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FSS Onboarding Lesson 4: Collaboration & Community Partnerships

How DPH and LIAs collaborate with community partners to connect families with wraparound services.

What Are Wraparound Services?

Wraparound services are the network of community resources and programs that address the social determinants of health -- the conditions in which people live, work, and grow that profoundly affect their health and well-being. For the families you serve, these might include emergency and transitional housing, food banks, WIC, and SNAP enrollment support, mental and behavioral health services for caregivers, domestic violence safety planning, childcare subsidies, Early Intervention services, substance use treatment and recovery support, and legal aid.

How FSS Workers Make Referrals

  1. Identify the need. Through conversation, observation, and the use of validated screening tools, you recognize a need the family has that goes beyond home visiting services.
  2. Discuss with the family. Share information about the resource or program with the family. The family's willingness and readiness to engage is central.
  3. Make the connection. When possible, make a warm referral: contact the partner agency with the family present or with their explicit permission.
  4. Document the referral. Record the referral in your documentation system, including the date, the resource, and the family's response.
  5. Follow up. At your next visit, check in to see whether the family connected with the resource.

The Delaware Family Support Hub as a Resource Tool

The Delaware Family Support Hub at defamilysupporthub.org includes a searchable resource library that FSS workers can use to find community resources by topic and location. You can use it to prepare for visits or search alongside the family during a visit, making the process collaborative.

Cross-System Coordination

As an FSS worker, you may interact with: Early Intervention (Part C) for children birth to age 3 with developmental delays; behavioral health systems including community mental health centers; schools and Head Start programs as children approach preschool age; WIC and SNAP offices; and child welfare in situations where you have safety concerns.

Learning Check

After completing this lesson, you should be able to:

  • Define wraparound services and explain why connecting families to community resources is a core FSS responsibility
  • Describe the five steps of an effective referral process
  • Identify at least three cross-system partners an FSS worker may coordinate with