The impetus for this initiative was a tragic case of a baby who was injured by her parents. A lot of different services had been involved with the young parents and family. Staff were not aware of the involvement of other services and the care plans for the family and baby.
When we reviewed this case we identified three key things we need to do to help support vulnerable families:
- plan care carefully together
- communicate clearly
What have we done?
We put together a steering group to help develop a Vulnerable Families Forum. Our programme was honoured by the gifting of a name from Māori health - Te Aka Ora (the vine of wellness).
The Steering Group consisted of a wide range of representatives:
- Maternity services
- Social Work
- Child Protection
- Maori Health
- Maternal mental health
- Community Alcohol & Drugs (CADS) pregnancy and parenting services
- Community mental health
This allowed us to debate complex privacy and confidentiality issues and develop a clear understanding of how we can share information and protect and support vulnerable families.
Te Aka Ora steering group
Referral process for forum
The Steering Group developed a process to help lead maternity carers (midwives, obstetricians and general practitioners) identify concerns and make a referral to the forum. A set of triggers for referral was developed. The triggers have been disseminated widely to maternity clinicians and others, and referrals now come to the forum from a variety of sources, including public health workers, Child, Youth and Family Service staff, social workers, mental health services and lead maternity carers.
The lead maternity carer’s concerns are discussed at the forum and any other information held by different agencies can also be shared and their knowledge pooled. The information is then used by the forum to develop a plan of care to support the family. This includes identifying a key worker who will ensure the plan is carried out and reviewed.
The forum meetings are structured and produce concrete actions that can be monitored and updated.
The forum is now receiving 4-5 new referrals per week. There has been a positive response from lead maternity carers and other agencies.
Triggers for referral
The triggers or referrals are factors known to be associated with poor attachment and poor outcomes for children.
Some families will have a trigger but will also have strengths that counter that risk. The triggers include:
- current or past Child, Youth, and Family Service involvement
- family violence concerns
- drug and alcohol concerns
- criminal offending or behaviour concerns
- mental health concerns
- concerns regarding previous trauma
- cognitive impairment
- concealed / unwanted pregnancy
- attachment concerns
- transient lifestyle
- teenage parents
- poor engagement with maternity care
How it works
The process of referral to the Vulnerable Families Forum is designed to help the lead maternity carer (LMC) to identify concerns and easily make a referral to the forum.
The forum members are informed in advance that a case is being discussed and will bring information known to their service to the meeting so that knowledge can be pooled.
The lead maternity carer attends the forum and participates in the development of a care plan.
Te Aka Ora - Vulnerable Families Forum referral process
Did we make a difference?
Midwives / lead maternity carers tell us...
Forum members tell us...
Winner in "Excellence in integrated care" category for Waitemata Health Excellence Awards 2012