Introduction to the ISM


The purpose of this course is to familiarize you with the Integrated Services Model (ISM), our framework for service delivery at Uplift Family Services.  

When you finish you will be able to:

The Purpose of the ISM


The Integrated Services Model (ISM) is our framework for service delivery at Uplift Family Services.  The ISM Diagram is a visual representation of this framework and illustrates how the process works from start to finish within our agency.  To best meet the differing needs of the children and families we serve as well as our community partners, a second diagram, the Steps of Service (SOS) was created outlining the different steps in the process.  The ISM Diagram is a complete and detailed version while the SOS Diagram is streamlined.

In addition to the two diagrams, two tools were developed to aid staff in partnering with families to strengthen engagement and facilitate authentic and effective participation in services.  These are the Shared Understanding Cards and the Action Planning Cards.  While there are many other agency tools you will use in the scope of your work with youth and families, the focus here will be on giving you the chance to familiarize yourself will these specific tools and get some ideas of how you can use them in the context of your individual role. 

Below is the detailed version of the ISM Diagram.  Take some time and review it before moving on to the next section.  

Another way to think of the ISM is a clear and comprehensive agency-wide road map of what we do.  

  • It gives us a structure to understand how our tools, services, principles, etc. all fit together
  • It brings uniformity to our service delivery
  • It provides a common language and promotes effective communication
  • It supports quality improvement and training efforts
  • It helps families know what to expect
  • It aids staff and supervisors in problem-solving when progress is poor

What purpose does the ISM serve for our agency? (Check all that apply.)

  • It integrates the many aspects of service delivery into a single agency-wide framework that supports training, supervision and quality improvement efforts.
  • It helps direct service staff, youth and families create effective and individualized service plans.
  • It facilitates communication and improves understanding within teams.
  • It provides a checklist of Do's and Don'ts for staff to follow in how they serve families.
  • It serves as a tool to monitor progress and trouble-shoot when problems arise within teams.

The ISM Diagram

A Framework for Understanding the Service Process

Phase 1: Contact

The quality of the initial contact we have with the youth and families we serve has the potential to set the trajectory of all our future work with them.  How we enter into this helping relationship in addition to our ability and commitment to providing timely access to services will set the tone for the more challenging work to come.

Our agency is currently in the process of developing some self-assessment tools for youth and families to use in the beginning stages of service to support them in identifying their needs and the direction they want to go with services.  (More to come on that...)

Phase 2: Engage and Stabilize

Beginning with our initial contact with a youth and/or family, the crucial work of engagement and stabilization has begun.  Keep in mind that while this step is at the beginning of the service delivery process, it continues throughout the course of services.  It is here that we establish trust, identify our purpose, and share hope.  Safety concerns that are impacting the stability of the family are addressed in the beginning and are revisited and attended to throughout the course of services.

While this phase occurs at the beginning of our work with families, it is never done.  We are always working to strengthen the engagement of families, natural supports and child and family team members.  There will be times when you have to go back and support a family in re-stabilizing after a crisis.  These primary activities, engagement and stabilization are pillars of our service delivery structure.  Done well, they create a strong foundation for us to facilitate healing and growth in the lives of the youth and families we serve.

Phase 3: Assess

In this phase of the service process we are using the various agency tools we have available in order to more clearly understand the needs and strengths of a family.  The outcomes of the work done in this phase set the course for most of the services delivered by individual team members moving forward. Before a team can effectively create an action plan, they must complete the activities within this phase to get a clear picture of where they are and where they want to go together.

Phase 4: Create an Action Plan

Once the team has a clear picture of what they need to accomplish, the work of this phase begins.  In this part of the process, the team is determining how they want to carry out their vision and achieve their goals.  The work involved here is in...

  • Developing solutions with families on how to meet their own needs
  • Considering what evidence-based practices would best serve the needs of the family
  • Identifying natural supports and community resources that can support and strengthen the family 
  • Selecting activities and self-care techniques that can improve the well-being of the family 

Phase 5: Implement Your Action Plan

Once your team has established an Action Plan, then the work becomes supporting the family through the strategies, interventions and evidence-based practices you have determined as a team to use.  The flowchart within this section of the ISM outlines the process the team should follow as it implements the plan and begins to see results.  If positive progress is being experienced, this tells the team to stay on course until the goal is completed.  If in contrast, the team is experiencing a lack of progress towards meeting a goal, then this should serve as feedback that they need to reconsider, reassess and revise what they're doing. 

When the team determines that the vision and goals of the family have been for the most part realized, then it's time to consider moving into Transition.  It's important that when this decision is made, the whole team begins to Prepare the Family for Transition to Aftercare.  

Phase 6: Transition

This final phase of the process is characterized by activities and conversations preparing the family for the end (or termination) of services and whatever comes after.  Here the team celebrates all that the family has accomplished through their hard work and perseverance.  

Now that we've reviewed the detailed version of the ISM diagram which was designed to support staff in understanding how our service process works, lets take a closer look at the Steps of Service diagram and get a picture of how we can use it to support our families.

Place the phases of service in order.


Which of the following are potential uses of the ISM Diagram?  (Check all that apply.)

  • Service Planning
  • Trouble-Shooting Problems
  • Promotional Materials
  • A Handout to Give Families
  • A Supervision Tool
  • Monitoring the Progress of Youth and Families

The SOS Diagram

The Steps of Service (SOS) Diagram: A Tool to Engage Families

The Steps of Service (SOS) diagram in simply a streamlined version of the complete and detailed ISM that you just explored.  This version is designed to be used as a tool of engagement with youth and families to explain the service delivery process and facilitate authentic and effective participation in services.  

Identify which of the following statements are TRUE or FALSE in relation to the SOS Diagram

  • The primary purpose of the Steps of Service (SOS) Diagram is to support youth and families in knowing what to expect from services.
  • The SOS Diagram and the ISM Diagram are unrelated to each other.
  • The SOS Diagram is a streamlined version of the ISM Diagram.

Shared Understanding Cards

A Tool to Facilitate Understanding

For a plan to effectively address a child’s or youth’s difficulties, it must be based on an accurate understanding (a formulation or explanation) of why those difficulties exist, ideally an understanding that all members of the team share.  The accuracy of this Shared Understanding and how much it rings true to families depends not only on the assessment skills and clinical knowledge of the staff but on the authentic contribution to the process by the youth and family.  In other words, it is the responsibility of staff not only to bring their expertise to the table but to facilitate the genuine and meaningful participation of youth and families.  The Shared Understanding Cards, which are prompts for various factors that may contribute to a youth’s and family’s difficulties, are a tool designed to help staff accomplish this.  By taking the family through the cards one by one, staff give families the opportunity to play a central role in identifying what may be contributing to their difficulties. 

Below are images of the Shared Understanding Cards for you to review.  

If you have not received a set of Shared Understanding Cards and would like one, talk to your supervisor - they will know how to get that for you.  Also available to you is a single page handout with the same information as the cards - the Shared Understanding Menu.  You can access and print that out at the end of this course.

Identify (and click) where in the Steps of Service we are first using the Share Understanding Cards to clarify the family's perspective on the nature and source of their struggles?

What are all the ways the Shared Understanding Cards can be used?  (Check all that apply.)

  • Help the team identify and understand the unique challenges facing a family.
  • As a checklist or menu of things we need to talk about with a family.
  • As a card game we can play with families to "break the ice."
  • Support the team in clarifying with a youth and/or family the reasons for the struggles they are experiencing.
  • Generate discussion and facilitate communication in child and family team meetings.

Action Planning Cards

A Tool for Setting the Course

The Action Plan Cards, like the Share Understanding Cards, are a tool to aid and support staff in identifying concrete steps that can be taken to address the unique challenges the family is experiencing. The cards are a set of prompts to help the team systematically consider possible components of an overall Action Plan (also called a Service Plan or Treatment Plan).  These cards help the team "ask the right questions" to determine how they want to proceed with achieving their shared vision.

Below are images of the Action Plan Cards for you to review. 

If you have not received a set of Action Plan Cards and would like one, talk to your supervisor - they will know how to get that for you.  Also available to you is a single page handout with the same information as the cards - the Action Plan Menu.  You can access and print that out at the end of this course.

It's important to note that when using either the Shared Understanding or Action Plan Cards, you will experience overlap.  For example, persistent defiance may serve a function for a young person, be a response to a particular family dynamic and  be a symptom of a behavioral health condition.  Both sets of cards are intended to serve as prompts to facilitate communication and consider all available options. 

Click on the Step of Service where we are first using the Action Plan Cards to facilitate conversations to set a course for our work with the family?

Which of the following statement is TRUE or FALSE in relation to using the Action Plan Cards in our work with youth and families?

  • They help the team develop concrete steps they can take to move toward accomplishing the youth and/family's goals and vision.
  • They can serve as a reminder or prompt to staff on the multiple options available to help families in getting their needs met.
  • Using them take a lot of extra time that we don't really have.
  • They can support staff in identifying their individual course of intervention in relation to helping the family meet their goals.

Putting it All Together

Conclusion and Next Steps

The ISM diagrams in addition to the Shared Understanding and Action Plan cards are all intended to serve as tools to generate and improve communication, facilitate understanding and engage in creative problem solving with families and within teams.  How you use them will be based on a number of variables, including:

  • Your comfort and familiarity with the tools - if you never use them, you'll never develop proficiency
  • Expectations of  your supervisor
  • Program and regional expectations around usage of tools
  • Your individual commitment to practice using them

Keep in mind that they are not a substitute for staff's clinical skills and acumen; in fact, they are only useful when staff bring their clinical know-how to the discussion. Staff should actively solicit the impressions, ideas and wisdom of youth and family and integrate that with their own impressions and expertise.

Now that you have a complete picture of the Integrated Services Model and the tools available to support you in your work with youth and families, your next step is to identify what actions you can take to strengthen your ability to use these tools.

 Thank you for your contribution to the children and families we serve!