Since 2013 White Earth Nation has transferred human service cases for tribal members and their families from delivery by Minnesota counties. In order to provide the best services the Tribe developed the White Earth Coordination, Assessment, Resource and Education (WE CARE) case management model. This system of care model is a client-focused, client-driven model that requires client input and involvement. WE CARE focuses on program collaboration and communication to develop and execute an interdisciplinary plan based on the goals that the client wants to work on. WE CARE utilizes RiteTrack to enable assessment, collaboration, plan development, and outcome tracking.

White Earth Coordination, Assessment, Resource and Education (WE CARE) is a coordinated and holistic case management approach seeking to assure the long-term well-being of children, families and communities. WE CARE’s goals are to

• decrease duplication while increasing access to services
• increase client referrals
• enhance access to resources for clients
• increase communication and coordination between tribal programs through innovative technology

A primary goal of WE CARE is for services to be client-driven, and success is defined by the client as well.

White Earth Nation recognized that while there were services available to clients, the administration of these services was often ineffective and inefficient. Programs did not communicate and services were not prioritized. Clients could be left feeling confused and overwhelmed, and while a program may claim “success,” the client did not feel successful. The WE CARE model seeks to enhance collaboration between tribal programs, non-tribal programs, community and family in order to address the physical, mental, spiritual and emotional needs of clients. WE CARE relies on client input to direct outcomes, define goals , and determine how success will be defined. The WE CARE Plan, developed with the client, may include services from Child Protection, Child Care/Early Childhood, Head Start, Employment, Education, Mental Health, Substance Abuse, and more.

WE CARE leverages RiteTrack in order to enable collaboration, communication and outcome reporting for this interdisciplinary approach. The process begins with the client signing a Universal Release giving permission allowing data entry of a Universal Intake form into the database system. The Universal Intake is completed in RiteTrack and automatic notifications are sent to programs which are identified as applicable to the needs of the client. These are delivered via secure email with a live link to the record in RiteTrack. Identified programs then individually call the client to offer services, which the client can accept or deny. Any program whose services the client accepts will become a part of the WE CARE team for that client. All team members sign a Legal Confidentiality Form defining responsibilities for sharing information about the client and plan. The WE CARE team and client then develop a WE CARE plan based upon the needs identified in the Universal Intake Form. This WE CARE plan is defined in RiteTrack and includes detailed views of goals, strategies, staff assistance, notes and assigned programs. The WE CARE plan is printed and shared with the client for review and sign-off on the goals and empowerment strategies developed. The plan is updated in RiteTrack throughout service provision and outcomes are tracked. Information reported from the system is then used for federal and state grants as well as communication of outcomes to Tribal Council and the community.

The WE CARE model was developed by a specially chosen development team that created the process and model. Included in this development was the creation of a Universal Intake form, confidentiality form, and WE CARE plan. Additionally, an educational curriculum for staff regarding WE CARE was created to ensure the model was understood and administered effectively. The development team proposed recommendations for the WE CARE Advisory Board, an entity that works to support the program for both staff and clients. Then a public relations campaign was initiated to inform the White Earth Nation about WE CARE and the services it offered. Because of comprehensive and thoughtful planning, the WE CARE model was given the best chance for a successful implementation.

A WE CARE Advisory Board was established based on the Development Team’s recommendations to support and strengthen case management teams. The Advisory Board is comprised of division managers, not WE CARE team staff, and represents WE CARE on several fronts. It acts as a liaison with WE CARE clients and other constituents using this communication to monitor and strengthen services provided.It also provides feedback to Tribal Council and ensure adequate financial resources to support the program.

Through thoughtful, interdisciplinary planning, careful execution and comprehensive support, the WE CARE program has become an exceptional model for comprehensive service delivery to children and families in Indian Country. The WE CARE model uses best practices and collaboration between programs and clients to ensure the best outcomes. The program has developed innovative ways of utilizing technology to enhance collaboration, communication and reporting and to safeguard funding while providing sustainability for the program.

Jennifer Stevens, RN, PHN, White Earth Nation Home Health Agency Manager and Casey Bader, Vice President at Handel IT, will be presenting on the WE CARE model at the upcoming NICWA Conference, April 19 – 22, in Portland, OR.