Effective Date: 5-28-20
The goal of an exit plan is to identify and arrange anticipated services for older youth who are in the process of transitioning out of foster care. Youth who have a comprehensive transition plan are better equipped to transition successfully from foster care to self-sufficiency. An unintended consequence of not preparing youth to exit from foster care is the youth becoming homeless. Exit planning is the result of preparation for transition from foster care and although certain steps are taken at “exit” the planning begins at age 14. Exit planning and transition planning should be viewed as occurring concurrently and interchangeably.
Exit planning should be viewed as a collaborative effort between the youth, staff and Family Support Team (FST) members to ensure needed services are in place or the youth is aware of how to access services in their community prior to release.
Transition planning should be a purposeful, organized and outcome-oriented process designed to ensure the youth’s quality of life. Transition and exit planning should be considered a continuum once the youth is eligible for the Older Youth Program.
The Council on Accreditation standards requires agencies to provide youth transitioning to independence with at least six months advance notice of the cessation of any health, financial, or other benefits which will occur at transition/case closing.
Transition to adulthood can involve complex issues and create anxiety for the youth. To assist with the process, youth involvement in their plan as well as recognizing the youth’s desire to have personal independence and find their own way is essential. Involving the youth’s other connections and community partners in the process to ensure services are accessible, coordinated and appropriate are also necessary.
In order to prepare youth for their exit from the foster care system, the child’s Children’s Service Worker must plan to meet with the youth to complete exit planning ninety days prior to release from custody. The child’s Children’s Service Worker is responsible for meeting with their youth to complete the exit plan interview. The Adolescent Family Support Team Guide (CD94) and Individualized Action Plan Goals (CD94) should be updated to reflect the youth’s plan for successful transition from foster care.
Consideration and planning must be conducted for youth who will continue to need supported care after transition to adulthood. The least restrictive environment which will meet the youth’s physical and mental health needs should be considered by the Family Support Team. For youth with special needs, coordination should occur at least one year in advance with the Department of Mental Health, Division of Developmental Disabilities, Vocational Rehabilitation, Department of Elementary and Secondary Education and other state and local resource providers if the youth is currently receiving services or involvement is necessary. Some youth may require continued formalized support in the form of guardianship or conservatorship. In these instances, it is very important to begin transition planning with the Division of Legal Services at least one year in advance to assure the youth will have a plan and funding in place for those supports and services needed.
The planning process must consider and address all of the following factors:
- Source of income
- Educational needs
- Vocational needs
- Financial needs, including eligibility for income maintenance programs, credit status needs
- Legal status needs, including whether a guardianship, conservatorship or other legal custody order is necessary or appropriate
- Peer support
- Caring adult/mentor
- Family information and involvement
- Safety concerns
- Physical health needs
- Mental health needs
- Insurance coverage needs (health and automobile as appropriate)
For youth with special needs who will require funding upon release:
- Ensure an application is made for the youth’s Medicaid to be transferred to the Family Support Division.
- Kids Account income: The Children’s Service Worker should check the KIDS/Dedicated KIDS Account screen in FACES or contact FACES Payment Unit to determine the savings limit due to the youth (up to $999.00). Once an amount is determined, the Children’s Service Worker should complete a CS-KIDS-2 form for the person (payee) to whom money is to be released from the child’s KIDS account. This person(s) may be the child’s parent, guardian, adoptive parent or him/herself, if an emancipated minor.
- Ensure youth is provided and assisted with Older Youth Change of Payee Request Form if the youth is receiving Social Security benefits.
For additional information, refer to the Child’s Income Disbursement System (KIDS) section in the CWM. The Older Youth Exit Packet and Personal Documentation Checklist is available in e-forms for additional guidance.
Upon leaving care, a letter signed by the child’s Children’s Service Worker shall be provided to the youth on state letterhead verifying the youth’s time in care and exit date. This will aid youth in receiving assistance after leaving care within the state and out of state for services which require eligibility verification.
A summary of the youth’s plans should be filed in the Older Youth Program Section of the case record as well as a copy of the eligibility verification letter. As staff work with youth who are nearing, or past, their 18th birthday and opting to exit from custody, it is imperative these youth are made aware of resources available to them upon release. The child’s Children’s Service Worker shall inform these youth of their eligibility for MO HealthNet, and, if possible, determine the address where the youth will reside upon leaving care.
Each county must designate a liaison/contact person(s) for those youth who have exited care to contact. An Exit Packet is to be provided to those youth currently in care as they exit the foster care system, or to former foster care youth requesting Aftercare services.
The Exit Packet includes information regarding:
- MO HealthNet
- Chafee Aftercare
- Education and Training Voucher (ETV)
- Missouri Reach Tuition Waiver and Credential Completion and Employment Programs
- Healthcare Treatment Decisions
- The National Youth in Transition Database (NYTD)
- Older Youth Change of Payee Request Form if the youth is receiving Social Security benefits.
Each county should also include additional resources pertinent to their own geographic areas into the packet. Resources may include, but should not be limited to the following:
- Employment Agencies;
- Service/Volunteer Organizations for Mentoring;
- Faith-Based Resources;
- Clothing Resources;
- One-Stop Centers;
- Transportation Resources;
- Child Care Resources;
- Emergency Housing Assistance;
- Food Pantries;
- Community Action Agencies;
- Adult Education Programs;
- Income Maintenance Programs/Resources;
- Medical Clinics; and
- Other State Agencies.
Former foster care youth will be required to enroll into a MO HealthNet Managed Care plan for their physical healthcare, if they reside in a geographic area covered by Managed Care. Their behavioral healthcare will be provided on a fee-for-service basis.
Some documents are useful as youth develop life skills to prepare them for successful transition and should be obtained as needed and appropriate for the youth’s age and placement type prior to release from care. Youth should have the following documents in their possession (with a copy in the file) as they prepare to transition from care:
- Original Birth Certificate
- Original Social Security Card
- An up-to-date credit report
- Financial statements from financial institutions in which youth has an account
- Driver’s license or ID Card
- Information regarding any policies of insurance the youth may have access to
- An accounting showing disposition of all monies received and distributed under the youth’s KIDS account
- Portfolio and Lifebook
- Documentation of tribal eligibility or membership
- Previous placement information
- Medical Records (e.g. immunizations, current medications)
- Educational Records (e.g. diplomas, report cards, IEP, list of schools attended)
- Original documentation of immigration, citizenship, or naturalization, when applicable
- Death certificates when parents are deceased
- Religious documents and information
- A list of known relatives, with relationships, addresses, telephone numbers, and permissions for contacting involved parties
- A resume, when work experience can be described
- CD-276, Custody Verification Letter
Documentation of receipt of exit packet and personal documents shall occur on the Older Youth Exit Packet and Personal Documentation Checklist.
5.9.1 Housing Services – Coordinated Entry System
Older Youth shall not exit to homelessness. Housing must be secured prior to release.
When Older Youth experience homelessness or are at risk for homelessness the Coordinated Entry System (CES) should be accessed to connect them to housing services. The CES is Missouri’s primary resource to connect people to housing services no matter how or where they present. This resource allows staff to connect youth and families to Missouri’s array of housing services with one referral to an Access Point. A listing of Coordinated Entry Access Points by region and county can be found HERE. All Access Point agencies will complete a pre-screening tool with clients and connect them with the appropriate level of housing services.
A referral to the CES may be made at any point of involvement with CD when housing stability is a challenge. Population served includes, but is not limited to intact families, birth parents, potential relative placement providers, guardians, and older youth.
Older Youth Scenarios where CES referral MUST be made include the following:
Older Youth preparing to exit care to independence and housing stability is at risk.
All referrals and activities involving the CES shall be documented in a contact note in FACES.
5.9.2 Guardianship and Conservatorship
Consideration and planning must be conducted for youth who will continue to need supported care after transition to adulthood. Planning documents which may assist with this process include:
- Power of Attorney
- Durable Power of Attorney
- Durable Power of Attorney for Healthcare
Possible court actions include:
- Limited guardianship
- Limited conservatorship
The Execution of a Power of Attorney, Durable Power of Attorney, and Durable Power of Attorney for Healthcare
These documents allow someone to appoint another person to make decisions for him or herself. To execute a power of attorney, durable power of attorney, or a durable power of attorney for healthcare, the youth cannot be disabled or incapacitated.
Each of these documents allows the youth to appoint another person, called an attorney in fact, to make certain decisions on his or her behalf. The decisions which can be made by the attorney in fact must be specified in the power of attorney document. A durable power of attorney for healthcare allows the attorney in fact to make specified healthcare decisions, which may include the decision to withhold or withdraw life prolonging procedures. Employees of the Department of Social Services and Department of Mental Health are prohibited by law from being appointed as an attorney in fact unless the employee is closely related to the youth.
A power of attorney which is not durable expires in the event the youth becomes disabled or incapacitated. A power of attorney which is not durable also expires at the end of one year or when specified in the document if earlier than one year. A durable power of attorney or durable power of attorney for healthcare does not expire in the event of disability or incapacity and may be of such duration as specified in the document or after the death of the youth when probate issues are resolved.
The Missouri Bar has available “Durable Powers of Attorney” and “Guardians and Conservators under Missouri Law” resource guides and an accompanying HIPAA form which further explains this option. The decision on whether a youth wishes to execute a power of attorney of any type is an important legal decision with important consequences. If the youth is competent to make his/her own decisions and is competent to execute a power of attorney the youth should be given an opportunity to consult with his/her guardian ad litem or his/her own attorney for legal advice before the youth is asked to sign a power of attorney of any kind. DSS/CD personnel need to be careful to avoid giving legal advice on this issue to the youth involved.
Guardianship and/or Conservatorship
A guardianship may be pursued by CD/DLS for a youth between the ages of 18 and 21 when the youth has a physical or mental condition so serious the youth cannot make decisions for the youth’s own safety and well-being. A conservatorship may be pursued when a youth between the ages of 18 and 21 is unable due to a physical or mental condition to effectively manage his or her financial resources. A guardianship and conservatorship often are pursued together, but obtaining both a guardianship and a conservatorship for the youth may not be necessary in all cases. A guardianship or conservatorship may be full or partial depending on the extent of the physical or mental condition of the youth.
A guardianship, under Missouri Law Chapter 475, is when a person is appointed by the Court (typically the Probate Division of the Circuit Court) to have the physical care and custody of an adult who has been legally determined to be incapacitated. A person deemed incapacitated refers to one who is unable by reason of any physical or mental condition to receive and evaluate information or to communicate decisions to such an extent he/she lacks capacity to meet essential requirements for food, clothing, shelter, safety or other care such that serious physical injury, illness, or disease is likely to occur.
A conservator is a person or a corporation, such as a bank or trust company, appointed by the Court (typically the Probate Division of the Circuit Court) to manage the property of an adult who has been found to be disabled. A disabled person is defined as one who is unable by reason of any physical or mental condition to receive and evaluate information or to communicate decisions to such an extent the person lacks ability to manage his/her financial resources.
In limited guardianship, the judge must specify the extent of the powers and duties of the limited guardian in order to allow the ward to care for himself to the maximum of his ability. The intent is to design the guardianship arrangement to encourage the development of maximum self-reliance and independence of the ward and should be considered before full guardianship.
Limited conservatorship is much like limited guardianship, except conservatorship deals strictly with the estate (property and financial resources) of the protectee. If a limited conservator is appointed, the judge must specify his powers and duties in such a way as to permit the person with a disability to manage his resources to the fullest extent of his ability. Furthermore, appointing a limited guardian and/or limited conservator does not impose any legal limitation on the person except for what is specified in the court order.
An adult incapacitated or disabled person may designate his or her own guardian and/or conservator if he or she is able to communicate a reasonable choice to the court. Also, any competent adult person can designate a suitable person to serve as guardian or conservator if done in writing and witnessed by at least two witnesses within five years before the hearing. This is typically done in a durable power of attorney. If the incapacitated or disabled adult does not have a preference, or is unable to express a reasonable preference, the court will consider appointing as guardian and/or conservative, in order:
- adult children,
- adult brothers and sisters,
- other close adult relatives.
The Family Support Team should follow this list of preferences. Only when there is specific evidence a family member is unable to serve as guardian and/or conservator should the team consider alternative providers. The team should also consider the appointment of an appropriate kinship resource if a suitable family member is not available. If there are no relatives or kinship resources willing or able to serve, the court has the power to appoint any suitable person (such as a close friend). The court may also appoint the Public Administrator, an elected county official whose job is to handle such matters when no one else is available. A person does not have to be a resident of Missouri to qualify for appointment as a guardian or conservator but this may be taken into consideration by the court when determining who may be suitable. If they are out of state, they do have to appoint a “resident agent” within the state to serve in the case the out of state guardian cannot be reached.
Any person who knows another person may require a guardian and/or conservator can commence the process by filing an application in the Probate Division in the county where the alleged incapacitated or disabled adult resides. The person alleged to need a guardian and/or conservator is called the respondent. Both the petitioner and respondent must be represented in court by an attorney. The court will appoint an attorney for the respondent if the respondent does not have an attorney. After a hearing, the court will decide whether a guardian and/or conservator are needed and make the appointment, if necessary. Notice of the application must be served to:
- the alleged incapacitated or disabled person,
- his or her spouse,
- children or other close relative over the age of 18 years;
- any person acting in a representative capacity with respect to any of the respondent’s financial resources;
- any person having care and custody of the respondent.
If the court has made a finding of total disability and incapacity, the person is presumed to be incompetent for all legal purposes.
Guardians must always act in the best interests of the ward. The guardian of an incapacitated person is responsible for the physical custody of the ward and must make decisions about the ward’s care, treatment, shelter, education, support and maintenance. Guardians may give legal consent for medical treatment of the ward. Guardians must report to the court at least annually on the ward’s physical condition.
A conservator is responsible for protecting and managing the protectee’s financial assets. The conservator must properly and prudently invest the protectee’s assets, apply those assets to the protectee’s care and maintenance, and account to the Probate Division for all monies received and expended on behalf of the protectee. Most expenditures on behalf of the protectee must be authorized by prior court order.
Guardians and conservators are not personally liable for the debts and obligations of a ward or protectee, so long as they make it clear they are acting on behalf of the ward or protectee in a representative capacity. However, any unauthorized use or misappropriation of the ward/protectee’s property by either the guardian or the conservator will render them liable and result in their removal.
Guardianship and conservatorship for an incapacitated and disabled person may terminate when the ward/protectee is found to be competent by the court. It may also be terminated if the court determines the guardian or conservator is not following the duties and responsibilities required by law. Anyone, including the incapacitated or disabled person or someone on their behalf may, at any time, petition the court for a change in who is guardian/conservator, or to increase or decrease the powers outlined in the letters of guardianship or conservatorship. The court may also accept resignations of the guardian or conservator. The court may issue an order terminating guardianship or conservatorship or the order appointing a guardian or conservator may expire unless the court orders an extension of the appointment. Conservatorship may terminate if the assets of the protectee are completely exhausted. Authority is also terminated upon the death of the ward/protectee.
Coordination should occur with the Department of Mental Health and the Division of Developmental Disabilities if the youth is currently receiving services or involvement is necessary. Some youth receiving these services while in care may not need continued care or a guardianship arrangement.
18.104.22.168 Effects of Guardianship/Conservatorship
A full guardianship or conservatorship means the youth is presumed to be incompetent and significantly limits the youth’s personal rights to make decisions and perform many activities enjoyed by other citizens. Therefore pursuance of a full guardianship or conservatorship should be carefully considered. Limitations may include:
- The stigma a ward feels regarding how he is now treated under the law. The person, for example, may have little or no say about where he lives, who his doctor is, or how this property and money is handled. In sum, the person’s status in society is confirmed through legal reinforcement.
- Loss of power to consent, or object, to medical care
- Loss of the right to vote
- Loss of the power to obtain the Department of Mental Health community placement if the guardian objects
- Loss of the right to marry without guardian/court permission
- Loss of the right to make enforceable contracts
- Being subjected to placement in a mental health or mental retardation facility without court hearing
- Loss of the right to hold public office
- Loss of the right to obtain a driver’s license or drive a motor vehicle
- Loss of the right to own or possess a firearm
- Disqualification from being a witness in court
22.214.171.124 Steps to be Taken
Transition planning is an ongoing process and community services and resources should be explored first as the least restrictive option for youth who will require supportive assistance when transitioning from care.
However, if guardianship/conservatorship may be the best plan for the youth then a referral should be made to the Division of Legal Services (DLS) to staff the case for legal advice. The legal advice DLS provides is confidential to the Children’s Division.
Communication with DLS should begin one year in advance to allow review of the supporting documentation, preparation and filing of legal documents and obtaining a hearing date as matters of guardianship/conservatorship are determined through a court hearing.
Evidence must be submitted on the youth’s current mental and physical status and current ability to care for him/her without assistance in order for a determination to be made. The burden of proof is on the person who is seeking to have a guardian/conservator appointed for the respondent, to prove the respondent is totally or partially incapacitated or totally or partially disabled. Therefore, it is essential the medical/professional evaluation meets the requirements of incapacitation. Guardianship or conservatorships involve time, expense, and continuing court supervision.
The guardianship referral and assessment information should be sent to DLS no later than 6 months prior to the youth’s anticipated transition from foster care.
The following items regarding the youth must be provided to the Division of Legal Services:
- DLS Case Referral form
- Copy of the original Jurisdictional Order;
- Copy of the most recent court order retaining youth in custody;
- Current (within the last six months) evaluation/report from physical and mental health medical professionals evaluating the physical and psychological ability of youth to care for himself/herself. Including a statement of the current diagnosis and prognosis;
- Medical records from all medical professionals;
- Vocational needs assessment. Vocational Rehabilitation Services may be able to assist with this in some situations;
- A report/assessment by DMH and/or DHSS of eligibility and services available;
- Educational needs assessment and records including Individualized Education Plan (IEP), current education level, abilities and needs;
- Report of any other special needs;
- Report from child’s Children’s Service Worker of why youth requires a guardianship.
- Assets and/or necessities:
- List of youth’s current medications;
- The sources and amounts of any income available to the youth, including any funds such as SSI payments, OASDI, trust accounts, employment, etc.
- The estimated value of the youth’s real and personal property (furniture, clothing, DVD’s, CD’s, computer, TV, etc.).
- The county in which the property of the youth, or a major part thereof, is located.
- Parties and/or witnesses:
- The names and addresses of child’s parents and any other adult relatives involved in child’s life including siblings or grandparents. Adult in this instance means anyone 18 years;
- The name and address of the current placement;
- The length of time youth has been in current placement;
- The name of the child’s Children’s Service Worker who works with the youth on a day-to-day basis.
There may be additional information DLS will need depending upon the facts of a particular case. The DLS attorney assigned to the case will let the child’s Children’s Service Worker know if additional information is needed. It is imperative all information needed to file a guardianship/conservatorship petition is sent to DLS in a timely manner or DLS will not pursue a guardianship/conservatorship.
A clear aftercare plan is needed in order for youth to transition from care into a guardianship or conservatorship successfully after the age of 21. As jurisdiction of the juvenile court and Children’s Division terminate on the youth’s 21st birthday, planning must begin well in advance of the date of the youth’s 21st birthday or the date the guardianship is needed to go into effect.
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