Coordinated Service Planning

What is Coordinated Service Planning?

Coordinated Service Planning (CSP) was created to support families and guardians with children or youth who have multiple and/or complex special needs. Coordinated Service Planning helps to ensure that all the professionals involved with the child or youth are working together as a team towards common goals, and that families and guardians are kept informed of the progress towards their goals. This service was started because families of children and youth with special needs were finding it difficult and complicated to coordinate multiple services and ensure the best plan of care for their child or youth.

Coordinated Service Planning was created, as a component of the Special Needs Strategy, by the Ministry of Children, Community and Social Services, the Ministry of Education and the Ministry of Health and Long-Term Care.

Who is this program for?

Families who:

have a child or youth up to 21 years of age who is still attending school
have a child or youth who has multiple and/or complex special needs
have at least two service providers involved in their child or youth's care (including schools, therapists, community supports, and medical professionals)
need extra support to navigate the system

This service is focused on your needs and is not specific to a diagnosis.

For more information, please see the information sheet for families on Coordinated Service Planning.

How do we support children and youth, and their families and guardians?

Children and youth participating in Coordinated Service Planning are assigned a Service Planning Coordinator.

Service Planning Coordinators will:

meet with families to help them establish their goals
connect with the professionals who work with the child/youth (including schools, therapists, community supports, medical professionals, etc.)
work to create a Single Plan of Care (SPOC)
lead a meeting with the family that brings the child/youth's professionals together as a team to discuss the family-centered goals within the Single Plan of Care (SPOC)
follow up with each professional and keep the family informed

Coordinated Service Planning will help you:

tell your story once, and be better understood by all professionals working with your child/youth
be empowered to make informed decisions about your child's care and your family's needs
get support to monitor the needs and progress of your child or youth through a coordinated service plan

How can my family be referred?

Coordinated Service Planning referral

For health-care professionals

Are you a professional working with a family who may benefit from this service? Obtain the family's consent and send in a referral. Please fax your referral to 613-738-4841.

Once the form is received, the Access Team will follow up to finish the referral process. We will do a needs assessment to identify the best way to meet your family's needs and determine eligibility for Coordinated Service Planning.

If you have any further questions, please call intake at:

Tel: (613) 737-0871, extension 2757
Toll Free: 1-800-565-4839, extension 2757

For families and caregivers

For families living in Ottawa, Prescott-Russell (PR), or Stormont Dundas and Glengarry counties (SD&G) who would benefit from Coordinated Service Planning, please fax us a copy of the referral form to 613-738-4841.

If you have any further questions, please call intake at:

Tel: (613) 737-0871, extension 2757
Toll Free: 1-800-565-4839, extension 2757

If you live in Leeds, Lanark, and Grenville, please connect with Kids Inclusive for further information on Coordinated Service Planning.

If you live in Renfrew County, please connect with the centralized intake at Family & Children's Services of Renfrew County.

Coordinating Agency and Service Providers

Coordinated Service Planning is an initiative across Ontario with a total of 34 regions offering this service. CHEO is the Coordinating Agency for Ottawa, Prescott-Russell (PR), and Stormont Dundas and Glengarry counties (SD&G).

CHEO and the following service providers offer Coordinated Service Planning:

CHEO would like to thank the key partners for their help in shaping this program, and for their continued commitment in sharing a common vision of seamless access to services for children, youth and their families.

Our key partners in Coordinated Service Planning

Ontario Autism Program - CHEO
Champlain Complex Care Program
Local Health Integration Network (LHIN)School Boards/School Authorities
Fetal Alcohol Spectrum Disorder Strategy
Moving on Mental Health

Frequently Asked Questions

Why was Coordinated Service Planning created?

Families have said they found that navigating the system was confusing and complicated when accessing services. Coordinated Service Planning was started in 2015 as part of the Ontario Special Needs Strategy.

The Ontario Special Needs Strategy is an initiative of:

The Ministry of Children, Community and Social Services
The Ministry of Education
The Ministry of Health and Long-Term Care

The Special Needs Strategy is committed to using a common approach to service coordination through all agencies based on the following values:

Family-centred/family-defined
Any door is the right door
Families tell their story once
One person to call
Flexible, individualized support for Coordinated Service Planning
Accessible service
Community vision and accountability
Shared and informed decision-making
Timely, effective, transparent information and communication
Holistic perspective that has a prevention lens

Who are children and youth with multiple and/or special needs?

Children and youth with multiple and/or complex special needs rely on many services for support (for example: rehabilitation services, autism services, developmental services, respite supports, criminal justice and/or mental health services). These children and youth may have difficulty in several areas, including their physical, communication, intellectual, emotional, social, and/or behavioural development.

How long can a family be supported by a Service Planning Coordinator?

The Service Planning Coordinator supports the family until they no longer need the support, and this will look different for each family. Discharge from Coordinated Service Planning may happen when:

goals are met and the family and team agree that Coordinated Service Planning is no longer needed,
the family moves away from the area served by CHEO (Ottawa, Prescott-Russell, and Stormont Dundas and Glengarry counties),
when the youth leaves school (between the ages of 18-21), or
the family asks to be discharged.

Families may re-enter the Coordinated Service Planning process as needed.

How is Coordinated Service Planning different from other services offered at CHEO or in the community?

Coordinated Service Planning may be initiated if the family is feeling overwhelmed with coordinating services and when the needs of the family go beyond the resources available through their current team. Coordinated Service Planning is not meant to duplicate services currently being used; instead it should ease communication between families and their team members. It provides the family with the chance to meet together with all of the professionals from different agencies and work towards creating a plan of care for the child/youth (known as a Single Plan of Care). Coordinated Service Planning is a formal process between CHEO, Service Providers, School Boards and Champlain Local Health Integrated Network (LHIN).

What can I expect from a Service Planning Coordinator?

The Service Planning Coordinator facilitates communication and collaboration amongst your ongoing care team members.

The Service Planning Coordinator will develop a Single Plan of Care (SPOC) in partnership with you and share that plan with the team. In doing so, their role is to take the lead in helping to open a dialogue between you and your care team, strengthen partnerships between your care team members and coordinate your services so that all members of your care team are working together toward a common vision and goals.

Once you are satisfied that your care team is working together effectively to meet your shared vision and goals, service from your Service Planning Coordinator will be complete.

Service Planning Coordinators recognize that the system is complex and cannot always meet all of your needs. Although Service Planning Coordinators will attempt to bridge any gaps within the system that you are facing, this may not always be possible. However, your feedback will be communicated by your Service Planning Coordinator to the leaders of Coordinated Service Planning who will then communicate these barriers to the Provincial Ministries involved in this initiative.

What is a Single Plan of Care?

The Single Plan of Care is a strengths-based document that addresses the service needs of the child/youth with multiple and/or complex special needs. Your Service Planning Coordinator will seek the active participation of the child/youth/family/guardian(s) in the creation of this document as it is driven by the goals of the child/youth and their family/guardian(s).

The Single Plan of Care is used to facilitate the exchange of information between relevant providers in the children’s services, education, and health sectors in each service delivery area.

Throughout a child/youth and their family/guardian(s)’ time with Coordinated Service Planning, the Service Planning Coordinator will monitor, review, and update the Single Plan of Care, in collaboration with the child/youth/family/guardian(s) and relevant providers in the children’s services, education, and health sectors, as needs and services change.

I’m already feeling overwhelmed by the many professionals in my life, how would adding another person to my team be helpful?

Coordinated Service Planning goes beyond regular inter-professional communication and collaboration that takes place when providers work together in an effort to ensure they are integrating practice and service delivery for children, youth and families. It is a support in and of itself that is intended to decrease family stress by providing families with a formal voice in the service planning process and by assisting families in navigating and coordinating services for their child/youth.

Do Service Planning Coordinators provide direct therapeutic services?

No. The role of the Service Planning Coordinator is not to provide direct therapeutic services.

Your Service Planning Coordinator can help connect you to services that will support the achievement of your vision and goals.

I’m not sure if I meet the eligibility criteria. Should I refer myself/my child/my youth/my client?

Yes. If you are struggling, please connect with us.

Even if Coordinated Service Planning is not identified as the most appropriate service for you at this time, our Outreach Worker will support you in connecting with a more appropriate service that will better meet your needs.

How can I provide feedback about my CSP process/experience?

We welcome your feedback.

As part of this provincial initiative, your Service Planning Coordinator will be asking for your feedback throughout their time with you.   If you don't feel comfortable providing feedback directly to your Service Planning Coordinator, please connect CHEO's Patient Experience team.