NYC Administration for Children's Services & NYC Department of Health and Mental Hygiene

Family Pathways to Care

How might we refine referral pathways for families and coordinate social services and mental health services to support healthy child development and well-being?

Partners and Funders

The Project

ACS Prevention and DOHMH Bureau of Children, Youth, and Families (CYF) each contract for services that aim to promote positive child outcomes by strengthening the family unit and parents’ ability to support their children’s development and well-being. These therapeutic and prevention services serve similar populations, sometimes using the same or similar approaches. However, these programs do not always coordinate to ensure that the referral process is streamlined, or that families are being referred to programs that best meet their needs.

 As part of the Collaborative Innovations Initiative, a grant awarded to ACS by the NYC Mayor’s Office for Economic Opportunity, PPL is partnering with ACS and DOHMH to understand how families connect with, and experience therapeutic and prevention services. We will develop strategies to refine referral pathways and improve service coordination. In turn, we aim to improve families’ access to services and impact positive child outcomes. This project also responds to new challenges caused by the COVID-19 pandemic, and the sudden transition to remote prevention and therapeutic services.

Work to Date

In April 2020, we paused the initial phase of work to respond to the COVID-19 pandemic and understand how both agencies could support providers and families experiencing disruptions in their therapeutic and prevention services due to illness and stay-at-home requirements. We conducted research with caregivers, service providers, and subject matter experts to better understand their experiences providing and receiving telemental health services. Findings from this research and design phase informed the development of NYC Telehealth Tips, a website that provided guidance for providers and families transitioning to remote prevention and therapeutic services. 

 In June 2020, we resumed focus on the original project goal and conducted research with caregivers and service provider staff to understand how families access and experience prevention and therapeutic services. The research insights helped the team determine the points of interaction in the service journey where it would be most impactful to design interventions. In January 2021, we worked closely with these stakeholders to design and test tools and processes to improve their experience with therapeutic and prevention services, as well as improve the coordination of services. This co-design and testing phase resulted in a set of high-fidelity prototypes of tools that will be piloted and tested in a real service environment. 


To identify core stakeholder needs we conducted over 200 hours of qualitative research with caregivers, provider staff, and subject matter experts to better understand how families find and use therapeutic and preventative services. Based on our research, we developed a Journey Map and a Referral Pathways Diagram to visualize our research insights and help us identify common needs for agency partners, provider staff, caregivers, and young people that informed our design interventions.

What We Designed

Currently, we are working with our project partners, ACS and DOHMH, to prepare for the pilot of the tools and materials. These tools and materials will be ready to be piloted with providers and families in the summer of 2021.

Design concepts from Release 4 were developed into a set of seven final pilot-ready prototypes of new policies, tools, and materials. This was achieved through iterative cycles of collaborative design and observed field testing with families and provider agency staff. Prototypes are organized around three primary interconnected objectives: A collaborative referral process (“Collaborative Referrals”), building trust with caregivers and youth at the beginning of treatment (“Trust-Building Intake”), and having a transparent and responsive feedback process (“Responsive Delivery”).

Collaborative Referrals 

We created a set of prototypes that aims to centralize comparable cross-agency program information, standardize referral processes around best practices across the system, and leverage existing referral platforms (NowPow).

 The Collaborative Referral Guide includes:
  • 7 Stages of the Referral Process: Outlines and offers a standardized seven-step process for making referrals, that was informed by best practices surfaced in our research. 
  • Youth and Family Choice Worksheet: Guides families and youth through a series of questions to help identify service delivery preferences.
  • Service Array Summary: A searchable and filterable directory of all ACS Prevention, DOHMH CYF-contracted programs, and NYS Office of Mental Health licensed clinics. The directory contains program descriptions, eligibility criteria, contact information, and next steps for making a referral. *The Service Array is not a final product. The content displayed has been aggregated from existing public referral sources. 
  • NowPow Tip Sheet: A set of instructions guiding provider staff on how to use NowPow, a referral platform, to connect families and youth to additional community-based services.
  • Interagency Collaboration Meeting Agenda: An agenda to facilitate recurring conversations between ACS Prevention and DOHMH CYF to assess the full-service array, and strategize on how to redistribute resources and solve common issues.


Trust-Building Intake

We designed a set of guides that explain the intake and consent process (“Welcome Kit”) to increase transparency and accessibility, and support provider staff in building trust with families and young people. For the intake guides, we created two versions: one provides context-specific information for families who are referred to services through a Child Protective Services (CPS) investigation, and the other version for those who are referred through different channels.  

The “Welcome Kit” includes:
  • What to Expect (CPS): A guide that CPS can use to inform families on what to expect in a joint meeting with CPS and their therapist or caseworker. *This prototype is pending PPL and the project partners’ engagement with CPS. 
  • What to Expect (non-CPS): A guide that staff can use to inform families and youth about the prevention or therapeutic program to which they were referred. 
  • Consent Explainer: A step-by-step guide that provider staff can use to inform and empower families and youth about the consent process.


Responsive Delivery 

We created a 5 Commitments Framework for Feedback Collection to support, coordinate, and streamline the feedback collection and response process across ACS Prevention- and DOHMH CYF- contracted agencies as well as NYS Office of Mental Health licensed clinics. This framework operates from a family and youth-centered perspective and can be tailored to meet the needs of provider agencies.



Currently, we are working with our project partners, ACS and DOHMH, to pilot these prototypes this summer.

Project Team

Cesay Camara
Nia Holton-Raphael
Natalie Sims headshot
Natalie Sims
Stephanie Yim
Antonia Yunge
Erika Lindsey