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FOCUS is an evidence-informed care coordination/planning practice.

The nature of complex problems suggests that we cannot give definitive answers about the best way to approach many issues facing families and communities, and so the term evidence-informed practice is used rather than “evidence-based” or “promising practice” to emphasize that there is a difference between care coordination/planning approaches and clinical interventions. Remaining committed to system of care values and principles, practitioners need to do more than ensure access to interventions: they need to actively approach their work in a fundamentally different way. An Evidence-Informed Practice (EIP) is a model that incorporates best available research evidence; youth and family’s needs, values, and preferences; practitioner wisdom; and theory into the care planning process filtered through the lens of youth, caregivers, agency, and community culture.

FOCUS was designed to support decreased system involvement while working to build connections and supports for families through community-based resources.

FOCUS was created to revolutionize traditional case management models and operationalize values within a System of Care framework for youth and their families with lesser or intermediate complexity of needs.

FOCUS is an intermediate care coordination model based on a 3-tier system that includes intensive care coordination (aka Wraparound), intermediate care coordination (aka FOCUS), and navigation (information, warm referrals and handoffs).

What is FOCUS?

Intended Population

FOCUS is intended for youth with lesser complex needs, who are system involved, at risk of deeper or multi-system involvement, and whose challenges exceed the resources of a single organization. FOCUS provides an essential component of a system of care for families that may not otherwise receive adequate or appropriate care coordination.


Most person-centered practice models adhere to a set of values and principles associated to the work. These four components are the grounding force behind the evidence-based component of FOCUS.


What does FOCUS stand for? 


FOCUS is designed specifically to serve families who have come to the attention of child welfare, juvenile justice, and/or behavioral health agencies. Best practice in the field details that the “core practice” of a model should include specific definitions of how the practice unfolds at the level of daily interactions with families (Bartley at al, 2020). It should also provide detailed descriptions of the types of behaviors, activities, and strategies that workers, and key partners in communities and systems can use in partnering with families (Bartley et al, 2020). FOCUS practice components align with best practice expectations in care coordination/planning.


In the FOCUS model, care coordinator to family ratios are small and work best when maintained at 1 care coordinator to 15-17 youth/families. Care coordinators work to ensure urgent needs of youth and their families are met by developing a comprehensive understanding of the current situation and supporting families in achieving their best lives rather than containing problems. Families deserve support that is helpful and relevant to their most pressing concerns. Care coordinators are supported through strong supervision practices and expert coaching designed to put families at the center of decision making and partner with them to attain the best outcomes. We center youth and families in our work, ensuring their voices are heard and they have choice and access to care that is relevant to their present situation and longstanding needs.

What will be different for our organization and families when we implement FOCUS?

  • Families get the level of services/support that they need and deserve

  • Care coordinators cultivate authentic partnerships with families that drive the planning process

  • System of care values are embedded and honored throughout day-to-day care coordination, supervision, and coaching activities

  • Consistent monitoring and adjustment of plans contributes to increased positive outcomes for families

  • Broadened community service array results as robust connections are built between each family and natural supports/relevant community resources

"In Nevada, the Division of Child and Family Services works with families with varying levels of needs. With the implementation of FOCUS, Nevada has created a Tiered Care Coordination service delivery model. This approach allows families to receive the right level of intervention at the right time. FOCUS, an intermediate care coordination model, provides families the individual support needed and works to eliminate the need for more intensive interventions."

- Kathy Cavakis & Beverly Burton, Nevada Division of Child & Family Services, December 2020

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