Pathways to Sucess Care Coordination and Support

Position Title

Pathways to Success Care Coordination and Support

Behavior Health Services

Pathways to Success Program Supervisors

Pathways to Success Contacts and Referral Sources

Pathways to Success is a State of Illinois initiative to provide comprehensive care coordination that will enhance access to critical behavioral, medical and social services for children with complex behavioral health challenges. The program utilizes the evidence‑informed Care Coordination and Support model. This is a structured approach to care coordination that adheres to required procedures for child and family engagement, individual care planning, identifying and utilizing strengths and natural supports while monitoring progress and fidelity to the required processes.

Care Coordinators assist the families in navigating the complex systems of care until they can navigate them on their own.

Under the direction of the Pathways to Success Supervisor, the Care Coordination and Support:
High Fidelity Wraparound (CCSW) takes primary responsibility for making the wraparound process happen for children with a mental health diagnosis and their families through facilitation of Child and Family Team Meetings, coordination with professionals, and helping the child meet their goals. CCSW is provided to children stratified into Tier 1. Designated CCSW Care Coordinators work with an average of 10 families at a time and are never assigned more than 12 families  CCSW helps the family develop a positive view of their future and learn how to use the strength‑based empowerment model to improve functioning in the home, school, and community.

• Perform outreach & engagement to locate, engage, and educate Pathways youth and their families.
• Use a trauma‑informed approach to effectively engage children/youth with significant behavioral health needs and their family/caregivers to resources within the community for their assigned caseload.
• Facilitate high‑fidelity wraparound services for families: utilize a strengths‑based approach to safety planning, development of family team and family support systems, and wraparound planning for the purpose of maintaining children in their homes, schools, and communities.
• Schedule, plan, and facilitate Child & Family Team Meetings.
• Build and maintain knowledge of available community resources and help link youth and family to needed supports.
• Provide regular communication and close collaboration with multiple community partners.
• Assist families to coordinate services from community resources, placement providers, collateral agencies, the court, and/or other community partners with families, clients, or patients receiving services.
• Collaborate with local MCR agencies, including UCAN’s BHS MCR team, when necessary.
• Facilitate the creation of safety and crisis prevention plans.
• Utilize UCAN’s BHS Care Coordination Model with every individual and family served.

• Effectively apply clinical knowledge to evaluate client situations and needs.
• Identify at‑risk clients and behaviors before serious acting‑out occurs.
• Successfully engage and develop rapport with a wide range of clients.
• Structure services in accordance with program expectations.
• Maintain consistency and safety throughout service provision.
• Guide decisions based on clinically appropriate, best practice, and ethical considerations.
• Seek case consultation.

• Follow all applicable regulatory standards, including COA standards, Pathways to Success policy and procedure, and Medicaid procedures.
• Clearly document actions taken (clinical, supervisory, and administrative) in a timely manner and in a format consistent with requirements.
• Ensure that all data entry is complete, accurate, and updated as required by program standards.
• Prepare and distribute reports and correspondence in a timely manner.

• Develop and maintain professional relationships with social service and government agencies and private organizations to enhance service…