4.24 SSW's Ongoing Contact with the Child and Family, Including the Medically Complex Child


​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​From the moment of the initial contact with the family, the SSW and the Department for Community Based Services (DCBS) are obligated under federal and state law to make reasonable efforts to keep families intact whenever possible; and in removal situations, to make reasonable efforts to reunify children with their families. As part of this obligation, the SSW is required to maintain personal contact with families and children. Ongoing contact with the family provides information that contributes to a thorough assessment of whether or not the family has reduced the risks that initially lead to the involvement of DCBS.

Caseworkers are required to conduct face-to-face visits with children placed in out-of-home care (OOHC) in all placement settings at least one (1) time every calendar month.

Features of an acceptable pattern of visits to parents or other significant family members include:

  • Face-to-face contact frequently enough to evaluate the family’s progress; 
  • Sufficient meaningful discussion of case planning tasks and objectives; 
  • Sufficient opportunity to observe the residence(s) of the parent(s) and child(ren), or other family members significant to the case; Assessment of the current condition within a home or family and considerations of whether or not there is an immediate safety threat to a child; and 
  • Assessment of risk, which includes the identification of risk factors, which are family behaviors that create an environment or circumstances that increase the chance that parents or caregivers will maltreat their children.

Through the life of the case, the burden is on the SSW to locate and maintain contact with family members.

Practice Guidance

Video Conferencing

Video conferencing is a beneficial tool for staff to contact families and children. Typically, video conferencing cannot be considered as a face-to-face visit with a family or child. However, under specific circumstances, such as a state of emergency, caseworkers can utilize video conferencing as a means to conduct face-to-face visits. When these special circumstances are in place, the Division of Protection and Permanency (DPP) will provide guidance to field staff indicating that video conferencing is an appropriate option for conducting face-to-face visits.

Ongoing Contact with the Child

  • The SSW may utilize the Caseworker Visit Template during the face-to-face contact with the child. 
  •  If a child is in a supports for community living (SCL) program, the SSW may use the Support for Community Living Program Visit-Review of Records and Facility Form at each monthly visit to the child’s placement setting, providing a copy to the central office SCL liaison. 
  • The SSW may contact the central office SCL liaison if there are concerns, questions, or a need for a Behavioral Health Developmental and Intellectual Disabilities (BHDID) case consultation after reviewing the Supports for Community Living Tip Sheet and the Resource Manual for Youth with Disabilities in Foster Care.

Ongoing Contact with the Family

  • The SSW makes face-to-face contact with parents, in their residences, at a minimum of once per calendar month. However, the appropriate frequency of visit is guided by the case specific circumstances. When the overall pattern of face-to-face visits is not monthly (once per calendar month), the SSW enters an explanation for the pattern of contact into the next case plan evaluation/ongoing assessment. 
  • In addition to face-to-face contact, the SSW may utilize telephone, mail, or email; however, the case specific circumstances should guide the overall pattern of contact within the case. 
  • The SSW documents a pattern of visits with the children and parents that will appropriately demonstrate reasonable efforts to reunify children who have been removed from their homes or finalize an appropriate permanency plan for children. ​Workers are not required to execute monthly visits to parents if there is a no contact order prohibiting contact, or if a judge has granted a waiver of efforts on the case. 
  • ​Workers will document the issuance of such orders in their ongoing assessment until the no contact order is lifted, or until case closure. 
  • Case workers are prohibited from documenting that a face-to-face contact occurred, unless a face-to-face visit was completed by department personnel. Falsification of documentation is an ethical violation. Please refer to chapter 2.1 Employee Conduct in the Personnel Procedures Handbook for additional information.​​

Ongoing Contact with the Medically Complex Child

  • The managed care organization (MCO) nurse visits a child designated as medically complex at least two (2) times per calendar month in the placement setting, which includes, but is not limited to a DCBS resource foster/adoptive home, a PCP foster home, psychiatric or medical hospital, independent living, or a SCL program, as determined by the child's needs. 
  • The SSW communicates with the assigned MCO nurse regarding the child monthly. This should include obtaining updates on the child’s medical conditions, diagnoses, progress or challenges, change in treatment or medications, etc. 
  • The SKY nurse uploads documentation of the monthly home visit in the TWIST/SKY module and to the SSW accesses the documentation from the TWIST/SKY module to enter the contact into TWIST and files a copy in the hard copy case file. 
  • The SSW, medically complex liaison, or caregiver may request consultation at any time with the Medical Support Section regarding a medically complex child. 
  • The Medical Support Section may: 
    • Upon request, provide consultation and a visit to the medically complex child and/or placement; and 
    • Notify the FSOS responsible for the child if the Medical Support Section determines a condition that warrants additional attention. 
  • The SSW, R&C worker, or SKY MCO nurse reviews and discusses the following, as related to the specific needs of the medically complex child during the home visit (as applicable): 
    • Managed care organization (MCO) case management; 
    • Transportation arrangements for the child; 
    • Home health referrals and/or durable medical equipment (SKY MCO nurse may assist); 
    • Availability of all medications and medical technology to care for the needs of the child; 
    • Supportive services to the caregiver(s); 
    • Future needs of the caregiver(s); 
    • Respite and/or babysitting issues; 
    • Upcoming service needs; 
    • Child/youth action plan and individual health plan with the caregiver and the child, when appropriate; 
    • Current diet and eating pattern; 
    • Medical passport, including medication logs; 
    • Transition planning; and 
    • Other information including: 
      • The child's weight; 
      • Alertness; 
      • Physical condition; 
      • Current diet and eating patterns;
      •  Mental health needs; 
      • Medication log; 
      • Current medical services; 
      • Any illness or medical change since the last visit; and 
      • Recent or future medical appointments. 
  • The foster/adoptive parent, relative, and/or out of state placement provider completes the DPP-104C Medically Complex Monthly Report and submits it to the SSW, who forwards it on to the: 
    • SKY MCO nurse; 
    • Region's medically complex liaison; and 
    • Medical Support Section, if issues are identified on the report.​​


Ongoing Contact with the Child

Following any placement (initial or move) the SSW:

  1. Uses face-to-face contact to assess safety threats and risk factors surrounding ​the child's placement and to ensure the child's assessed needs are being served appropriately through correct services referrals; 
  2. Will review/update the child youth action plan and complete a new Partnership Plan with all required individuals as outlined in SOP; 
  3. ​Must return within ten (10) calendar days after placement, to have an additional private face-to-face visit with the child; 1 
  4. Has phone contact with the child within five (5) calendar days of placement, if the child is age appropriate to respond by phone; if not age appropriate, the SSW assesses the child’s transition to placement and any placement needs through child’s caretaker; 
  5. Has a private face-to-face visit with the child, and a face-to-face visit with their caregiver in their placement at least once every calendar month in order to assess progress toward case plan goals and objectives and to assess adjustment to the out of home care placement; 
  6. Visits a child designated as medically complex: 
    1. Jointly with the Supporting Kentucky Youth (SKY) MCO nurse within thirty (30) calendar days of the child’s designation as medically complex for the initial visit; then 
    2. At least one (1) time per calendar month, in the placement setting, which includes DCBS foster/adoptive homes, PCP foster homes, PCC facility, psychiatric or medical hospital, SCL programs or a relative placement as determined by the child's needs; 2 
    3. Face-to-face annually in the placement setting, when the child is placed out of state, or as often as needed, based on the child’s needs; 
    4. Monthly by phone contact in order to receive the child’s medical updates for out of state placements; and 
    5. Enters into TWIST that the CCSHCN nurse had face-to-face contact with the child as reported on his/her contact note. 
  7. Has private face-to-face contact, at least one (1) time per calendar month, in the child's placement setting; 
  8. Has private face-to-face contact in the child’s placement setting annually if the child is placed out of state; 
  9. Reviews service recordings submitted by the PCC/PCP to document monthly face-to-face contact between the PCC/PCP personnel and the child, but contacts the facility's treatment/clinical staff, by telephone, at least monthly (when no face-to-face contact occurred with PCC/PCP staff during the monthly visit) to assess the child's progress towards case plan goals, objectives, and tasks; 
  10. When a child is placed out of state, uses progress reports, collected at least every six (6) months, from a caseworker for the state agency where the placement is located or from the placement provider, to document monthly face-to-face contact and assess the child’s progress towards case plan goals, objectives and tasks; and 
  11. Has monthly phone contact with the child or the child’s placement when a child is placed in an out-of-state setting.

Ongoing Contact with the Child's Family

The SSW:

  1. Conducts face-to-face visits with parents and other household members frequently enough to: 
    1. Facilitate reasonable efforts; 
    2.  Communicate effectively about case plan objectives; 
    3. Identify and resolve barriers to case objectives; and 
    4. To assess parental progress in reducing risk.3 
  2. Accomplishes case-specific intervention tasks during the contact, as well as: 
    1. Assesses for safety threats, high-risk behaviors, or risk factors; 
    2. Evaluates the family’s progress at reducing the immediate safety threats and/or reducing the risks that necessitated case action; 
    3. Reviews the family’s progress toward accomplishment of their case planning tasks and those of other service providers; 
    4. Identifies and resolves barriers to case objectives; 
    5. Provides the family with information about their child, especially placement and well-being issues; 
    6. Prepares for a case planning conference, periodic review or court hearing; and 
    7. When appropriate, prepares an aftercare plan. 
  3. Thoroughly documents: 
    1. Observations regarding the family and the home setting; 
    2. Progress towards each task on the family case plan; 
    3. The family’s response to services they receive to other providers; 
    4. Additional assessment and planning information provided by the family; and 
    5. That the family has been provided information about the child’s: 
      1. Placement; 
      2. Physical and mental health; 
      3. Education; and 
      4. Activities; 
  4. Documents in their ongoing assessments any barriers to their ability to maintain contact with the family including, but not limited to: 
    1. The parent’s whereabouts are unknown; 
    2. Written determination by the FSOS that family members are or may be violent; or 
    3. Family members refuse to participate in ongoing visits.

Ongoing Contact with the Caregiver

The SSW:

  1. ​Conducts face-to-face visits with caregivers and other household members during visit with the child to: ​
    1. Assess for safety threats, high risk behaviors, or risk factors;
    2. Assess progress in the following areas on the child youth action plan and assist in identifying barriers to meeting the needs of the child:
      1. ​​Physical health; 
      2. Mental health; 
      3. Education/development; 
      4. Attachment/visitation issues; and 
      5. Permanency. 
    3. ​ ​​Assess needed supports and resources for the caregiver; and 
    4. Provide assistance and prepare caregiver for court hearings, case planning conferences, and appointments. ​​​
  2. Accomplishes case specific intervention tasks during the contact, such as: ​
    1. Assess placement stability; 
    2. Evaluate caregiver's commitment; and 
    3. Implement Partnership Plan (i.e. working in partnership with the birth family) 
  3. Thoroughly documents: 
    1. Observations regarding the family and the home setting; 
    2. Progress towards each task on the child youth action plan; 
    3. Caregiver's response to services they receive and their response to meeting the child's needs; 
    4. Additional assessment and planning information needed for the caregiver; and 
    5. That the caregiver has been provided information about the child's: ​
      1. Physical and mental health; 
      2. Education; and 
      3. Activities. ​​​
  4. Documents in the ongoing assessment any barriers to their ability to maintain contact with the caregiver.


  1. This is in addition to the initial visit when the child is taken to the placement for the first time. 
  2. The Department for Medicaid Services (DMS) nurse will visit the child in the placement setting one (1) time every calendar month and provide a contact note to the SSW. 
  3. The SSW may also contact the incarcerated parent in between quarterly visits by using mail, telephone, or technology such as Skype, if appropriate.