ensuring that youth have voice and choice in their own care and are active
participants in the WISe process.
• Be certified as a Peer Counselor and have training in WISe when serving as WISe Provider Agency staff.
• Provide consultation to the youth and the youth’s family members as the family learns new skills to
support the youth’s treatment
Youth Partners should participate in activities with the youth that pertain to the youth’s goals and treatment.
Some examples include:
• Providing self-esteem building activities
• Taking the youth to a music or art studio. Engaging in the activity with the youth is important.
• Asking the youth what they like to do and taking interest in activities that are of interest to the youth
• Linking youth to leadership trainings, Family, Youth, System Partner Round Tables (FYSPRTS)
committees and councils.
• Connecting the youth to education, housing and other prosocial activities.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 70
Note: Additional information for Youth Peers can be found online in the Youth Peer Toolkit
Practice Considerations and Potential Conflict
The National Wraparound Initiative views the Family Partner, Youth Partner, Care Coordinator and Mental
Health Therapists four distinct, full-time roles. Placing these roles together may result in none of them being
done well. There is also a distinct difference in the role of coordination/ facilitation, support and a specific
therapeutic treatment modality. A person acting as both mental health therapist and care coordinator puts
them in the position of having dual roles. This has been known to result in confusion, conflicts and frustration
for families, youth and team members.
WISe Supervisor – an individual responsible for supervising WISe practitioners and who fully understands WISe
policies, procedures and mandates. Equally important, a WISe supervisor should have experience in the role in
which they are supervising, have received specific training in being a high-quality supervisor, and use a
structured, directed model for supervision including observation of practice and review of records.
WISe Agency Administrator – a champion for WISe, providing the appropriate level of support and flexibility for
this work aligning it with other agency books of business and the system of care.
Child and Family Team (CFT) - A group of people – chosen with the family and connected to them through
natural, community, and formal support relationships – who develop and implement the family’s plan, address
unmet needs, and work toward the family’s vision and team mission, monitoring progress regularly and using
this information to revise and refine the comprehensive care plan. The CFT must include the youth (or caregiver
of a young child) and parent/caregiver/family member. A youth over the age of consent must be invited to
attend CFT meetings and agree to the membership of that team. As the team matures, membership should
expand to include formal and natural supports with the long-term goal of replacing formal supports with natural
supports.
Family Organization - a family run and family led grass roots, non-profit community organization providing
connection, empowerment and education to families and their communities to assure improved outcomes for
youth experiencing significant behavioral health challenges and to fulfill a significant role in facilitating
family/youth voice in local, state and national policy making.
Managed Care Plan (MCP) – encompasses managed care organizations (MCO’s) and Behavioral Health services
only (BHASO) contracted through the Apple Health managed care delivery system.
Youth Organization - a youth-led non-profit organization dedicated to improving the services and systems that
foster and promote positive growth of youth and young adults by using peer support and uniting the voices of
individuals who have lived through and experienced obstacles in child-serving systems. Typically focus on
activities such as increasing youth participation in service planning, delivery, coordination and evaluation;
awareness of challenges young people with cross-systems needs face as adolescents and young adults; and
youth involvement in community councils/organizations.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 71
Documents
Child and Adolescent Needs and Strengths (CANS) - a communication tool developed for children’s services to
support decision making and service planning, to facilitate quality improvement initiatives, and to allow for the
monitoring of outcomes of services. CANS was developed from a communication perspective to facilitate the
linkage between the mental health assessment process and the design of individualized service plans including
the application of evidence-based practices. All CANS (screen and full) must be performed by CANS certified staff
and entered in the Behavioral Health Assessment System (BHAS). CANS info is available online.
Child and Family Team Meeting Minutes (CFT Minutes) - A document that captures the details of a Child and
Family Team meeting including a list of team members present, ground rules, family vision, team mission,
strengths, needs, outcomes, action items and next team meeting date and time.
Crisis/Safety Plan/Support Plan - A family-friendly, 1-2 page document that the CFT creates to address
potential crises that could occur for the youth and their family and to ensure everyone’s safety. It should include
24/7 response, formal and natural supports/back-up care, details of what leads to crises, successful strategies
that have worked in the past, as well as strengths.
Cross System Care Plan - An individualized comprehensive plan created by a Child/Family Team that reflects
treatment services and supports relating to all systems or agents with whom the child is involved and who are
participating on the CFT. This plan does not supplant but may supplement the official individual service plan
that each system maintains in the client record.
Individual Service Plan – A document that outlines the progression and planning of an individual’s treatment.
WISe Training and Coaching
Training - An expert-led educational experience designed to introduce or reinforce a theoretical framework.
May occur live or in virtual settings.
Coaching - An intentional process designed to help staff apply information learned in training in real world
settings. It is a future-oriented intervention that leverages staff knowledge and experience to enhance critical
thinking and build generalizable skills. Coaching is collaborative; goals are grounded in competencies
associated with desirable practice standards.
Supervision - A directive process designed to enforce agency policy and procedures, monitor and ensure
compliance and facilitate improvement in specific areas of practice.
WISe Planning Elements
Youth and Family Vision - A statement constructed, elicited from the family with only the youth and family’s
voice and describes how they wish things to be in the future (including long-term goals, hopes and dreams),
individually and as a family. Youth and Family Vision is the long-term, overarching goal of the family as identified
and described by them.
Team Mission - A statement crafted by the CFT that provides a one to two sentence description of what the
team needs to accomplish while they are together and to know when WISe services have been completed.
The Team Mission describes the pre-determined end point of WISe as described by the family and members of
the CFT. Mission statements are written in the present tense, as if they were true today.
Strengths - Strengths are the assets, skills, capacities, actions, talents, potential and gifts in each family
member, each team member, the family as a whole, and the community. In WISe, strengths help youth, family
members and others to successfully navigate life situations; thus, a goal for the WISe process is to identify and
promote these strengths and to use them to accomplish the goals in the team’s plan of care.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 72
Needs - Anything that is necessary, but lacking. A need is a condition requiring relief and something required or
wanted. Needs are not considered services. Needs are essential requirements of life that, when left unmet, can
create a gap or void that causes behavior to occur.
Outcomes - Youth, family and/or team goals stated in a way that can be observed and measured as indicators of
progress related to addressing an identified need.
Strategies - Ideas, plans and/or methods for achieving the desired outcome. When coming up with strategies in
the WISe process, a brainstorming process is applied.
Action Steps - Statements in a Cross System Care plan that describe specific activities that will be undertaken,
including who will do them and within what time frame.
Peer Support – State certified peer counselors who work with their peers, mental health consumers and the
parents of children with serious emotional disturbances. They assist consumers and families with identifying
goals and taking specific steps to achieve them such as building up social support networks, managing internal
and external stress, and navigating service delivery systems.
Services and Supports
Formal supports - Services and supports provided by individuals who are “paid to care” under a structure of
requirements for which there is oversight by state or federal agencies or national professional associations, or.
Informal supports - Supports provided by individuals or organizations through citizenship and work on a
volunteer basis under a structure of certain qualifications, training and oversight.
Natural Supports - Individuals or organizations in the family’s own community, kinship, social, or spiritual
networks, such as friends, extended family members, ministers and neighbors who are not “paid to help.”
C. Service Array and Coding
The Service Encounter Reporting Instructions (SERI) provide Apple Health Managed Care Plans (MCP) and the
Behavioral Health Administrative Services Organizations (BH-ASO), and all BH providers in licensed community
mental health clinics/licensed behavior health agencies assistance for reporting behavior health service
encounters. These instructions describe the requirements and timelines for reporting service encounters,
program information and assignment of standardized nomenclature, which accurately describes data routinely
used in the management of the public behavior health system.
For service array and coding, follow the most recent Service Encounter Reporting Instructions. The Service
Encounter Reporting Instructions (SERI) can be found online.
For technical specifications related to encounter submission, follow the most recent Encounter Data
Reporting Guide. The Encounter Data Reporting Guide (EDGR) can be found online.
Updated policies and procedures on the use of telemedicine can be found online in the Telemedicine policy and
billing guide (wa.gov).
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 73
D. WISe Attestation(s) for Managed Care Plans and Tribal
Behavioral Health
To become an approved WISe agency, a completed attestation form must be submitted to HCA for review and
approval. Forms are submitted by a Managed Care Plan or from a Tribal Behavioral Health Agency. On the
following pages are example form templates: 1) for MCO and 2) for Tribal Behavioral Health Agencies. These
forms are available for download online.
WISe Attestation for a Managed Care Plan (MCP)
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 75
E. Washington’s CANS Algorithm
7/24/14
A child will be recommended for Wraparound with Intensive Services (WISe) if:
Criterion 1 AND (Criterion 2 OR Criterion 3)
Criterion 1. Behavioral/Emotional Needs
1a. Rating of 3 on “Psychosis” OR
1b. Rating of 2 on “Psychosis” and 2 or 3 on any other Behavioral/Emotional Needs item OR
1c. 2 or more ratings of 3 on any Behavioral/Emotional Needs items OR
1d. 3 or more ratings of 2 or 3 on any Behavioral/Emotional Needs items
Note: Behavioral/emotional needs items we plan to include in our screener: Psychosis; Attention/Impulse; Mood
Disturbance; Anxiety; Disruptive Behavior; Adjustment to Trauma; Emotional Control
Criterion 2. Risk Factors
2a. Rating of 3 on “Danger to Others” or “Suicide Risk” OR
2b. One rating of 3 on any Risk Factor item OR 2 or more ratings of 2 or 3 on any Risk Factor item
Note: Risk factors included: Suicide Risk; Non
‐
Suicidal Self
‐
Injury; Danger to Others; Runaway;
Criterion 3. Serious Functional Impairment
3a. 2or more ratings of 3 on “Family”, “School”, “Interpersonal” or “Living Situation” OR
3b. 3 or more ratings of 2 or 3 on “Family”, “School”, “Interpersonal” and “Living Situation”
F. WISe Example Templates
Below is a sample from the example Crisis Plan Template adapted from a template provided by En Route with
input from the WISe Training Advisory Group. The template is presented as an example of what a WISe Cross
System Care Plan that includes all the required elements might look. However, it is not required that agencies
use this format. The full template is available on the WISe website on the WISe provider resource page.
An example Cross System Care Plan template can also be found online.
WISe Manual Update for version (MM/DD/Year)
Section
Update
Introduction
•
Update to language to reflect continuation of the
format and for clarity
Children’s Behavioral Health Principles
•
Removed list of principles and definitions from
the manual and linked to the information on the
HCA website.
WISe Service Delivery, Policy, Procedure, and Resource Manual
2/20/2024
Page | 76
Agency infracture
• Updated required certifications to match new
DOH BH Certifications available as of 5/2023
• Added list of services that are include under the
new certifications
• Updated links
• Language edits for clarity of WISe agency
expectations throughout section
• Added information about the CANS and updated
CANS timelines requirements and information on
BHAS and CANS
WISe Access Protocol
• Clarify language around how to refer youth to
WISe
• Added a WISe referral must be made by a MCO
when a youth is discharging from CLIP
• Added WISe Interest List Quality Improvement
Monitoring expectations
Phases of WISe
•
Language edited for clarity and readability
• Added clarity around expectation that CANS is
completed in collaboration with youth and
family
Crisis Delivery
• Added note about Mobile crisis and WISe
Governance and Coordination
•
Language update to reflect current structure and
name of legislative groups and to add clarity in
the FYSPRT Governance Structure Component
Descriptions
Quality Plan
•
Update on the use of the Quality Improvement
Review Tool
Training and Coaching Framework
•
Updated training list
Section 2
• Content edits to WISe and BRS Concurrently
• Content edits to Birth-Five
Section 3
•
Removed T.R. Settlement Agreement
• Removed information around COVID-19 special
billing
• Added link to telemedicine billing guide
• Updated WISe Attestation forms and added link
to fillable form on HCA website
• Added link to WISe example form templates on
HCA website
