DSS Liaisons Making a Difference: Cabarrus County

Cardinal Innovations Healthcare — August 5, 2021 — 4 min read
The Department of Social Services (DSS) had been involved with Chelsea’s* family for months. Even though Chelsea was receiving mental health services, her behavior wasn’t improving.

DSS was at a loss. But then we launched our DSS liaison program.

*All names have been changed to protect privacy.

Chelsea’s Story

Our Cabarrus County DSS liaison learned of Chelsea’s case through the DSS prevention team. Because of her behavioral health challenges, Chelsea was at risk of entering foster care.

“I jumped in and just tried to assess the situation,” the DSS liaison said. “What was she participating in? What was going well? What was the family struggling with?”

He learned that Chelsea would steal her grandmother’s car. She was verbally aggressive. And she refused to participate in school.

Meanwhile, her grandmother Joan faced age-related health issues. Joan’s partner, Dan, was in the early stages of dementia. So, as both Chelsea and Dan’s symptoms worsened, Joan’s caregiving responsibilities grew.

“Whenever we have grandparents raising teenagers—it comes with its own set of challenges,” the liaison said. Joan was experiencing severe caregiver burnout.

Furthermore, Chelsea’s main support service, Day Treatment, wasn’t working for her. She wasn’t participating in her therapy sessions. And the provider wasn’t sure how to move forward. So, our liaison took action.

Connecting Chelsea to the Right Service

A clinician himself, the DSS liaison evaluated Chelsea’s behaviors and then contacted one of our providers that offers Multi-Systemic Therapy (MST). MST targets the kind of behaviors Chelsea struggled with the most. It’s designed to help prevent kids from entering the juvenile justice and/or child welfare system.

A Race to Prevent Foster Care

When a child gets connected to a new provider, they receive a Comprehensive Clinical Assessment (CCA). However, it can take weeks to schedule a CCA, and Chelsea couldn’t start treatment without it. So, our liaison knew he had to move quickly—DSS was preparing to take custody of her.

“We got down to the wire,” he said. “We were either going to get Chelsea into MST in a week—or in a month. So, I just encouraged the provider to see the fragility of the situation.”

His encouragement worked. Chelsea received her CCA that week and began treatment shortly after.

The “Best” Child and Family Team Meeting Ever

Back when Chelsea was in Day Treatment, she and her family met with their Child and Family Team (CFT) every month. CFT meetings allow the family and their support system to set goals and plan services. The team usually includes:
  • The child
  • The child’s family members and/or caregivers
  • The family’s assigned social worker (from DSS)
  • Clinicians who closely support the child and family
  • Any other person who is involved in helping the family thrive
Before this point, DSS was seeing little progress during the CFT meetings. Joan and Dan were the only family members who attended. Joan also felt like she didn’t have any other family or friends willing to support them.

But then Chelsea began the new treatment. And in May, her MST therapist joined her CFT meeting for the first time.

“DSS told me it was the best CFT meeting they ever participated in,” the liaison said. “There were about 12 people there, and the MST clinician got the entire family to participate. It was just phenomenal.”
Information & Resources

Learn more about our Child Program.

A Behavioral Health Journey Is Not a Straight Line

Chelsea’s behavior started to change, and the family was finding hope. However, after a couple months, Joan and Dan faced caregiver burnout again. They weren’t participating as much in CFT meetings.

Their exhaustion impacted Chelsea’s progress. “We saw some increase in behaviors,” our DSS liaison said.

So, to give the family a much-needed break, he helped DSS temporarily remove Chelsea from the home. This kind of short-term removal is called “respite.”

A DSS Liaison’s Unyielding Faith

Everyone, including MST and DSS, soon believed that Chelsea would need residential treatment—that this temporary solution would turn permanent.

But the DSS liaison pushed back. “You can still do MST while she’s in this respite home,” he told the provider and DSS, urging them to give Chelsea a chance to improve.

That was a month ago.

“Now she’s doing amazing at her respite home. She’s following all the rules, doing her chores, participating in therapy. Doing absolutely everything right,” he said. “That was not the case a few months back.”

Joan and Dan are also getting the rest they need.

What’s Next for Chelsea

It’s normal to face lots of ups and downs in a health journey like Chelsea’s. That’s why our DSS liaisons exist: to be our members’ greatest advocate—especially during their downs.

“We did have a little bump in the road,” our liaison said. “But the team got together and fully supported Chelsea and her family. And now we’re working on a plan to get her back home.”
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