PHASE 2
2025
A ttachment 1: Cit y of Sa n José Chi ldr en and Yo uth Serv ices Ma ster Pla n A nnual St a tus Report 2025
Acknowledgments
The City of San José Children and Youth Services Master Plan (CYSMP) Phase 2 Report was developed through a collaborative partnership between the City of San José, Collective Impact Solutions and Sobrato Philanthropies. This effort reflects a shared commitment to fostering impactful community solutions through collaboration and innovation.
We extend our sincere gratitude to the many partners who contributed to the design process and the Priority Area Workgroups. Your dedication and insights were invaluable in shaping this report and advancing meaningful change for children, youth and families in San José. © 2025 Collective Impact Solutions. All rights reserved. This document may not be reproduced, distributed, or used without prior written permission from Collective Impact Solutions.
Families and Youth: Representing City of San José, Department of Parks, Recreation and Neighborhood Services, Project Hope Priority Neighborhoods Organizations:
African American Community Service Agency
Alum Rock Counseling Center
Alum Rock Union School District
Amigos de Guadalupe Center for Justice and Empowerment
Bay Area Tutoring Association
Berryessa Union School District
Blue Zones, LLC
CalTrans
California Afterschool Network
Catholic Charities of Santa Clara County
Child Advocates of Silicon Valley
City of San José
City Manager’s Office Commissions:
· Library and Education Commission
· Youth Commission
Housing Dept
Mayor and City Council:
·Neighborhood and Services Education Committee
Office of Economic Development/work2future
Office of Racial and Social Equity (ORSE)
Parks, Recreation and Neighborhood Services (PRNS)
Public Library
County of Santa Clara
Board of Supervisors
2 © 2025 Collective Impact Solutions. All rights reserved. This document may not be reproduced, distributed, or used without prior written permission from Collective Impact Solutions. · Office of the County Executive:
Office of Children and Families Policy
· Office of Immigrant Affairs
· Office of LGBTQ Affairs
Behavioral Health Services
Behavioral Health Services
Probation Department
Public Health Department
Social Services Agency, Department of Family and Children Services Department Evergreen Valley College
East Side Union High School District
Excite Credit Union
FIRST 5 Santa Clara County
Franklin-McKinley School District (FMSD)
Gardner Family Health Network
Go Kids, Inc.
Grail Family Services
Healthier Kids Foundation
Hispanic Foundation of Silicon Valley
International Children Assistance Network ICAN
Kidango
Kids in Common
Latina Coalition of Silicon Valley
Latino Education Advancement Foundation
Low Income Investment Fund
Monterey County Office of Education/Region 5 Expanded Learning New Hope for Youth
Northern California College Promise Coalition
Pacific Clinics
Parent Voices CA
Rebeka Children’s Services
San Jose Unified School District
San Jose City College
Sacred Heart Community Services
San Andreas Regional Center
San Jose City College
San Jose Jazz
San Jose State University, Spartan East Side Promise Program Santa Clara County Office of Education (SCCOE)
3 © 2025 Collective Impact Solutions. All rights reserved. This document may not be reproduced, distributed, or used without prior written permission from Collective Impact Solutions.
Santa Clara Family Health Plan
Second Harvest of Silicon Valley
Shine Together Inc.
Si Se Puede Collective
Silicon Valley Adult Education
Silicon Valley at Home
Silicon Valley Council of Non-Profits (SVCN)
Silicon Valley Education Foundation (SVEF)
Sobrato Philanthropies
·Youth Advisory
Somos Mayfair
The Tenacious Group
Think Hopeful
Work 2 Future
Working Partnership USA (WPUSA)
4 Table of Contents
7 IntroductiontotheCityofSanJose
ChildrenandYouthServicesMasterPlan
PhasesofDevelopmentandImplementation
8 CommunityandYouthEngagementCollective
CollectiveImpactnetwork(CIN)
17 NoWrongDoorServiceDeliveryModel
Collective
20 34
© 2025 Collective Impact Solutions
Phase2: Installation(Design)
Collective ImpactSolutions'’Approach
andProcess
FiveComponentFramework
LayingtheGroundworkforPhase2
CommonAgenda,TeamingStructure
andCommunicationFeedbackLoops
CountySystemofCareandSchool
Districts Informed
Data-basedDecisionsMaking
Theco-designingstory Integrated System of C
arethroughaNo
WrongDoorServiceDeliveryModel
5 Table of Contents
43 60
67 68
70 Step-by-Step Process of the CSJ NWDSDM
Priority Area Workgroups
77 Transition from Design to Demonstration Site
Installation and Implementation
© 2025 Collective Impact Solutions
Single Point of Entry
Level of Need and Tiers
Goals, Metrics and Strategies
Challenges and Lessons Learned
Phase 3: Advancing the CSJ System of Care
and NWDSDM
Laying the Groundwork for Phase 3
Technical Assistance for the Initial
Implementation
CIS Leading Technical Assistance
Appendices
Appendix A - Proposed Evaluation
Framework
Appendix B - No Wrong Door Handbook
6 INTRODUCTION TO THE CITY OF SAN JOSÉ CHILDREN AND YOUTH
SERVICES MASTER PLAN
The City of San José Children and Youth Services Master Plan (CYSMP) is a strategic roadmap to ensure every child, youth, and young adult in San José has access to the resources, opportunities, and support they need to thrive. Developed through robust community engagement and data-driven insights, the plan addresses inequities, aligns systems, and fosters collaboration across organizations and stakeholders to improve outcomes for young people and their families.
Strategic Priorities
The CYSMP outlines a comprehensive approach centered on seven priority areas:
Early learning and childcare
Health and mental wellness
Housing access and security
Learning and empowerment
Meaningful and sustaining jobs
Safe, clean, and connected communities
System transformation
The City of San José Children
and Youth Services Master Plan
These priorities are shaped by extensive input
from families, youth, and community
organizations, ensuring the plan reflects the real
needs and aspirations of San José’s diverse
population.
Why This Plan Is Needed
Many children and youth in San José face
persistent disparities in education, health,
housing, and employment opportunities. Too
often, services meant to support young people
operate in silos, making it difficult for families to
navigate systems and access help.
The CYSMP recognizes these challenges and commits to transforming how services are delivered, aligned and accessed to ensure all children and youth can thrive, regardless of their background.
© 2025 Collective Impact Solutions 7
A Shared Vision
Fostering a future where every child and youth in San José grows into a healthy, resilient and thriving adult, enriched with equitable opportunities to live, work, play, dream and prosper within the vibrant landscape of Silicon Valley.
Unifying Purpose
Creating and expanding opportunity pathways and supports, from cradle to career, that develop 21st-century skills and lead to better health, education and employment outcomes for San José children, youth and young adults, particularly those most vulnerable.
The City of San José Children and Youth Services Master Plan: Phase 2
PHASES OF DEVELOPMENT AND IMPLEMENTATION
The CYSMP is being implemented in three key stages:
Phase 1: Community Exploration and Voice (Completed in 2023) The city engaged more than 3,000 youth, young adults, family members, and community partners through focus groups, town halls, and listening sessions. Advisory groups helped identify priority areas and shape strategies for the plan.
Phase 2: Planning and Design (2024–Current, Reflected in Phase 2 Report) This phase focuses on collaboration to formulate inclusive, concrete, and actionable goals, strategies, and objectives to guide the work over the next three to five years. It involves planning, designing, and piloting strategies to transform ideas into measurable outcomes. Key priorities include:
Developing integrated systems that prioritize accessibility and user-friendly processes
Designing evaluation metrics to monitor progress and ensure accountability Strengthening community partnerships to build trust and shared ownership of results
Phase 3: Systems Transformation Installation and Initial Implementation (2025–2027)
The prototyping process will begin with the launch of pilot sites involving youth, community members, and system partners. Using continuous quality improvement, this process will test and validate the initial implementation of systems change.
This phase will be carried out through the CSJ System of Care and the "No Wrong Door" service delivery model, with the goal of creating an integrated, seamless support system for families.
© 2025 Collective Impact Solutions 8
Phase 4: Full Implementation and Sustainability
(2027 and Beyond)
The CSJ System of Care must be fully implemented and sustained with the support of system leaders, partners, and the community. Regular evaluation and continuous quality improvement are essential to ensure its long-term sustainability, effectiveness, and responsiveness to community needs.
Ongoing evaluation will enable the city and its partners to maintain a nimble, responsive system that adapts to evolving needs and priorities.
Key Goals of the Plan
Eliminating Barriers – Implementing a No Wrong Door Service Delivery Model to ensure families can easily access the resources they need without duplication or gaps.
Systems Transformation – Aligning services across city, county and community organizations to remove systemic barriers and create sustainable solutions.
Empowering Community Voice – Engaging youth, families and community leaders as active partners in shaping and implementing solutions.
Building Resilient Systems – Establishing equitable policies and sustainable funding structures to ensure long-term success for San José’s youngest residents.
The City of San José Children and Youth Services Master Plan represents a bold and necessary step toward ensuring every child and young adult has the support they need to succeed. By prioritizing collaboration, equity and innovation, the plan lays the foundation for a stronger, more inclusive system of care—one that adapts to the evolving needs of San José’s youth and families.
As implementation and systems transformation move forward, community engagement and cross-sector partnerships will be at the heart of this work. The success of the CYSMP depends on shared responsibility, continuous learning and a commitment to long-term change. Together, we can create a San José where every child and youth can thrive, not only today but for generations to come.
The City of San José Children and Youth Services Master Plan: Phase 2 9 The City of San José System of Care and No Wrong Door service delivery model are being implemented through a multi-phase approach guided by implementation science’s implementation phases, as outlined in the City of San José Children and Youth Services Master Plan.
Phase 2 marks a critical shift from concept to execution, laying the structural foundation for a cohesive, community-driven system that breaks down silos, aligns resources, and ensures equitable access to support services for all children, youth, and families.
At the heart of this effort, Collective Impact Solutions serves as the strategic backbone, providing expertise, frameworks, and facilitation to transform San José’s service ecosystem. Through a structured, multi-phase approach, Collective Impact Solutions guides stakeholders in designing a sustainable, equity-driven system built with the community, not just for the community.
PHASE 2: INSTALLATION (DESIGN): TRANSFORMING VISION INTO ACTION Phase 3 marks the Initial implementation of the CSJ
System of Care and No Wrong Door service delivery
model at demonstration sites. This phase will:
Test the effectiveness of newly designed service
delivery models
Refine and adjust strategies based on real-world
application and feedback
Establish best practices for scaling the system citywide This phase is pivotal in transforming the CYS Master Plan’s vision into reality. The work ahead will require continued collaboration, commitment, and innovation to make San José a model city for equitable, effective, and impactful services for children and youth.
The City of San José, in partnership with
Collective Impact Solutions, has ensured that the
CSJ System of Care is shaped by those it seeks to
serve. Rather than simply delivering services, this
initiative centers on community leadership,
engaging youth, families, community-based
organizations, schools, and public agencies as cocreators in every development phase. © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 10 BUILDING THE STRUCTURAL FOUNDATION: COLLECTIVE IMPACT SOLUTIONS’ APPROACH AND PROCESS
Phase II April 2024 – Feb 2025
Collective Impact Solutions (CIS) has been instrumental in driving systemic transformation for the City of San
José’s CSJ System of Care. As a consulting
organization, CIS has ensured the initiative’s strategic alignment, sustainability, and accountability. By fostering cross-sector collaboration and dismantling silos that
have historically fragmented service delivery, CIS has
united diverse stakeholders around a shared vision.
Phase 2 has played a pivotal role in establishing the core components of the CSJ System of Care, integrating best
practices in assessment, shared culture, outcomes
alignment, and service coordination.
At CIS, strong, trusting relationships are the foundation of lasting systems change. Our approach is rooted in
collaboration, equity, and systemic transformation,
ensuring that diverse stakeholders—from community
leaders to public agencies—work together to create
solutions that more effectively serve disadvantaged
populations.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 11 To guide the development of the CSJ System of Care, Collective Impact Solutions (CIS) implemented a structured, multi-phase process centered on five key components:
1. Assessment and Analysis
CIS reviewed San José’s existing infrastructure, data systems, initiatives, and services internally to identify gaps, inefficiencies, and opportunities. The needs assessment informed the design of a responsive, community-driven System of Care and supported the establishment of a cross-agency backbone infrastructure.
2. Shared Culture and Vision
A sustainable system requires a shared vision among stakeholders. CIS facilitated collaborative processes to build a shared understanding of goals, challenges, and solutions. Establishing a strong culture of collaboration ensured the CYSMP System of Care would endure beyond any single initiative or funding cycle.
3. Outcomes and Strategies (Evaluation Framework)
CIS supported stakeholders in developing a proposed evaluation framework using a three-pronged approach. This multi-level framework considers the current landscape and progress of the master plan. See Appendix A for details.
4. Single System of Support (CSJ System of Care)
CIS guided the co-design and alignment of services into a single, unified system, ensuring support is tailored to family needs rather than fragmented across multiple agencies. This holistic approach makes services more coordinated, prevention-focused, and equitable.
THE CIS FIVE-COMPONENT FRAMEWORK
5. Implementation & Sustainability
As Phase 4 begins, CIS will work
alongside cross-sector partners to
establish the infrastructure, policies, and
processes necessary for the successful
full implementation and long-term
sustainability of the CSJ System of Care.
The focus will shift from planning to action
and data collection, ensuring systems are
built for longevity, adaptability, and
effectiveness.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 12 The City of San José Children and Youth Services Master Plan (CYSMP) entered Phase 2 with a clear focus on reimagining the current system. The goal was to co-design the City of San José System of Care safety net in partnership with youth, families, and community stakeholders.
To achieve this, the CYSMP implementation model follows a collaborative, multi-phase process that emphasizes:
Capacity building
Coaching and technical assistance
Cross-sector collaboration and alignment
Key System Design Components in Phase 2
Phase 2 focused on four key system design components to ensure the CSJ System of Care is effective:
Establishing a Cross-Agency Backbone Infrastructure – Developing a common agenda framework and teaming structure with communication feedback loops to ensure alignment across agencies.
Creating a CSJ No Wrong Door Service Delivery Model and Community Pathway – Establishing clear pathways for seamless, equitable access to services for children, youth, and families.
Aligning Goals, Measures, and Strategies – Developing a citywide evaluation framework with goals, objectives, metrics, and strategies.
Developing a Community Engagement Plan – Ensuring that youth, families, and community members are co-creators of the system.
LAYING THE GROUNDWORK FOR SYSTEMS TRANSFORMATION
The City of San José Children and Youth Services Master Plan: Phase 2 © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 13 The CSJ System of Care follows a design, development, implementation, evaluation, and continuous quality improvement process based on theoretical frameworks for systems change. These frameworks provide concepts and principles to guide the transformation of complex systems, helping to identify key elements, relationships, and influencing factors.
In Phase 2, these frameworks were instrumental in driving meaningful progress and setting the stage for impactful initial implementation.
The Collective Impact Framework provided a unified vision across stakeholders, enabling a common agenda focused on improving outcomes for children and youth.
Shared metrics were developed to evaluate progress and success, while mutually reinforcing activities ensured coordination between city agencies, schools, and community-based organizations, preventing duplication and maximizing impact.
Continuous communication fostered trust and alignment through transparent updates and backbone support organizations established strong leadership for managing processes and resources.
The No Wrong Door Service Delivery Model (NWDSDM) prioritized a familycentered approach emphasizing ease of access and seamless service navigation. It ensured that every entry point led families to the appropriate support, regardless of where they began. This model also implemented tiered services, ranging from direct referrals to short-term guidance and intensive care coordination.
The Asset-Based Community Development (ABCD) Framework recognized the community's strengths, skills, and resources as essential to achieving outcomes. It empowered community members as co-creators and decision-makers, shifting them from passive recipients to active contributors. This approach highlighted opportunities for community-led initiatives to address service gaps.
The Life Course Framework emphasized prevention and early intervention by considering the developmental trajectory of children and youth. Services were mapped to ensure equitable support across all age groups and stages of development, providing comprehensive, tailored care.
Equity-centered design ensured the inclusion of underrepresented voices in decision-making. By addressing disparities and allocating resources based on need, this framework sought to level the playing field. Principles of diversity, equity, and inclusion were applied to foster belonging and representation throughout all processes.
Together, these structured and collaborative methodologies created a solid foundation for the progress made in Phase 2 and laid the groundwork for the transition to Phase 3. The work must also be guided by dedicated work groups responsible for informing and shaping implementation efforts.
SYSTEMS CHANGE FRAMEWORKS
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 14 PHASE 2 WORKGROUPS: REIMAGINING SYSTEMS TO IMPROVE
OUTCOMES
Phase 2 Workgroups: Reimagining Systems to Improve Outcomes Four key workgroups were formed to ensure the CSJ System of Care was shaped by lived experience and expertise. Each group played a vital role in advancing system design.
Phase 2 priorities focused on collaboration, community engagement, and continuous improvement to create a transformative and sustainable impact on youth services in San José. The process was designed to keep the CSJ System of Care responsive to the evolving needs of San José’s children, youth, and families by leveraging existing expertise and avoiding duplication of efforts. These workgroups refined and aligned system components, demonstrating a commitment to community-centered decision-making and system integration.
Community and Youth Engagement Collective – Strengthening Community and Youth Engagement
This workgroup ensured that community expertise and lived experience guided system transformation by:
Removing barriers to participation for underrepresented communities Actively integrating community feedback into service design and evaluation Ensuring youth and families were co-creators, not just stakeholders, in decisionmaking © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 15 "No Wrong Door" Service Delivery Model (NWDSDM) Collective - Co-designing Service Pathways
This workgroup aimed to create a seamless, family-centered system that ensures equitable access to services through tiered support levels:
General referrals and self-navigation – For families needing basic resources Moderate support services – For families requiring short-term case coordination Intensive care coordination – For families facing significant barriers to stability Priority Area Workgroups (PAWGs) - Aligning Goals, Measures & Strategies A critical component of Phase 2 was establishing measurable objectives and evaluation metrics to track progress and assess system effectiveness. This included:
Defining shared goals and success measures across stakeholders Developing real-time data systems to monitor service utilization and impact Building capacity for ongoing evaluation to ensure continuous system improvement Collective Impact Network (CIN) – Establishing Backbone Infrastructure This group focused on system alignment to reduce fragmentation and duplication of services by:
Establishing a common agenda framework
Developing governance structures and communication feedback loops Strengthening cross-sector collaboration to create a unified system that provides coordinated, holistic support for families
Streamlining funding and policy alignment to ensure sustainability Enhancing data-sharing and communication protocols for improved service coordination
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 16 A foundational commitment of the City of San José System of Care has ensured that community engagement is meaningful and equitable. Recognizing that true systems transformation requires the voices and leadership of those directly impacted, the codesign process was built around deep engagement with community members, Youth, service providers and cross-sector partners.
The vision was clear: to create a seamless, person-centered system where individuals and families could access services without barriers regardless of where they entered the system. Achieving this required intentional engagement, community leadership and sustainable investment in those shaping the system.
From the beginning, the CSJ System of Care prioritized co-design with lived experience by engaging:
Community-based organizations (CBOs)
Youth and families
School districts and service providers
Through listening sessions, engagement meetings and design workshops, community members shared their challenges, aspirations and ideas for transforming service delivery.
COMMUNITY AND YOUTH ENGAGEMENT COLLECTIVE
Centering Community Voice: Engagement, Equity and Sustainable Support The Impact of Community Engagement in Phase 2
By embedding community engagement at the heart of the co-design process, the City of San José System of Care is not just a policy initiative—it is a movement toward equitydriven, community-centered systems transformation.
Key Takeaways and Outcomes
Community Leadership – Engagement efforts ensured that those most affected by the system had decision-making power in its redesign.
Service Model Shaped by Lived Experience – The No Wrong Door model was codesigned with real-world input, ensuring it meets the diverse needs of San José families.
Youth-Led Systems Change – Youth engagement efforts positioned young people as leaders in shaping their city’s future, making services more responsive and effective.
Sustainability Through Shared Ownership – The engagement process built a foundation of trust, collaboration and shared responsibility that will extend into Phase 3 and beyond.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 17 Broad and meaningful participation was central to the engagement strategy, requiring thoughtful efforts to reduce barriers and amplify community leadership. Key strategies included:
Culturally Responsive Engagement – The No Wrong Door model was designed to reflect the diversity of San José families. Engagement materials were provided in English and Spanish, with Vietnamese translations available upon request to ensure equitable language access.
Grassroots Recruitment and Outreach – Flyers, promotional materials and digital content were shared through trusted community partners, emphasizing communitydriven, bottom-up engagement rather than relying solely on top-down outreach.
Valuing Lived Experience – Recognizing the importance of community expertise, efforts were made to compensate individuals for participating in design sessions, underscoring the value of their contributions.
Facilitating Barrier-Free Participation – A user-friendly registration process ensured accessibility regardless of language, literacy or digital access. This intentional approach made participation inclusive and welcoming for all.
Youth-Centered Engagement – Young people were active participants and cocreators in shaping the system. Through visual storytelling and facilitated discussions, youth identified challenges and proposed innovative solutions to improve services.
Creating an Equitable Engagement Process
The Challenge: Ensuring Sustainable Support for Community Leadership Through the engagement process, key opportunities
emerged to strengthen governmental support for
community partnerships. Compensating community
members for their contributions is pivotal in fostering trust and collaboration. While some delays in funding have
occurred due to procedural complexities, efforts are
actively underway to address these challenges and move
the process forward effectively.
To build a foundation for sustainable support, governments can integrate compensation and community resources into funding structures from the outset. This proactive
approach creates an environment where communities are
valued as equal and essential partners in co-creation.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 18 In alignment with its commitment to equity in engagement, the City of San José submitted a funding proposal to Santa Clara County to compensate community members for their expertise, time and lived experience. This funding proposal reflects a shared vision of making community engagement participatory and sustainable, ensuring all stakeholders are supported throughout the process.
The importance of investing in community leadership is outlined in the proposal priorities, including
Providing fair compensation – Recognizing community members’ critical contributions to shaping systems transformation.
Supporting ongoing engagement efforts – Enabling youth, families and CBOs to remain key partners in implementing the CSJ System of Care.
Strengthening outreach and accessibility – Expanding translation services and culturally responsive facilitation to ensure inclusive and community-centered engagement.
While this funding request aligns with initiatives like the Santa Clara County Families First Initiative and AB2083, progress has been challenged by the complexities of public funding processes. These delays highlight an opportunity to refine systems and implement transparent, responsive funding structures prioritizing timely community support.
Securing Funding for Sustainable Community Engagement
The City of San José can continue building a foundation for inclusive, sustainable systems transformation by fostering greater collaboration and shared accountability.
Streamlining Funding Processes – Enhancing systems to ensure timely, equitable compensation for community involvement.
Institutionalizing Fair Compensation – Embedding community remuneration as a standard practice in future initiatives.
Fostering Shared Responsibility – Promoting a culture of mutual accountability between government and community stakeholders.
The City of San José System of Care embodies the principle that meaningful transformation is achieved through true partnerships. By refining processes to reflect shared values, this initiative can advance equity and collaboration, laying the groundwork for long-term success.
Priorities for Strengthening Engagement
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 19 Phase 2: Establishing the Collective Impact Network
In fall 2023, Phase 2 of the CYS Master Plan commenced with initial efforts to form a Collective Impact Network (CIN). Composed of stakeholders from diverse sectors, the CIN was established to address the urgent need for improvements within the CSJ System of Care. This collaborative approach aimed to break down silos and improve coordination within the existing ecosystem.
Applying a Life Course Framework, the CIN sought to understand systemic complexities and implement policy and systems changes that remove barriers and shift conditions. The ultimate goal is to create a more interconnected, responsive system that effectively addresses complex challenges.
The Role of the Collective Impact Network
The CIN played a critical role in driving collaboration, aligning efforts and laying the groundwork for lasting systems change. As the backbone, the CIN united diverse stakeholders to create a focused, effective decision-making body. The CIN created a strong foundation for equity-focused, collaborative systems transformation by formalizing its team structure, setting decision-making protocols, and establishing a communication feedback loop.
Developing a Common Agenda Framework
To ensure the integration and leverage of city prevention efforts, CIN partners developed a Common Agenda Framework. This framework included guiding principles and agreements, a shared problem definition, common measures, a strategy for change, and a plan for continuous learning.
CIN partners also formalized a teaming structure with specific agreements to address complex, multi-layered challenges. Solutions were developed and co-designed in partnership with the affected community, requiring all stakeholders to work differently— together—in trusting relationships. Using the collective impact model, the CIN advanced a shared agenda to shift fragmented, siloed systems into a coordinated, community-driven approach.
DEFINING PROGRESS IN THE CSJ SYSTEM OF CARE
COLLECTIVE IMPACT NETWORK (CIN)
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 20 The Common Agenda Framework provides a structured approach to guide the City of San José System of Care (CSJ System of Care). It ensures alignment among stakeholders, fosters collaboration, and supports the effective implementation of community-driven solutions.
Guiding Principles – Agreed-upon values that guide decision-making and define the group's operation.
Common Problem Definition (Shared Vision, Priority Population, and Areas) – A shared understanding of the problem, including data review, analysis of root causes and defining the boundaries of the change effort.
Goal (Shared Measures) – A measurable, population-level goal that defines success.
Framework for Change (Teaming Structure, Feedback Loops, Strategic Action Framework) – A structure to divide the workload, including working groups, backbone roles, feedback loops and resource prioritization.
Plan for Learning (Continuous Improvement and Evaluation Plan) – A plan for evaluation and continuous improvement includes defining, monitoring and recognizing progress, identifying challenges and integrating learning at every step.
Common Agenda Framework Elements
The Collective Impact Network (CIN) co-design process established common goals and a shared vision. Through discussions, stakeholders examined desired outcomes, root causes, influential factors, and system boundaries. This process resulted in developing a Common Agenda, Guiding Principles, a Shared Vision, a Unifying Purpose and Strategic Priorities.
Shared Vision – A future where every child and youth in San José grows into a healthy, resilient, self-sufficient adult with access to opportunities to live, work, play, dream and prosper within the vibrant landscape of Silicon Valley.
Unifying Purpose – Create and expand pathways and supports from cradle to career that develop 21st-century skills and lead to better health outcomes, sustainable employment and a competitive living wage for San José children, youth and young adults (birth through age 24), particularly those most vulnerable.
Guiding Values
Accessibility and inclusion for all youth
Cross-sector collaboration, investment and accountability Equity
Outcomes- and results-driven approach
Youth and community voice-driven solutions
Defining a Shared Vision and Common Agenda
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 21 The demonstration sites for the CSJ System of Care were identified during Phase 1 through a process combining community input, data analysis and cross-sector collaboration. This approach ensured pilot sites were selected based on need and capacity to leverage existing resources, investments and expertise.
Two neighborhoods in East San José were chosen:
Poco Way neighborhood, including the Mayfair community (ZIP code 95116) Seven Trees neighborhood, including the Santee community (ZIP codes 95111 and 95122)
The East San José neighborhoods were selected due to their strong community assets and significant disparities in health outcomes, life expectancy, income, housing stability, educational attainment and justice system involvement. The demonstration sites will serve as early adopters of the No Wrong Door Service Delivery Model by focusing on these areas, helping refine and strengthen the CSJ System of Care before broader citywide full implementation.
The selection process was a collaborative effort involving the City of San José’s Department of Parks, Recreation and Neighborhood Services (PRNS), the Youth Empowerment Alliance, Project Hope, the CSJ Library and key community stakeholders. Through this collective impact approach, the demonstration sites will expand existing strengths, test innovative service coordination strategies and provide real-time feedback to shape future implementation. These sites will serve as foundational hubs for the CSJ System of Care, ensuring service delivery remains responsive, equitable and community-driven.
Shared Measures
The CSJ System of Care relies on a shared measurement framework to track progress, align efforts across agencies and ensure accountability in service delivery. Shared measures or common metrics reflect the key priorities of the Children and Youth Services Master Plan (CYSMP), allowing the city to assess the effectiveness of interventions and drive continuous improvement. The evaluation framework (see page ##) provides further details. © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 22 Teaming Structure
To establish the City of San José System of Care, a collaborative teaming structure was developed to encourage systemic communication, support evidence-based practices and ensure data-driven improvement of processes and outcomes.
The CIN includes school districts, city and county departments, community-based organizations (CBOs), system leaders, families, youth and other key stakeholders. A communication feedback loop was created to enable regular updates, collaboration and problem-solving among participants. CIN partners facilitate discussions, document challenges and solutions, track progress and manage strategies to maintain momentum.
The integrated teams promote shared decision-making among community members, service providers and system partners. A diverse network of stakeholders is essential to effectively address common goals, fostering a supportive environment for social, emotional and behavioral health. Community-level teams focus on implementing practices, while city and county agency-level teams support system infrastructure.
Key Components of the Teaming Structure
Integrated Teams – Diverse representation ensures a comprehensive perspective on challenges and solutions.
Specialized Councils – The Youth Leadership Council and Community Leadership Council ensure community voices are heard and hold systems accountable.
Demonstration Sites – Partners test and refine practices using a collective impact approach.
The diagram below illustrates the teaming structure and communication feedback loops of the City of San José System of Care. The City of San José System of Care Network coleads the initiative, builds capacity across sectors and provides leadership and backbone infrastructure.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 23 The CSJ System of Care: Teaming Structure and Communication Feedback Loops The CSJ System of Care operates through a structured, multi-tiered framework designed to leverage resources, align efforts and ensure community-driven, equity-focused service delivery. The framework consists of three primary components:
First Column: CSJ System of Care Partnership Opportunities This tier aligns and leverages resources and supports as needed, such as the County of Santa Clara System of Care (SCC System of Care). The SCC System of Care provides county-level resources and services, addresses countywide barriers and challenges and supports policy changes to enhance service accessibility.
Second Column: CSJ System of Care Network
This governance structure is responsible for vision, strategy and policy implementation. It includes key entities such as the CSJ City Council, CSJ YEA Policy Team, CIN Executive Leadership Team and Collective Impact Network.
The CSJ System of Care Network plays a central role in:
Providing leadership and governance – Establishing strategic direction and aligning policy initiatives
Facilitating collaboration and funding – Supporting aligned activities and mobilizing resources
Ensuring systemic change – Addressing both service practices and infrastructure to improve outcomes
Building public will – Strengthening stakeholder engagement and reinforcing a shared vision
A cascading system of communication and feedback loops ensures alignment between practice and infrastructure. Those closer to the community level focus on direct service implementation, while those at the county level support system infrastructure and policy development.
Community members and youth with lived experience are invited to actively participate in all aspects of the CSJ System of Care Network under the guiding principle of "Nothing About Us Without Us."
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 Third Column: Demonstration Site Community Collectives
This tier represents the mutually reinforcing activities of the CSJ System of Care, focusing on implementing the CSJ No Wrong Door Service Delivery Model. These efforts include:
Service delivery within each priority area
Partner-driven initiatives such as advocacy efforts, CSJ programs and external partnerships
24 Sobrato and Demonstration Sites Youth Leadership Advisory This group ensures that young people's perspectives are reflected in the design and implementation of the CSJ System of Care.
Project Hope
A neighborhood engagement and empowerment program that improves the quality of life by fostering neighborhood associations in underserved areas affected by crime, blight, and violence.
CSJ City Council
San José's legislative body formulates citywide policies, adopts laws and ordinances and approves budgets.
CSJ YEA Policy Team
Co-chaired by the mayor and police chief, this team sets strategic direction, allocates resources, establishes goals and monitors progress. It includes government department heads, senior officials, school district leaders, CBOs, faith-based organizations and neighborhood leaders. This team plays a key role in guiding the CSJ System of Care.
CIN Executive Leadership Team (Steering Committee)
Serving as the backbone of the CSJ System of Care, this oversight body unites diverse leaders to drive implementation, oversee policy alignment and coordinate citywide solutions for children and youth.
Collective Impact Network (Technical Team)
A high-functioning learning and strategy network responsible for:
Finalizing the Common Agenda Framework, Implementation Plan and Evaluation Framework
Connecting initiatives to ensure new programs are collaborative Leading a continuous improvement process and evaluating system performance with a focus on community success
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 Youth and community voices are
incorporated into all design aspects,
including evaluation and data
collection. Youth with lived
experience will engage in ongoing
discussions to shape policies and
programs.
Integrated Teams
Youth and Community Members with Lived Experience
25 Demonstration Sites Community Collectives (FMCI & Sí Se Puede) Demonstration site partners leverage existing resources, investments and expertise to develop innovative service coordination strategies. Using a collective impact approach and implementation science frameworks, they ensure that all CSJ System of Care elements are community-driven and research-informed.
Priority Area Workgroups
These workgroups ensure that services remain effective, responsive and equitable by:
Focusing on specific areas of need
Promoting cross-sector collaboration
Driving policy by providing strategic recommendations and best practices Monitoring service and program effectiveness within their areas Santa Clara County Children and Youth System of Care (CYSOC) The Santa Clara County Children and Youth System of Care (CYSOC) operates under an interagency framework to ensure coordinated, trauma-informed and culturally responsive services for children, youth and families.
Aligned with the Integrated Core Practice Model (ICPM), Multi-Tiered System of Supports (MTSS) and Upstream Prevention, CYSOC follows a No Wrong Door approach to improve service access and collaboration across agencies.
CYSOC Governance and Service Coordination
Four interagency teams guide CYSOC, each responsible for oversight, coordination and policy implementation:
Interagency Leadership Team (ILT) – Oversees the strategic direction, policy implementation and system-wide accountability. Composed of agency leaders, the ILT ensures integrated, trauma-informed services and advises the County Board of Supervisors.
Executive Advisory Committee (EAC) – Supports the ILT by providing policy and program recommendations, streamlining service delivery and enhancing family engagement.
Technical Working Group (TWG) – Develops and refines service policies, procedures and best practices, ensuring program effectiveness through continuous evaluation.
Interagency Placement Committee (IPC) – Coordinates specialized placement decisions for youth with complex needs, ensuring services are delivered in the least restrictive settings.
COUNTY SYSTEM OF CARE
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 26 Expanding Student Success Through Integrated Support Systems To improve academic success, schools and districts must expand their support to address students' health and social well-being. The Center on PBIS (2022) recommends that school leadership teams use existing systems, practices and data to guide prevention and response activities within a Multi-Tiered System of Support (MTSS) framework.
For systemic change to be sustainable, county offices of education, school districts and school sites should fully embrace the MTSS framework. This collaborative approach engages all stakeholders in building a connected ecosystem that aligns internal structures and processes to improve efficiency. It also establishes a comprehensive Single System of Support that meets all students' and families' academic, behavioral, social-emotional and mental health needs. Collaboration with community partners is essential to the success of this collective effort.
Transformational Community Schools and Collaborative Leadership Transforming California's education system requires a collective impact approach centered on Transformational Community Schools, where students, families, educators and community partners share decision-making power. Collaborative leadership, which recognizes and leverages community strengths, fosters collective expertise and empowers all school community members. This model challenges historical power imbalances, ensuring marginalized and underserved communities have a voice. By centering relationships and racial justice, collaborative leadership sustains the community schools strategy, driving transformative change in alignment with MTSS.
SCHOOL DISTRICTS
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 The Single System of Support Framework
Using the Collective Impact approach, the Single System of Support Framework integrates health and human services with school districts to promote racial and economic justice. It focuses on:
Dismantling the school-to-prison pipeline
Disrupting cycles of poverty through the Life
Course Framework
Aligning system partners around student and
family needs
Strengthening community partnerships
Implementing the CSJ No Wrong Door
Service Delivery Model (NWDSDM)
grounded in upstream prevention
This framework ensures schools can access individualized, compelling and trustworthy services for students and families precisely when needed. 27 Establishing a Collaborative MTSS Teaming Structure
To achieve this, an MTSS teaming structure (see visual below) will be established or enhanced within school districts and school sites. This structure will align with the CSJ System of Care and County of Santa Clara System of Care, ensuring system partners can communicate systematically, implement evidence-based practices, evaluate progress and share data.
This approach integrates process evaluation and quality improvement, ensuring milestones are met as intended. It enables community members, program staff and leaders to communicate effectively, work toward shared outcomes and support intended population groups through a structured, collaborative system.
SCHOOL DISTRICTS
Advancing Systemic Change and Resilience
The CSJ System of Care fosters collaboration between institutional partners to drive systemic change and build resilience within schools and neighborhoods. By working together, partners can:
Enhance early learning and school readiness
Strengthen student and family resilience
Support healthcare and safety services
This model ensures that students, families, and communities receive the support they need to thrive through alignment, partnership, and equity-driven strategies. © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 28 MTSS District Executive Leadership Team (DELT)
The MTSS District Executive Leadership Team develops and updates district-wide MTSS implementation plans, ensuring alignment with current resources, guidelines and research.
The team oversees the consistent implementation of MTSS across all schools, standardizing procedures and measures while identifying and allocating necessary resources.
By working closely with the City of San José and County of Santa Clara Systems of Care, the team aligns MTSS with broader community support systems to address students' academic, behavioral and social-emotional needs. The team ensures continuous improvement through data-driven decision-making and advocates for policy changes, professional development and resource allocation to eliminate systemic barriers.
MTSS School Site Leadership Team
The School Site Leadership Team ensures a unified vision for school-wide MTSS implementation, aligning staff and resources toward common goals. The team:
Develops, implements and evaluates the School Improvement Plan Analyzes data to set student achievement goals
Distributes leadership responsibilities to improve the execution By collaborating with the City of San José (CSJ) and County of Santa Clara (SCC) Systems of Care, school teams connect their MTSS framework with broader community support systems using the CSJ No Wrong Door Service Delivery Model (NWDSDM). They identify and address school-specific barriers, ensuring students receive needed community support while continuously refining MTSS practices through data review and feedback.
MTSS Teacher Teams (Grade Level/Department)
Teacher teams refine the curriculum to meet students' academic, behavioral and socialemotional learning (SEL) needs. They focus on:
Enhancing core instruction through collaboration
Using data analysis to drive instructional strategies
Engaging in professional development to strengthen teaching practices These teams integrate the Collective Impact approach, conducting community assessments to identify strengths, gaps and needs. They incorporate community perspectives into system design and build cross-sector partnerships to co-create solutions.
A no wrong door approach, grounded in upstream prevention, ensures services are accessible and tailored to the community.
Multi-Tiered System of Supports (MTSS) District Teams
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 29 Decision-Making Protocols
Phase 2 established decision-making protocols to balance inclusiveness and efficiency within the CIN:
Collaborative problem-solving – Teams identify challenges and propose solutions, escalating complex issues to the CIN Executive Leadership Team Authority delegation – Decisions are shared across councils and teams, with clear escalation pathways to prevent delays
Transparency – All decisions are documented and communicated through the feedback loop, ensuring accountability
This shared approach avoids siloed decision-making, builds trust and promotes equity across stakeholders.
INFORMED DATA-BASED DECISION MAKING
How These Teams Collaborate
Collective Impact Network (CIN) teams collaborate to align efforts and drive shared goals.
Regularly scheduled meetings provide opportunities to:
Identify priorities – Discuss challenges and set goals aligned with the CYSMP Develop strategies – Design actionable plans specific to focus areas Share progress – Present updates, avoid duplication and leverage best practices Problem-solve – Address barriers using network resources and expertise Each team follows clear accountability guidelines, including tracking progress, reporting outcomes and adjusting strategies based on real-time data and feedback.
As part of the CSJ System of Care's continuous improvement framework, data-based problem-solving informs the design of services and supports. This intentional process ensures services adapt to the evolving needs of youth, families and system partners.
Using the continuous improvement framework, teams can:
Identify needs and gaps within the system
Design and implement interventions tailored to those needs Assess implementation fidelity to ensure consistency
Evaluate outcomes and adjust services as needed
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 30 Data-Driven Decision-Making and Continuous Improvement Using data to drive decision-making occurs at all levels of the prevention framework, ensuring continuous improvement within the CSJ System of Care. Prioritized, targeted data helps identify areas for improvement, refine strategies, and enhance system-wide effectiveness.
Data-based decision-making is embedded within the problem-solving process, allowing teams to assess youth and family needs across the system. It informs instruction, interventions, and movement within the tiered system of support, ensuring services align with the needs of stakeholders, youth, families, and communities.
The communication feedback loop, including fidelity assessments, facilitates ongoing reflection and refinement to maintain effectiveness and accountability.
Data-Based Problem Solving
Data-based problem-solving is a key component of the CSJ System of Care’s continuous improvement framework, ensuring the intentional design of services and supports. This process allows for rapid identification and adaptation, enabling services to meet the evolving needs of youth, families, and system partners.
Regular fidelity assessments within the communication feedback loop ensure implementation remains consistent, effective, and aligned with system goals. © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 31 Levels of Data-Based Problem Solving
The CSJ System of Care uses a structured four-level data-based problem-solving approach:
Identifying needs – Using data to recognize service gaps and areas for improvement Designing interventions – Developing and implementing strategies based on identified needs
Assessing fidelity – Monitoring implementation to ensure effectiveness Evaluating outcomes – Measuring impact and making necessary adjustments By integrating communication feedback loops between the City of San José System of Care, Santa Clara County System of Care and school districts, the CSJ System of Care ensures a cohesive, coordinated approach to continuous improvement.
Effective communication feedback loops foster collaboration between the City of San José System of Care, Santa Clara County System of Care and local school districts. These loops ensure:
Ongoing information exchange
Alignment of efforts
Identification of service gaps
Support for data-driven decision-making
Structured communication channels allow stakeholders to share best practices, refine interventions and enhance service delivery, improving outcomes for youth, families and communities.
Communication Feedback Loops
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 32 The CSJ System of Care is transforming vision into
action—creating a future where every child, youth
and family in San José has equitable access to the
support they need to thrive.
Why This Work Matters
The work accomplished in Phase 2 is critical to the success of the CYSMP, as it establishes the foundation for sustainable, system-wide change.
Organized and aligned efforts – The teaming structure ensures a coordinated approach to service delivery
Equitable and efficient decision-making – Established protocols prevent delays and ensure accountability
A dynamic, data-driven system – The communication feedback loop enables continuous learning, adaptation and responsiveness
By creating this collaborative infrastructure, Phase 2 has positioned the CSJ System of Care Network to drive equitable, accessible and effective services for San José’s children, youth and families.
Formalized Communication Feedback Structures
Monthly reporting to the Neighborhood Services City Service Area team, which includes the City Manager’s Office, Library, Parks, Recreation and Neighborhood Services, Planning, Building and Code Enforcement, Housing and Public Works (Animal Care and Services).
Quarterly reporting to the Alliance Technical Team, a formalized subcommittee of the Alliance Policy Team. The Alliance Technical Team includes the San José mayor, City Council members, Santa Clara County Board of Supervisors and representatives from more than 70 agencies, including city departments, community and faith-based organizations, Santa Clara County and other stakeholders.
Annual reporting to the San José City Council through the Neighborhood Services and Education Committee. These reports track progress on Children and Youth Services Master Plan goals and objectives while providing opportunities for guidance and input from council and committee members.
By prioritizing transparency and open communication, these feedback loops build trust among stakeholders and ensure that decisions are informed by both data and lived experiences.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 33 The Story of San José’s System of Care through a No Wrong Door Service Delivery Model
The City of San José, in partnership with Santa Clara County, community-based organizations, school districts and families, recognized the urgent need for change. The solution: a No Wrong Door Service Delivery Model—an integrated, community-driven system ensuring families receive seamless, culturally responsive support no matter where they enter.
This transformation wasn’t a policy handed down from leadership. It was built from the ground up, co-designed with the people it serves. It emerged through listening, learning and collective action, ensuring every piece of the system was informed by lived experience and guided by community wisdom.
For more details on the No Wrong Door Service Delivery Model, see the appendix.
NO WRONG DOOR COLLECTIVE - CO-DESIGNING
The Story Behind No Wrong Door
The NWDSDM emerged from a vision of accessibility, equity and seamless care for families and youth in San José. Rooted in the County of Santa Clara’s Community Pathway and aligned with the Family First Prevention Services Act, this model represents a collaborative commitment to breaking down systemic barriers and transforming service delivery.
Rather than duplicating existing efforts, the city strategically unified and leveraged work already underway in San José and Santa Clara County.
The model integrates best practices from systems change frameworks, ensuring cross-sector collaboration and trustbased partnerships between system leaders, community organizations, families and youth.
For too long, families in San José seeking support faced confusing pathways, siloed agencies and inconsistent access to vital services. Parents searching for mental health support for their children, housing assistance or educational resources were often shuffled from one department to another, forced to repeat their stories, fill out multiple forms and navigate bureaucratic hurdles. These inefficiencies delayed care, increased frustration and disproportionately harmed underserved communities.
This work requires ongoing honest conversations and co-design efforts to shape a system that truly serves the needs of children, young adults and families. © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 34 Co-Design: A Community at the Heart of Change
Key Steps in the Co-Design Process
Community Listening Sessions: Families shared their challenges, needs and aspirations for a better system.
Youth Engagement: Young people played a vital role, using tools like the Aspirational Iceberg to identify systemic barriers and reimagine solutions.
Culturally Responsive Design: Services were tailored to the diverse needs of San José’s communities, with materials translated into multiple languages.
Grassroots Outreach: Flyers, social media and trusted community partners helped spread the word and recruit families for the design process.
Compensating Community Voices: Recognizing the value of lived experience, families and youth were compensated for their time and contributions.
The result? A model shaped by the people, for the people—one that prioritizes equity, trust and accessibility.
Co-Designing with Lived Experience
The CSJ System of Care through a No Wrong Door Service Delivery Model was developed through extensive co-design sessions with community members, youth, service providers and various stakeholders. These sessions emphasized lived experiences and community voice to identify system gaps and co-create solutions.
Community Mapping and Engagement
Participants engaged in exercises to map out current service delivery models, identifying barriers and best practices. One impactful activity, the Aspirational Iceberg, helped participants explore underlying values, structures and mental models that shape the service delivery experience. This exercise allowed community members to envision what they wanted from their city and collaboratively identify visible and invisible factors that influence the culture and success of the service system. © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 The co-design process was rooted in listening
and learning and held as part of the No Wrong
Door work group. The city and its partners
launched an extensive engagement effort,
bringing together youth, families, communitybased organizations, schools and service providers to reimagine how services should be
delivered. The goal was to develop a model
with multiple entry points, universal intake and
assessments and a tiered approach to
services.
35 Aspiration Iceberg: created by community members 2024 The Aspirational Iceberg reveals a deep community vision for a healing, equitable system.
It moves beyond surface-level changes to address the root causes of inequity, creating a service delivery model driven by compassion, cultural sensitivity and shared accountability.
X
with access to abundant opportunities to live, work and prosper in the vibrant landscape of Silicon Valley.
To achieve this vision, the City of San José, in partnership with Sobrato Philanthropy and Collective Impact Solutions, makes a bold commitment to centering youth as key
stakeholders in transforming the service delivery system.
Recognizing that young people—those most affected by
these services—must be heard and empowered, this effort ensures their voices shape meaningful change.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 By aligning values, patterns and structures with this vision, the City of San José System of Care becomes more than a system—it evolves into a community-driven culture of care and belonging.
Along with incorporating family stories and experiences, the work also highlights youth voices. The Sobrato Youth Engagement effort is driven by a clear vision: fostering a future where every child and youth in San José can thrive, becoming resilient, self-sufficient adults 36 Youth participation is integral to the co-design process. Their perspectives are captured in graphics and visuals (see visuals), which illustrate systemic challenges and reveal the underlying values and structures that need transformation. This exercise allows youth to reimagine their city and identify the visible and invisible factors that shape the culture and success of the service system.
These activities reveal a deep community vision for a healing, equitable system, moving beyond surface-level changes to address root causes of inequity. This is a story of building a service model driven by compassion, cultural sensitivity and shared accountability. By aligning values, patterns and structures with this vision, the City of San José System of Care becomes more than a system—it transforms into a community-driven culture of care and belonging.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 37 The CSJ System of Care No Wrong Door workgroup, guided by the vision of youth and community members, developed a comprehensive service delivery framework, tools and processes. The group aimed to establish a shared understanding of the key elements needed to provide children, youth and families with seamless access to services. This access would be facilitated through a robust network of collaborative partners, including schools, community-based organizations and city and county departments.
Mapping Current Service Delivery Models
The Aspirational Iceberg exercise was used to examine the underlying values, structures and mental models that influence service delivery. Conducted in alignment with youth and community members, this activity envisioned potential city- and countywide collaborations that would benefit youth and families. Throughout the process of co-designing the No Wrong Door Service Delivery Model, cross-system partners participated in exercises to map and identify barriers and best practices in current service delivery models.
Identifying Key Elements of the CSJ No Wrong Door Service Delivery Model Through this process, the workgroup identified key elements essential to creating an effective “no wrong door” approach to accessing a range of services, from initial contact to assessment, service delivery and follow-up.
Key Elements of the CSJ NWDSDM
1.Initial contact and engagement
2.Universal intake, screening, determining level of need, multi-dimensional assessment
3.Service coordination
4.Service delivery
5.Follow-up and progress monitoring
6.Outcome evaluation and continuous improvement
Integrated System of Care through a No Wrong Door Service Delivery Model
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 38 Collaboration With Santa Clara County's System of Care Collaboration with the Santa Clara County System of Care expands residents' access to services beyond the city's scope. Services must be designed and delivered within the context of the history, background, conditions and environments that young people and their families experience.
This model ensures families and children can access the right services at the right time, regardless of where they enter the system. It emphasizes a seamless, integrated approach to service delivery that removes barriers, reduces duplication and fosters collaboration across agencies.
Community Pathway Overview
The CSJ System of Care is grounded in the County of Santa Clara Community Pathway, reflecting the county's and city's commitment to a collaborative, collective impact approach. This approach creates a seamless system of care that bridges city and county services, ensuring families and children receive the support they need across multiple sectors.
With support and guidance from the County of Santa Clara, collaborative partners integrate the goals and principles of the Family First Prevention Services Act and Assembly Bill 2083 throughout the design, development, implementation and evaluation of the CSJ System of Care. This partnership aims to reduce barriers, promote equity and enhance the delivery of culturally responsive services. See Community Pathway Journey for more details.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 39 Alignment with Community Pathway of the Families First Prevention Services Act The California Community Pathway of the Families Prevention Services Act (FFPSA) FFPSA aligns with SJ System of Care, emphasizing accessible community-based support for families and children at risk of entering the child welfare system. Key alignment areas include:
Community-Based Services: FFPSA underscores the importance of providing culturally appropriate, relevant and responsive services within the community.
Families can access trusted organizations and community partners that reflect their cultural and social contexts
Prevention and Early Intervention: FFPSA focuses on proactive measures, offering primary, secondary and tertiary prevention services to keep children and families out of the child welfare system
Equity and Social Justice: Addressing disparities within the child welfare system is central to FFPSA. The framework includes specific provisions to support Indian and Alaskan Native families, families of color and LGBTQ+ children and youth, promoting fairness and reducing disproportionality
County Connection to the Community Pathway
Building a strong, efficient and effective CSJ System
of Care in partnership with the County of Santa
Clara ensures alignment with the county's Children
and Youth System of Care. This alignment supports
a comprehensive continuum of services from
prevention to intervention that extends beyond the
city’s purview. Together, the city and county can:
Provide a Continuum of Services: From
primary prevention to targeted interventions,
ensuring families access the right support at the
right time
Reduce Child Abuse and Neglect: Through
early intervention strategies that prevent trauma
and mitigate risks associated with child welfare
and juvenile justice involvement
Enhance Family and Community Well-being:
Offering culturally responsive, community-based
supports that strengthen families and build
resilience
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 40 Community Pathway Elements
Single Point of Entry (SPE) – Individuals can access services through multiple entry points, including phone lines, in-person visits, websites and mobile apps.
Initial Screening – Trained staff assess individual needs using a brief intake form, interview or electronic tool to capture key information and determine the appropriate services.
Clear Communication – Clients are informed that every entry point provides consistent assistance in navigating the system. Regardless of how they seek help, they will be connected to the right services.
Children, youth and families will benefit from a
seamless, integrated and coordinated service
delivery approach that has been and will continue
to be informed by the County of Santa Clara
System of Care, Community Pathway and Families
First Prevention Services.
The CSJ System of Care is designed around a no
wrong door service delivery approach (see image
below). The image represents a circular, cyclical
process that visually emphasizes the continuous,
interconnected nature of service delivery. The
individual's entry point starts with Initial Contact and Engagement, followed by Intake and Screening,
and moves into Multidimensional Assessment. It
continues through Service Coordination and
Delivery, followed by Follow-Up and Monitoring,
before looping back into Outcome Evaluation and
Continuous Improvement.
By aligning the City of San José System of Care with the County of Santa Clara Care System of Community Pathway and Families First Prevention Services, children, youth, and families have access to robust integrated and coordinated services and supports that:
Ensure Accessibility: Families receive comprehensive support without navigating complex bureaucracies
Promote Equity: Services are designed to meet the diverse needs of all communities with a focus on reducing systemic barriers
Strengthen Community Partnerships: Collaborative efforts between city, county and community organizations foster a more resilient support network © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 41 The NWDSDM framework incorporates three tiers of need:
Tier 1: General referrals and basic support for families with minimal needs.
Tier 2: Short-term guidance and case management for families requiring moderate support.
Tier 3: Intensive care coordination for families with complex, high-level needs.
The City and its partners will continue to develop shared databases and communication systems to facilitate coordination and will report annually to community stakeholders on progress toward the goals and strategies of the Children and Youth Services Master Plan (CYS Master Plan), including advancements in system transformation and the development of a comprehensive system of care through a no wrong door service delivery approach.
Central to this NWDSDM are universal intake, screening, and assessment processes which streamline how families navigate support systems. A universal intake form was created to serve as a standardized entry point, enabling families to provide their information once. This approach reduces frustration and ensures that service providers have access to consistent, accurate data. Detailed screening and assessment tools were designed to identify the unique needs of families and connect them to the appropriate level of care within a tiered support system.
THE STEP BY STEP PROCESS OF THE CSJ NWDSDM
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 42 The CSJ System of Care No Wrong Door workgroup was convened to develop a comprehensive service delivery framework, tools and processes through a shared understanding of the key elements necessary to provide children, youth and families with seamless access to services across a robust network of collaborative partners, including schools, community-based organizations and city and county departments.
The workgroup identified key elements essential to creating an effective “no wrong door” approach to accessing a range of services, from intake and screening to assessment tools and processes. The group aimed to create a centralized universal intake form that would be used by all collaborative partners in the CSJ System of Care, preventing families from having to complete multiple intake forms for each provider.
Development of Single Point of Entry Tools and Processes To develop a universal intake form, the workgroup conducted an environmental scan of intake forms used by various agencies, community-based organizations and public services. The goal was to identify common questions and best practices that would inform the development of a centralized intake process. The scan revealed significant inconsistencies in how information was collected—some forms focused heavily on servicespecific needs, while others missed critical data points necessary for effective service coordination.
The group’s first task was to define and align key elements of intake, screening and assessment to ensure clarity and consistency across all entry points. This effort aimed to develop a unified intake process that could be implemented at community centers, libraries and demonstration sites. Each element was carefully examined and discussed to establish shared definitions and best practices.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 43 2. Screening
Definition: Screening is a systematic process used to identify individuals who may require further assessment or intervention.
Purpose: Quickly determines specific needs or risk factors and informs the appropriate next steps.
Key Features of the Screening Process:
Standardized Screening Tools: Consistent tools ensure accuracy across service areas.
Assessment Domains: Screening evaluates key areas such as:
Housing stability
Employment status
Health and mental wellness
Education and social support
Tiered Service Connection:
Tier 1 – Universal Supports: Direct referral to general services.
Tier 2 – At-Risk Services: Referral to a Site Navigator or Promotora for targeted support.
Tier 3 – Intensive Services: Assignment to a Care Coordinator for long-term, personalized care.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2
1. Intake:
Definition: Intake is the initial step in the process where basic information is gathered from individuals or families entering the system.
Purpose: Intake ensures efficient collection of relevant information, guiding decisionmaking and connecting clients to appropriate services and supports.
Key features of the intake process:
Welcoming and Inclusive Approach: Clients are greeted in a warm, engaging environment that fosters trust and
encourages participation.
Basic Information Collection: Intake gathers essential
details to prioritize immediate needs.
Single Point of Entry (SPE): A centralized system
streamlines intake across multiple access points, including physical locations, hotlines, and online portals.
Unified Information System: A shared database securely
stores client data, enabling service coordination while ensuring compliance with privacy regulations
44 The community began to inform the Children and Youth Services (CYS) NWDSDM from vision to reality, work also began to define the piloting of the CSJ System of Care (SOC) through two community demonstration sites. These cross-sector collaborations include:
City & County agencies
Community-based organizations (CBOs)
Faith-based institutions
School districts & education partners
Businesses & philanthropic organizations
Families & youth
3. Assessment
Definition: Assessment is a comprehensive and client-centered process that gathers detailed information about an individual’s strengths, needs, and preferences.
Purpose: The goal of assessment is to develop a personalized intervention plan that promotes positive outcomes and improves quality of life.
Key Features of the Assessment Process:
Holistic Approach: Assessments consider financial stability, mental and physical health, housing and social support systems.
Client Engagement: Clients actively participate in identifying their goals and preferences.
State-Mandated Tools: Tools such as the Child and Adolescent Needs and Strengths (CANS) assessment are used for children and youth.
Data-Driven Service Planning: Assessment findings inform personalized service planning and ongoing care coordination.
Single Point of Entry Overview: Designing the NWD Entry Points The City and its partners will continue to develop
shared databases and communication systems
to facilitate coordination and will report annually
to community stakeholders on progress toward
the goals and strategies of the Children and
Youth Services Master Plan (CYS Master Plan),
including advancements in system
transformation and the development of a
comprehensive system of care through a no
wrong door service delivery approach.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 45 The CSJ System of Care establishes
multiple entry points, a no wrong door
service delivery mode, for children,
youth, and families to access a myriad of
services and supports through an
integrated and coordinated network of
cross-sector partners. This ensures that
individuals receive the services and
support regardless of their point of entry,
X wherever their journey begins.
These entry points include key City of San José departments, school districts, and a crosssector of community partners each playing a vital role in the system’s success. “NO WRONG DOOR” APPROACH
The demonstration sites allow for smaller-scale testing, refining, and developing a replicable system of care model at the neighborhood level, which can be expanded across the city and county. This multi-phased, collective approach aligns with implementation science, ensuring sustainable systems transformation.
At the heart of this model is a commitment to community voice and lived experience, ensuring families and youth play a central role in decision-making.
Single Point of Entry Overview: Designing the NWD Entry Points (continued) City departments serve as primary entry points for families and individuals seeking services, ensuring connections to the appropriate resources. Department-specific entry points will be detailed in subsequent sections.
The City of San José Department of Parks, Recreation and Neighborhood Services and the Public Library provide welcoming, inclusive environments where children, youth and families can access various amenities, programs and services. Located in neighborhoods, libraries and community centers naturally serve as entry points where community members can request referrals and access services offered by the city and external partners.
The vision is for these entry points to be family- and community-centered, grounded in the Children and Youth Services Master Plan (CYS Master Plan) values:
Accessibility and inclusion for all youth
Cross-sector collaboration, investment and accountability Equity
Outcomes- and results-driven solutions
Youth- and community voice-driven decision-making
City of San José Departments Entry Points
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 46 Key Elements of the Community Entry Point
Welcoming Environment – The space is clean, accessible and inviting, with clear signage and materials available in multiple languages.
Immediate Needs Prioritization – Staff collect basic information to quickly assess urgent needs, such as housing insecurity, food access and immediate health concerns. A brief intake process follows, helping individuals articulate their needs and connect to appropriate services.
Standardized Screening Tools – These tools assess an individual’s situation across multiple domains, including health, housing, employment, education and social support.
Facilitated Warm Hand Offs – For individuals needing comprehensive support, libraries and community centers serve as bridges to external service providers. Staff ensure individuals understand the next steps and are connected to appropriate services.
Service Navigation – Staff assist with scheduling appointments, completing forms and connecting individuals to specialized resources, such as legal aid, financial assistance and mental health services.
Preventing Fragmentation – By coordinating with external partners, staff reduce the need for individuals to retell their stories multiple times, improving efficiency and support.
As community members inquire about additional resources outside of the CSJ department scope of services and supports, staff will initiate the CSJ NWDSDM process: Initial Contact, Universal Intake and Screening, Determine Level of Need, and Warm Hand Off to the appropriate Tier of Need.
Environment: The space is clean, accessible, and welcoming, with clear signage and available materials in multiple languages.
Immediate Needs Prioritization: Staff collect basic information to quickly assess urgent needs, such as housing insecurity, food access, or immediate health concerns.
Seamless Access Through the No Wrong Door Service Delivery Model When community members inquire about resources beyond the scope of City of San José departments, staff initiate the City of San José No Wrong Door Service Delivery Model (NWDSDM) process, which includes:
Initial Contact
Universal Intake and Screening
Determining Level of Need
Warm Hand Off to the Appropriate Tier of Need
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 47 The CSJ No Wrong Door Service Delivery Model is essential in addressing long-standing challenges in the service delivery landscape, including fragmentation, inefficiencies and inequitable access. By creating a unified system that places families at the center, the No Wrong Door model ensures that no matter where a family turns for help, they are seamlessly guided to the right resources. This progress represents a significant step toward achieving the Master Plan’s vision of equitable and accessible services for all children and youth in San José.
This collaborative approach engages all stakeholders in building a connected ecosystem that aligns internal structures and processes to establish a Single System of Support. This system addresses the academic, behavioral, social-emotional and mental health needs of all students and families. Integrating schools into the CSJ NWDSDM framework is crucial, ensuring educational institutions become integral parts of this unified support system.
Collaboration with community partners, including schools, is essential for the success of this collective endeavor.
The Single System of Support Framework, grounded in upstream prevention, utilizes the Collective Impact approach to promote racial and economic justice by connecting and integrating health and human services with school districts. The CSJ NWDSDM centers on student and family needs and community partnerships, ensuring individualized, effective and trustworthy services and supports are accessible within and for the community. As a result, schools can promptly access essential resources for students and families, eliminating the need for labels, diagnoses or insurance plans through an interconnected, multi-tiered approach to prevention and intervention.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 48 The integration of schools within this model reinforces the importance of addressing the holistic needs of students and families, ultimately contributing to a more equitable and supportive educational environment. Schools and school districts will act as a Single Point of Entry, connecting educational, health and mental health systems across all support levels.
Multi-disciplinary teams, also known as Coordinated Care Teams or Coordination of Services Teams (COST), will consist of educational and community-based professionals at Tier 2 and Tier 3 levels. These teams will use data to implement evidence-based practices that address academic, behavioral, health and social-emotional needs. They will initiate referrals, select interventions and monitor progress.
Students identified by Coordinated Care Team and COST meetings as needing family support or services beyond the school team’s expertise will be referred to a School Link Services (SLS) Coordinator. The SLS Coordinator, at either the district or school site level, will then initiate the CSJ NWDSDM process, similar to the City of San José departments:
1.Initial Contact with the student’s family
2.Universal Intake and Screening
3.Determine Level of Need
4.Warm Handoff to the appropriate tier of need
This process creates a seamless No Wrong Door Service Delivery Model. (See Initial Contact in NWDSDM Handbook in Appendix B)
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 49 Determining Level of Need
Determining level of need is crucial for connecting individuals to services that match their unique circumstances. The CSJ System of Care classifies needs into the following tiers:
Tier 1: General referrals and basic support for individuals with minimal needs Tier 2: Short-term guidance and case management for individuals requiring moderate support
Tier 3: Intensive care coordination for individuals with complex, high-level needs This tiered approach ensures
individuals receive the appropriate level
of care, reducing barriers and
promoting equitable access to services.
Targeted Support and Multi-Dimensional Assessment
For individuals needing more targeted support, a multi-dimensional assessment is conducted. This evaluation examines financial stability, mental and physical health, housing, employment and social support systems.
Client-Centered Approach: Individuals actively participate in the assessment process, ensuring their voices are heard and preferences respected.
State Requirements: For children and youth, the Child and Adolescent Needs and Strengths (CANS) assessment tool is used to inform care coordination and service planning.
Continuum of Service Delivery: Structuring tiered services and supports within a no wrong door service delivery framework involves organizing services into levels that align with the varying needs and complexities of the clients served. This approach ensures clients receive appropriate levels of intervention based on their circumstances, with more intensive services reserved for those with higher needs. © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 50 Service Coordination
Service coordination within the CSJ System of Care, using a no wrong door service delivery model, ensures individuals receive comprehensive, integrated support by managing and organizing services across multiple agencies and providers. Various roles within the collaborative cross-sector partners of the CSJ System of Care provide different services to individuals and families. Case coordination focuses on delivering personalized, continuous care across sectors, preventing gaps or overlaps in services. (See Service Coordination in NWDSDM Handbook in Appendix B.)
Tier 1 – Universal Supports: Direct referral to a service provider Strengthens communities and improves child well-being by addressing social determinants of health for the general population
Tier 2 – At-Risk: Referral to a demonstration site navigator, promotora or service guide
Serves clients with moderate needs identified through assessment Includes activities defined by the state to support at-risk populations, mitigate risk factors and build protective factors
Tier 3 – Intensive/Tertiary: Referral to a care coordinator and care team Provides individualized, comprehensive support for individuals with complex needs who have not been successful with less intensive interventions © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 51 Specialized and Crisis Services: Immediate Referral to Demonstration Site An immediate needs assessment is conducted to identify any critical or emergency needs that require urgent attention and to provide referrals or direct assistance as needed.
Cross-Agency Coordination: Agencies collaborate to ensure seamless service delivery without duplication or service gaps. Regular communication among providers helps adjust services as needed.
Prevention Plan: For at-risk individuals, a prevention plan is created to avoid escalation into crises.
Once the assessment is complete, a personalized service plan is developed, and the individual is connected to the appropriate services.
The Service Coordination Step By Step Process is further detailed in the CSJ NWDSDM Handbook in Appendix B.
The Triage and Care Team
If a service navigator or service guide determines that a family or individual needs additional support, they can refer them to a triage team for further guidance on services or programs. This helps prevent cases from escalating to Tier 3.
Similarly, if a care coordinator determines that a family or individual requires extra support, they can refer them to a care team. The care team provides comprehensive, coordinated care by bringing together professionals from various fields to address complex needs.
These professionals collaborate to develop and implement a holistic service plan for individuals or families.
Triage Team
The triage team conducts initial assessments to determine the level of support and intervention required. Acting as the first point of contact, they quickly identify urgent needs and prioritize cases for appropriate Tier 2 services.
Key Functions of a Triage Team
Initial Assessment: Quickly evaluates the needs and urgency of each case Prioritization: Determines the severity of needs and prioritizes cases based on urgency
Resource Allocation: Directs individuals or families to the appropriate services or support within the system
Coordination: Ensures families are connected to the right resources without having to navigate complex systems
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 52 The City of San José’s System of Care ensures individuals receive the right level of support through a structured, tiered approach. By assessing needs and coordinating services across agencies, the system provides universal, targeted and intensive supports to strengthen communities and address complex challenges. A no wrong door service model streamlines access, ensuring individuals receive the help they need without barriers.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 53 Care Team
At the Tier 3 level within a No Wrong Door service delivery model, the care team provides specialized, intensive support to individuals with complex needs.
Key Functions of a Care Team
Comprehensive Assessment: Conducts thorough evaluations to understand each individual's unique needs and circumstances
Personalized Care Planning: Develops tailored care plans that address specific requirements and preferences
Resource Coordination: Coordinates services and resources from various providers to ensure seamless, integrated support
Advocacy: Advocates for individuals' needs and rights, ensuring they receive appropriate services and support
Monitoring and Evaluation: Continuously monitors care plan progress and makes necessary adjustments to improve outcomes
Support and Education: Provides education and support to individuals and families to empower them in managing their care
Crisis Intervention: Responds promptly to crises or emergencies, providing immediate assistance and support
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 Service Delivery
Service delivery focuses on executing the
personalized service plan developed during the
service coordination process. Individuals and
families receive appropriate services based on
their identified tier level and needs, whether
through short-term interventions or long-term,
intensive support. (See Service Delivery in
NWDSDM Handbook in Appendix B.)
Service Delivery Process
1.Initiate Services
2.Monitor Service Delivery
3.Case Management and Ongoing Support
4.Cross-System Coordination
The step-by-step service delivery process is further detailed in the CSJ NWDSDM Handbook in Appendix B.
54 Ongoing support ensures that individuals continue receiving the services they need.
Regular follow-ups are scheduled to monitor progress and address emerging challenges. (See Follow-up and Monitoring in the NWDSDM Handbook in Appendix B.) Key Support Actions
Check-ins: Service guides, navigators, or care coordinators review an individual’s progress and update the service plan as necessary.
Referral to higher tiers: If progress stalls, individuals may be referred to higher-level services for more intensive support.
Flexible service models: Create adaptable service models that allow smooth transitions between tiered service levels without gaps or delays.
Regular reassessments: Conduct ongoing evaluations to ensure individuals receive the appropriate level of support and can be “stepped up or down” as needed.
Steps to the follow-up and progress monitoring process:
1.Initial follow-up contact
2.Regular monitoring and check-ins
3.Progress assessment and documentation
4.Adjustments to the service plan
5.Coordination with service providers
6.Ongoing support and resources
The follow-up and progress monitoring step-by-step process is further detailed in the CSJ NWDSDM Handbook in Appendix B.
Driving Results and Ensuring Accountability
The CSJ System of Care creates a seamless service delivery system that evolves with its community by focusing on continuous improvement. Regular evaluation, open communication, and shared responsibility are key to ensuring services remain accessible, effective, and equitable for all.
Continuous improvement is not a destination but an ongoing journey—one that reinforces the model’s core values of accessibility, equity, and client-centered care.
Unified Information System
A key component of the CSJ System of Care is the Unified Information System—a shared, secure database that stores community member information and facilitates real-time collaboration across participating agencies.
Ongoing Support, Progress Monitoring and Follow-Up
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 55 This system supports integrated, high-quality care by:
Centralizing community member information: Ensuring all authorized providers can access up-to-date information to deliver informed, coordinated support.
Improving cross-agency collaboration: Enabling agencies to work together more effectively, preventing duplication of services, and ensuring continuity of care.
Ensuring data security and privacy: Complying with federal, state, and local regulations—including the Health Insurance Portability and Accountability Act (HIPAA) —to protect community member confidentiality.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 Installation and Initial Implementation at Pilot Sites
As outlined in the approved CSJ Children and Youth Services Master Plan, the City of San José (CSJ) System of Care and NWDSDM framework will be implemented using a multi-phased approach aligned with implementation science. This will allow the two demonstration (pilot) sites to advance to Phase III: Installation and Initial Implementation.
A. Core Planning Team Implementation
The initial step involves establishing a core planning team at each demonstration site.
This team, comprising CBO leaders, staff, system partners, school district representatives, youth, and community members, will lead the model’s design and initial implementation.
Their responsibilities include:
Ensuring internal structures align with the CSJ System of Care framework Facilitating training sessions for service providers
Developing communication channels across participating agencies 56 B. Assessment of Current Systems
The core planning team will conduct a comprehensive assessment of existing infrastructures, data, systems, initiatives, services, and programs to identify systemic issues and potential solutions.
The assessment will include:
Reviewing reports, site, and community data
Conducting site learning walks to observe current practices Holding empathy interviews and listening sessions to capture lived experiences This data-driven approach ensures implementation strategies are grounded in real-time data, community perspectives, and systemic analysis.
C. Alignment and Refinement of the CSJ NWDSDM
Insights from the assessment will inform refinements to the System of Care – NWDSDM to best meet community needs.
This process involves ongoing analysis of:
Service delivery processes
Community partnerships
Staff capacity and training needs
D. Action Plan and Capacity Building
An implementation and capacity-building plan will be developed, focusing on:
Creating shared data systems to enhance communication and tracking Providing ongoing training and coaching on person-centered approaches Aligning internal processes with the broader goals of the CSJ CYS Master Plan E. Demonstration Site Structure
Each demonstration site will function as a multi-functional hub, integrating key components of the NWDSDM, including intake and referral services, multi-dimensional assessments, and coordinated service delivery.
Key features include:
A central intake point to streamline referrals
On-site support services
Regular community input sessions
F. Data Collection, Feedback, and Iterative Improvements Data collection and analysis will be ongoing, with regular feedback and reflection sessions to ensure continuous improvement. Data-driven adjustments will be made to enhance intervention effectiveness, and learnings will be documented and shared with other sites and stakeholders.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 57 THE EVALUATION GROUNDWORK
Priority Area Workgroups - Phase 2
The CSJ CYS Master Plan is designed as a dynamic, living document that evolves in response to the community's changing needs. In developing this plan, significant efforts were made to align its priorities with community voices, integrating feedback from families, youth, city departments, community-based organizations (CBOs), and other key stakeholders.
Establishing the CSJ System of Care balances immediate, measurable impacts with the broader goal of creating long-term, sustainable systems change.
During Phase 2, these early-identified priorities were refined and expanded through collaboration across diverse sectors to address the complex, interconnected challenges faced by children and youth in San José. This process resulted in developing seven unique solutions —each representing a critical priority area for the first two years of initial implementation at two pilot sites. These priority areas are the foundation for goals, objectives, metrics, and strategies to guide progress and ensure accountability throughout the plan's execution. © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 Evaluation Framework: Priority Area Workgroups
(PAWGs)
CIS supported stakeholders in developing a proposed
evaluation framework using a three-pronged approach. One aspect of the evaluation includes PAWGs and their work
plans. Each PAWG developed a specific goal, objectives, and a list of metrics (see list below), along with strategies to consider for implementation.
Each PAWG goal and objective are relatively high-level since their work plans guide scaling interventions across different regions. For example, objectives are not yet time-bound or measurable but indicate the intended direction of change, such as increasing or decreasing specific outcomes. Teams at each pilot site will refine the objectives to make them timebound, measurable, and specific to their communities and current conditions. This approach prioritizes equity,
recognizing that each region or neighborhood has distinct needs.
The PAWG work plans consistently address the seven
priority areas identified for San José while allowing
communities to modify and implement objectives, metrics, and strategies based on their needs.
58 Pilot Site Implementation
Over the next two to three years, the focus will be on two pilot sites serving as demonstration areas for strategy planning, marketing, evaluation, and service integration.
These pilot sites will inform scalable implementation strategies for other regions by addressing specific population needs and contextual challenges.
The proposed evaluation framework aligns partner efforts to plan, implement, and evaluate the CYSMP consistently. This approach ensures strategic alignment with overarching goals, such as leveraging resources, blending funding streams, and preventing service duplication. Consistent with the master plan’s vision, the OMS emphasizes a collaborative, community-centered approach that integrates services across sectors.
Key Objectives
Develop annual strategic and marketing plans with measurable goals and actionable month-to-month activities.
Establish systems for project management, data collection, tracking, and reporting, with staff training to ensure consistent use.
Conduct a two-year evaluation of all programs to assess effectiveness, refine approaches, and identify opportunities to scale successful initiatives.
As part of the implementation process, teams will refine broad objectives into specific, measurable goals tailored to the needs of their populations. By leveraging blended resources and integrating services effectively, the OMS will foster a unified, equitable system of care for children, youth, and families in San José.
Achievements and Next Steps
Established seven priority areas for targeted efforts, including health and well-being, housing access, and systems transformation.
Facilitated workgroup sessions to develop measurable objectives, strategies, and initial implementation timelines for each priority area.
Engaged diverse stakeholders, including families, youth, city departments, and CBOs, to ensure all perspectives were represented.
Data and Evaluation Integration
Partnered with experts to implement shared measures and data systems that track progress and evaluate the impact of initiatives.
Conducted service mapping across the life course framework to identify gaps and overlaps.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 59 Each of the seven priority areas was developed to align with the vision of equitable opportunities and systemic transformation.
Early Learning and Child Care
Goal: Ensure children and families have access to affordable, high-quality early learning and care experiences that promote optimal growth and development.
Objective: Increase the number of early childhood education (ECE) professionals, both informal and licensed, in San José’s early system of care to enhance access to highquality childcare.
Strategies:
Create pathways for ECE training and skill-building.
Conduct outreach and engagement efforts to promote opportunities for entering ECE pathways.
Develop scholarship and financial support opportunities for individuals seeking certification or skill-building.
Engage in collaborative efforts that align with, support, and endorse initiatives within the City of San José’s Education and Digital Literacy Strategy, including early education, expanded learning, college and career pathways, and digital equity and inclusion.
Expand early childhood resources (ECR) and programs such as Mommy and Me classes.
CSJ System of Care: PAWG Goals, Metrics and Strategies
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 60 Metrics: (Early Learning and Child Care)
Number of ECE professionals in San José completing:
Family, friend, and neighbor (FFN) child development courses/series Apprenticeship assistant teacher program
Apprenticeship teacher program
Pre-K–3 credential program
Additionally, monitor:
Enrollment rates in quality early learning programs
Availability of childcare slots
Workforce retention in early education fields
Health and Mental Wellness:
Goal: Ensure all children, youth and young adults feel valued, supported, and have a sense of purpose in their community while accessing holistic, culturally appropriate services throughout their developmental health journey.
Objective: Increase the number of children and youth receiving universal health screenings, including socio-emotional and behavioral health assessments, to facilitate appropriate service referrals.
Strategies:
Organize a Universal Screening Day.
Train demonstration site staff to administer the Ages and Stages Questionnaires (ASQ) and Revised Child Anxiety and Depression Scale (RCADS) within the CSJ NWDSDM.
Implement the CSJ “No Wrong Door” service delivery model to connect children, youth, and families with community services and support through schools and providers.
Collaborate with NAMHI to develop mental health screening awareness and education initiatives for pilot communities, the City of San José, and school districts.
Metrics:
Expected number of children and youth (ages 8–18) to be screened Actual number of children and youth screened
Number of children and youth who screened positive
Number of children and youth who screened positive and were linked to behavioral health services
Additional tracking to measure effectiveness:
Reduction in unmet healthcare needs
Increase in youth accessing mental health services
Rate of participation in wellness programs
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 61 Housing Access and Security
Goal: Ensure San José children, youth, and their families have equitable access to affordable and stable housing.
Objective: Increase outreach to families classified as “extremely low income” to ensure they understand how to access affordable housing services in San José.
Strategies:
Build Trust and Collaboration
Ensure the same organizations consistently work together to build trust within the community.
Establish regular meetings and communication channels to foster collaboration among stakeholders.
Increase Multilingual and Culturally Responsive Outreach Incentivize hiring individuals with lived experience of homelessness, particularly people of color and LGBTQ+ persons, to reflect the client population.
Provide ongoing cultural competency training for all outreach staff.
Onsite Resource Coordination
Ensure individuals and families have access to resources through the CSJ No Wrong Door Service Delivery Model.
Assign resource coordinators to be onsite at affordable housing multifamily properties.
Stock resource centers with information on all available programs and services.
Coordinated Outreach Campaigns
Develop and implement coordinated outreach campaigns led by an advocacy committee.
Use diverse advertising methods, including bus stop advertisements, radio, robocalls, and flyers, to reach a wide audience.
Metrics:
Outreach and Access
Number of families attending homeless outreach and access services Number of CBO partners participating in outreach
Number of homeless outreach activities conducted
Service Delivery
Fidelity of implementation of the CSJ No Wrong Door
Service Delivery Model
Timeframe for individuals and families to receive
services (goal is to decrease this timeframe with
streamlined services)
Outcomes
Reduction in youth and family homelessness
Successful transitions to stable housing
Utilization of housing support programs
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 Homelessness and Housing Costs
62 Learning and Empowerment
Goal: Ensure San José residents from birth to age 24 have equitable access to graduate from high school and enter pathways that promote economic mobility and generational wealth.
Objective: Increase proficiency rates in English language arts (ELA) and math for each subgroup in third and eighth grades on the Smarter Balanced Assessment Consortium (SBAC) English language arts and mathematics assessments.
Strategies:
Enhance community awareness of available academic support resources and rebuild trust with school districts by using diverse marketing strategies to connect families to services.
Offer high-dose, one-on-one tutoring based on proven research at school sites, community hubs, and libraries. Provide evidence-based coursework and summer STEM clubs at school sites, with services available after school, during intersessions, and in the summer.
Organize and facilitate annual professional learning communities (PLCs) using structured protocols for monthly CBO collaboration, alignment, and data sharing.
Metrics:
Community engagement: Strengthen trust-building efforts with families.
High-impact tutoring: Track student participation and progress.
Awareness and outreach campaigns: Assess reach and effectiveness.
Additional tracking:
High school graduation rates
Participation in postsecondary education or training programs Gains in youth-reported self-efficacy
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 63 Meaningful and Sustainable Jobs
Goal: Ensure San José children, youth, and families have equitable access to affordable, stable housing and economic opportunities.
Objective: Coordinate and enhance programs and services that facilitate the transition from high school to postsecondary education, ensuring college readiness and access.
Strategies:
Support youth and adults in earning high school diplomas and finding programs that best fit their needs.
Increase engagement in financial literacy programs and activities that help youth and families understand how to pay for college.
Develop and refine an inventory of college readiness and access programs in San José, including all postsecondary pathway options.
Metrics:
Participation and graduation rates: Track and improve rates for middle and high school students. Reduce the number and percentage of opportunity youth (young people who are not in school or employed).
Workshop effectiveness: Measure the number of workshops offered, collect survey data to assess quality, and track participation rates for youth and parents.
Resource inventory: Develop and maintain a database to track the usage of college readiness and access programs in San José.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 64 Safe and Connected Communities
Goal: Provide opportunities for San José children, youth, families, and community systems to access safe, clean, and vibrant neighborhoods where they can thrive, heal, organize, and gather.
Objective: Increase access to and awareness of programs and services related to advocacy, leadership development, and capacity-building opportunities for youth and young adults.
Strategies:
Create an inventory of existing programs and services that support youth and young adults in advocacy, leadership development, and capacity-building.
Establish and evaluate community connections and access to resources while celebrating cultural diversity.
Strengthen and enhance community collaboration to improve access to resources and services.
Metrics:
Number of youth and families currently participating in programs Number of available services offered
Number of neighborhood associations established
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 65 System Transformation
Goal: Collaborate with the community to create a unified, cross-sector ecosystem that dismantles systemic barriers and provides timely, equitable, and culturally responsive support to families, ensuring they receive the care they need.
Objective: Design and implement an integrated system of care using a "No Wrong Door" service delivery approach to enhance coordination and access to services for children, youth, and families.
Strategies:
Formalize the CSJ System of Care infrastructure by establishing agreements and partnerships that enhance coordination and accountability.
Strengthen stakeholder engagement and collaboration.
Conduct a needs assessment and gap analysis.
Develop an evaluation framework that includes assessment, monitoring, and continuous quality improvement.
Design and pilot the “No Wrong Door” integrated service delivery system.
Implement the CSJ System of Care service delivery model at demonstration sites.
Provide initial training and capacity-building support.
Establish evaluation framework (assessment, evaluation, monitoring, quality continuous improvement) processes and tools
Metrics:
Fidelity measure: Track adherence to the implementation protocol for the System of Care and No Wrong Door service delivery model.
Access and coordination: Measure reductions in time to access services and referral redundancy.
Service delivery: Track client satisfaction and engagement rates.
System efficiency: Monitor interagency collaboration and data-sharing utilization.
Outcomes: Measure positive outcomes achieved and reductions in equity gaps.
Training: Track the number of staff trained, feedback on training effectiveness, and application of training in practice.
Community connections: Count the number of entities that families are connected to for resources and services.
Referrals: Measure the number of individuals and families connected to services.
These priority areas are interconnected and mutually reinforcing, reflecting the comprehensive approach required to address systemic challenges effectively. By focusing on these seven areas, the CSJ CYSMP System of Care seeks to deliver targeted interventions while building the infrastructure for sustained progress. The strategies, goals and metrics associated with each area provide a roadmap for achieving meaningful change and ensuring that all children, youth, and families in San José can thrive. © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 66 TRANSITION FROM DESIGN TO DEMONSTRATION SITE INSTALLATION
AND IMPLEMENTATION
Phase 2 established the foundation for the installation and initial implementation of the CYS Master Plan and systems transformation by developing the CSJ System of Care with a “No Wrong Door” service delivery model. This model creates a safety net of resources and support for children, youth, young adults and their families. The groundwork laid in Phase 2 ensures the CSJ System of Care and NWDSDM model are not just theoretical concepts but practical frameworks ready for deployment.
Through trust-building, shared goal setting and practical tool development, Phase 2 positioned the two demonstration sites to align with and refine the CSJ System of Care and NWDSDM at the neighborhood level. The model can then be expanded and replicated in other communities facing similar challenges across the city and county. © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 Preparation for Soft Launch and Continuous Improvement
Phase 2 prepared pilot sites for a soft launch with a plan for technical assistance. Collective convenings and capacity-building sessions familiarized community and system partners with new tools and workflows. A communication feedback loop was formalized to support data sharing and problem-solving among partners. This continuous improvement mechanism will allow the system to adapt to challenges and refine processes as installation and initial implementation progress.
67 Systems transformation is complex and requires intentionality, perseverance and a willingness to confront long-standing structural and personal barriers. Phase 2 of the CSJ System of Care design process provided critical insights into building sustainable, community-driven change.
1. Systems Change Requires Self-Change
One of the greatest challenges in systems transformation is recognizing that meaningful change begins within individuals. Throughout Phase 2, a recurring theme emerged: many expected the system to change without acknowledging the personal transformation required to sustain it.
The most significant setbacks occurred when individuals and organizations struggled to confront their roles in maintaining inequitable structures. Sustainable systems work requires truth-telling about strengths, biases, assumptions and limitations. Without self-reflection, change efforts risk becoming superficial and reinforcing existing inequities.
Lesson Learned: Effective systems transformation requires leaders to commit to selftransformation. This means adopting a growth mindset, engaging in continuous learning and being open to feedback from the communities they serve.
2. Bridging Silos and Shifting Mindsets
A fundamental goal of the CSJ System of Care is integrating services across city, county and community organizations. However, shifting from siloed service delivery to a No Wrong Door model proved challenging. Many stakeholders found it difficult to abandon longstanding practices and embrace collaboration.
The challenge was not just technical—it was cultural. Some organizations hesitated to share decision-making power, fearing a loss of autonomy. Others struggled with deeply ingrained habits that prioritized institutional efficiency over community-centered approaches.
Lesson Learned: Successful system alignment requires both technical solutions, such as shared databases and referral systems, and cultural shifts. Building trust, fostering humility and prioritizing collaboration over control are essential.
3. Centering Community Voice in Meaningful Ways
A key commitment of Phase 2 was ensuring youth, families and community partners were co-creators in designing the CSJ System of Care. While significant progress was made, challenges arose in ensuring engagement was truly influential in decision-making rather than performative.
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 CHALLENGES AND LESSONS LEARNED:
THE HUMAN SIDE OF SYSTEMS TRANSFORMATION
68 Some community members expressed concerns about power imbalances, feeling their lived experiences were not always prioritized in shaping final decisions. Others noted the emotional toll of systems work, particularly for those directly affected by inequities.
Lesson Learned: Authentic engagement requires continuous self-examination by decision-makers. It is not enough to invite community members to discussions; power must be shared, community expertise must be compensated and lived experience must be valued as essential knowledge. Additionally, trauma-informed, healing-centered spaces must be created for both community and system leaders.
4. Navigating Resistance and Discomfort in Change
Resistance to change surfaced in many forms—some explicit, some unspoken. Some stakeholders hesitated to challenge existing policies that disproportionately harmed marginalized communities. Others expressed fatigue from previous reform efforts that failed to produce lasting impact.
Fear of failure and discomfort with vulnerability sometimes stifled innovation. Systems leaders struggled to acknowledge missteps, fearing it could undermine credibility.
However, real transformation requires embracing both success and failure as part of the learning process.
Lesson Learned: Systems change is inherently uncomfortable, but discomfort is necessary for growth. By normalizing reflection, accountability and adaptive learning, organizations create an environment where transformation is sustainable rather than performative.
5. Prioritizing Healing-Centered and Trauma-Responsive Approaches Many communities served by the CSJ System of Care have endured historical and ongoing trauma, systemic racism and economic injustice. Designing equitable service models means acknowledging that systems have contributed to harm—and that trust cannot be built overnight.
A trauma-responsive approach is not just about service delivery; it must be embedded into organizational culture, leadership practices and policy decisions. This requires intentional space for reflection, healing and relationship-building among system leaders, service providers and community members.
Lesson Learned: Healing is a critical part of systems transformation. Without acknowledging past harm, efforts risk replicating cycles of distrust. Embedding healingcentered practices—such as restorative circles, cultural humility training and wellness initiatives for staff and community members—will be essential for long-term success. © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 69 6. Shifting the Backbone from Government to Empowering Communities Government inefficiencies have often left communities in turmoil, hindered by systemic barriers that prevent responsive and effective support services. Traditional structures have not always met the needs of individuals and families.
Lesson Learned: To address ongoing challenges and inefficiencies, the System of Care must transition its backbone from government agencies to community leadership.
Empowering community stakeholders to take a leading role will help sustain systems that are responsive, inclusive and adaptable to each community’s unique needs.
This shift fosters ownership and engagement, ensuring support services are comprehensive and delivered with a deep understanding of local contexts. Policymakers and government partners will remain involved to help address systemic barriers, but communities will lead the effort.
Philanthropy and government must work alongside residents in collective impact efforts. A deep partnership, committed to common goals and clearly defined outcomes, ensures evidence-based solutions drive meaningful progress. Philanthropy, through flexible funding, can seed new strategies, advance learning, support evaluation and influence policies that prioritize vulnerable communities. City and county governments can leverage contracts worth millions of dollars to support, scale and sustain programs that improve lives and economic opportunities for underserved populations.
Building a Resilient and Effective Support Network
By shifting leadership to communities and ensuring deep collaboration between government, philanthropy and local stakeholders, San José can build a more resilient, effective support network. This approach will ensure services are not only sustainable but also deeply rooted in the strengths and needs of the communities they serve.
PREPARING FOR PHASE 3:
ADVANCING THE CSJ SYSTEM OF CARE AND NWDSDM
As spring 2025 approaches, the City of San José Children and Youth Services Master Plan (CYSMP) enters a pivotal phase as the CSJ System of Care and the No Wrong Door Service Delivery Model (NWDSDM) transition from planning to initial implementation. © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 70 Looking Ahead
The community pathway will serve as the foundation of the model, providing a structured approach to connecting families with services while fostering collaboration among city agencies, community organizations and schools. The establishment of pilot sites and the CSJ System of Care Network backbone in spring 2025 will transform these sites into learning laboratories, generating valuable data to refine and expand the model citywide.
Phase 2 played a crucial role in bringing the plan to life, shifting it from concept to an actionable, collaborative and sustainable system. With the CSJ System of Care and No Wrong Door model set for initial implementation, San José’s children, youth and families are poised to experience lasting, transformative change.
Measuring Success: Ensuring Impact and Continuous Improvement A comprehensive evaluation framework has been established to assess the effectiveness of the CSJ System of Care and NWDSDM (see Appendix B). This framework integrates qualitative and quantitative measures to ensure accountability, monitor outcomes and support continuous improvement efforts.
Success will be measured through two key dimensions:
1.Individual and community-level impact at pilot sites and, later, citywide
2.System of Care intervention focused on structural transformation Individual and Community-Level Impact
Access and equity are top priorities, with metrics evaluating the number and demographics of families accessing services through the NWDSDM. These measures will track efforts to reduce disparities, particularly among historically underserved communities, ensuring the system reaches those most in need.
Efficiency and coordination will also be critical, with assessments focusing on the time required for families to move from initial intake to referral and service delivery. The goal is to minimize duplication and improve the seamless flow of resources along the community pathway.
Family outcomes will serve as another key measure of success. Progress will be tracked in areas such as housing stability, mental health access, early education enrollment and youth employment. Feedback from families will provide insight into their experiences with the system and how well it meets their needs. Additionally, collaboration among service providers will be evaluated based on the number of coordinated cases across organizations and stakeholder feedback on communication and alignment. © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 71 System of Care Intervention
System transformation will be measured by the adoption of shared tools, including the universal intake form and standardized screening protocols, across pilot sites. The implementation and refinement of the tiered service levels, based on pilot site feedback, will be a key indicator of progress toward an integrated, family-centered system of care.
The communication feedback loop established in Phase 2 will ensure the NWDSDM remains responsive and adaptive. This loop will collect real-time data from pilot sites, identifying bottlenecks, challenges and emerging service needs. Regular updates will provide stakeholders with opportunities for collaborative problem-solving and continuous model improvements.
Accountability will be maintained through structured reporting mechanisms. Monthly updates will track pilot site performance, quarterly reviews will assess service delivery outcomes and annual reports will provide citywide evaluations, sharing successes, lessons learned and strategy adjustments with all stakeholders.
As the NWDSDM expands, insights from pilot sites will guide its implementation in additional locations. Early successes, combined with lessons learned, will ensure the model scales effectively and remains aligned with the evolving needs of the community.
Through this approach, the City of San José aims to build a system that not only meets immediate needs but also drives long-term, transformative change for children, youth and families.
LAYING THE GROUNDWORK FOR PHASE 3: MOVING FROM DESIGN
TO INITIAL IMPLEMENTATION
Phase 2 established a strong foundation for the next stage: initial implementation. As Phase 3 begins in summer 2025, the focus will shift to:
Testing and refining the CSJ System of Care and NWDSDM at demonstration sites Monitoring effectiveness and adjusting strategies based on real-time data and feedback
Scaling successful practices for citywide adoption to ensure sustainability and longterm impact Securing funding to support foundational preparation, technical assistance and capacity building
Developing comprehensive success metrics to measure impact, track service utilization and inform continuous improvement
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 72 Securing Funding for Long-Term Sustainability
To ensure the long-term viability of the CSJ System of Care and No Wrong Door Service Delivery Model (NWDSDM), dedicated funding is essential for both initial implementation and long-term sustainability. Key funding priorities include:
Technical Assistance (TA) and Capacity Building: Providing ongoing TA, coaching and professional development for service providers, school districts and communitybased organizations (CBOs) to ensure they are fully equipped to implement and sustain the model
Training and Workforce Development: Ensuring staff at all entry points—including schools, community centers, CBOs and city agencies—receive specialized training in universal intake, tiered service navigation, trauma-informed care and cultural responsiveness
Community Engagement and Outreach: Establishing a public awareness campaign to inform families about the system and involve community members in ongoing improvements
Technology and Data Integration: Investing in shared data platforms and tracking systems to ensure seamless coordination across agencies and real-time monitoring of service access and impact
Sustainability Planning: Developing long-term financing strategies, including leveraging Medicaid reimbursements, securing multi-year grants and establishing policy-based funding streams to support ongoing service delivery
TECHNICAL ASSISTANCE FOR THE FIRST LAUNCH OF INITIAL
IMPLEMENTATION (SPRING 2025)
Demonstration Sites as Learning Laboratories
Demonstration sites will serve as innovation hubs where Collective Impact Solutions (CIS) will provide structured TA, coaching and capacity-building to:
Test real-world applications of the CSJ System of Care and NWDSDM in diverse service environments
Identify best practices and challenges in implementation to inform continuous improvement
Build the capacity of service providers and leadership teams to sustain and scale the model
Develop data-driven strategies to measure impact and ensure accountability Through hands-on technical assistance, structured learning sessions and ongoing evaluation, CIS will ensure that lessons from the demonstration sites inform citywide expansion, making the CSJ System of Care and NWDSDM scalable and sustainable. © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 73 The Role of Technical Assistance (TA) in Implementation The City of San José, the County of Santa Clara and Sobrato Philanthropies have partnered to develop a Technical Assistance (TA) Plan to support demonstration sites in effectively implementing the CSJ System of Care and NWDSDM. The goal is to ensure the successful initial implementation and refinement of this model, which will improve service accessibility, responsiveness and effectiveness.
The TA Plan will provide support in the following areas:
Establishing the CSJ System of Care Network: Overseeing implementation, tracking progress and addressing challenges
Common Agenda Framework: Ensuring alignment across agencies and stakeholders
Teaming Infrastructure: Defining roles and responsibilities for coordinated service delivery
Communication Feedback Loops: Facilitating continuous learning and system adaptation
TA Coordination and Site Readiness: Preparing demonstration sites for successful initial implementation
Staff Training and Capacity Building: Equipping service providers with the knowledge and skills necessary to support families effectively Pilot Initial Implementation and Real-Time TA Support: Providing ongoing technical assistance as the model is tested and refined
Through tailored technical assistance, coaching and resource alignment, the CSJ System of Care and NWDSDM will become an operational reality.
The Importance of Technical Assistance for Demonstration Sites Although demonstration sites participated in the design process, they require technical assistance to build capacity for successful initial implementation. While these sites contributed insights, they may not be fully fluent in the theory and practice necessary for effective execution.
As innovation hubs, demonstration sites rely on structured TA, coaching and capacitybuilding to:
Test real-world applications of the model in diverse service environments Identify best practices and challenges in initial implementation Strengthen the capacity of service providers and leadership teams to sustain and scale the model
© 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 74 Without tailored technical assistance, demonstration sites may face inconsistencies in service delivery and missed opportunities for improvement. TA ensures that these sites develop data-driven strategies to measure impact, maintain accountability and contribute valuable insights to the broader citywide expansion of the CSJ System of Care and NWDSDM. Through hands-on support, structured learning sessions and ongoing evaluation, demonstration sites can transform aspirations into actionable practices, establishing a scalable and sustainable model for comprehensive, family-centered support.
COLLECTIVE IMPACT SOLUTIONS: LEADING TECHNICAL
ASSISTANCE
Collective Impact Solutions (CIS) developed the TA Plan to guide the initial implementation of the CSJ System of Care and NWDSDM. As a leader in systems transformation, cross-sector collaboration and capacity-building, CIS brings the expertise, strategic vision and hands-on experience necessary to guide demonstration sites through the successful execution of this innovative model.
The CSJ System of Care and NWDSDM are designed to create an integrated, familycentered system of care that ensures seamless access to services while eliminating barriers and improving cross-agency coordination. Through the TA Plan developed by CIS, demonstration sites will receive comprehensive guidance, training and real-time support to ensure the model is effective, sustainable and aligned with state and federal mandates.
Investing in the Future: Building a Sustainable System of Care The initial launch of the CSJ System of Care and No Wrong Door Service Delivery Model in spring 2025 marks a significant milestone in creating a seamless, family-centered system of care.
Through the expertise of Collective Impact Solutions, the City of San José System of Care has moved from concept to action. By centering equity, collaboration and systemic change, this community-driven system will ensure that every child, youth and family in San José has access to the support they need to thrive.
However, the success of Phase 3 depends on strategic investments in site preparation, capacity building and long-term sustainability. Funding must be secured to provide foundational support, technical assistance and training for service providers, ensuring demonstration sites serve as effective models for citywide expansion. © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 75 Investing in workforce development, system infrastructure and sustainable financing strategies will allow San José to build a System of Care and No Wrong Door Service Delivery Model that transforms the city’s landscape for current and future generations. © 2025 Collective Impact Solutions
The City of San José Children and Youth Services Master Plan: Phase 2 76 APPENDIX
The City of San José Children and Youth Services Master Plan: Phase 2 © 2025 Collective Impact Solutions 77
CITY OF SAN JOSÉ SYSTEM OF CARE PROPOSED EVALUATION FRAMEWORK Appendix A
Table source: What is Implementation Science? – Implementation Science at UW The City of San José Children and Youth Services Master Plan: Phase 2 Multi-Level Evaluation Framework
The multi-level evaluation framework assesses the current landscape and tracks progress in implementing the master plan, which will first be piloted at two sites in East San José.
The evaluation will focus on:
1.System of Care intervention – Evaluating implementation at the two pilot sites
2.Sub-population outcomes – Assessing the impact of interventions on targeted groups PAWG metrics and city-level data – Informing future pilot expansion or citywide system interventions
3. 1. Evaluation Framework
The evaluation will assess the system of care intervention (e.g., no-wrong-door approach, teaming structure, communication and feedback loop across systems) through the lens of implementation science at the two pilot sites. By incorporating implementation science, the evaluation will use both quantitative and qualitative data to determine whether the intervention is implemented as planned.
Acceptability
The perception among implementation stakeholders that a given treatment, service, practice, or innovation is agreeable, palatable, or satisfactory.
Cost
The financial impact of an implementation effort. The true cost of implementing a treatment depends upon the costs of the particular intervention, the implementation strategy used, and the location of service delivery.
Feasibility
The extent to which a new system, or an innovation, can be successfully used or carried out within a given agency or setting. Typically, the concept of feasibility is invoked retrospectively as a potential explanation of an initiative’s success or failure, as reflected in poor recruitment, retention, or participation rates.
Fidelity
The degree to which an intervention was implemented as it was prescribed in the original protocol or as it was intended by the program developers. Compare the original evidence-based intervention and the disseminated/implemented intervention in terms of (1) adherence to the program protocol, (2) dose or amount of program delivered, and (3) quality of program delivery.
Penetration The integration of an intervention within a service setting and its subsystems. © 2025 Collective Impact Solutions 78
Appendix A
The City of San José Children and Youth Services Master Plan: Phase 2 © 2025 Collective Impact Solutions
2. Develop and Measure Outcomes at the Two Pilot Sites
Evaluation will take place at the subpopulation level (zip code or census tract data related to the two pilot sites) and at the participant level (individual and family outcomes). The PAWG seven-priority-area work plan will inform both the interventions and evaluation plan.
For each site, the following will be determined:
The priority areas the pilot site will focus on, based on subpopulation data and needs.
Goals and associated measurable objectives for each priority area (e.g., “By June 30, 2027, increase by 5% the number of students living in the pilot site zip codes who are college-ready, as measured by A-G completion rates”).
Metrics, data sources, data systems, and analysis methods for each objective.
Some goals and objectives for the pilot sites may overlap with other cross-system efforts in East San José. The evaluation process will align these efforts to ensure consistency in measurement and reporting.
The pilot sites will use the Priority Area Workgroup work plans to define measurable objectives and metrics.
Data collection, storage, and analysis of subpopulation outcomes (e.g., family and individual data) will be conducted in collaboration with system partners to leverage expertise and resources. This approach minimizes the burden on families by reducing redundant data requests from multiple stakeholders.
3. Continuous Review of City-Level Data
Citywide data specific to the identified PAWG metrics will be reviewed continuously. As of March 2025, the plan is to implement a single system of support at the two pilot sites.
Changes in citywide PAWG metrics may not directly reflect the impact of the pilot sites, but ongoing data tracking will help the city assess whether priorities should be adjusted before expanding the system to other regions.
79 Appendix A
The City of San José Children and Youth Services Master Plan: Phase 2 © 2025 Collective Impact Solutions 80
Appendix A
The City of San José Children and Youth Services Master Plan: Phase 2 © 2025 Collective Impact Solutions
Multi-level evaluation model 1
Multi-level evaluation model 2
81 Spring 2025
Creating Opportunity Pathways for Children and
Youth through the City of San José System of Care
with a No Wrong Door Service Delivery Model
City of San José Children and Youth Services Master Plan Appendix B
Creating Opportunity Pathways for Children and Youth through San José’s System of Care At the heart of every community is the desire to ensure that children, youth and families have access to the support they need to thrive. Imagine walking through any door, in any building, and finding exactly the help you’re looking for. That’s the vision behind the City of San José System of Care with a No Wrong Door (NWD) Service Delivery—a system designed to eliminate barriers and create seamless connections to services, no matter where someone starts their journey.
The No Wrong Door approach is built on the belief that access to support should be easy, efficient and centered on the unique needs of each individual. It’s more than a pathway—it’s a promise. A promise that no matter where someone turns for help, they’ll find a they will find a service provide within a system that is ready to respond with the right resources, compassionate care and coordinated services.
Achieving this vision requires more than good intentions. It demands collaboration, co-design and a commitment to continuous improvement. Together, by identifying and addressing systemic barriers, we can create a network where every door is the right door.
This handbook is a key resource for frontline staff, service providers, supervisors and community partners who are instrumental in bringing the NWD model to life. It offers guidance to ensure consistent implementation across all pilot locations and serves as a tool to support the work you do every day.
Thank you for your dedication and partnership. Your role is vital in shaping a system that truly meets the needs of our communities, ensuring that every child, youth and family receives the support they deserve—no matter which door they choose.
A Message from the
Deputy City Manager,
City of San José
Angel Rios, Jr.,
Deputy City Manager
City of San José
Creating Opportunity Pathways for Children and Youth through San José’s System of Care 3 Imagine walking into any door in a massive building, and no matter which door you choose, you find exactly what you need. That's the essence of the No Wrong Door (NWD) service delivery model—a seamless approach to delivering services where every entry point leads to the right support.
The No Wrong Door service delivery model (NWDSDM) is a person-centered, coordinated approach designed to simplify access to services and supports, ensuring individuals can receive assistance no matter where they first seek help. A NWD service delivery model has multiple access points, meaning any person can seek services from any participating agency, organization or provider that is part of the NWD and be directed to the right resources without being turned away or sent elsewhere.
Access points can include community-based organizations, government offices, healthcare providers, community centers, libraries or online platforms. The NWDSDM also uses a streamlined process, including universal intake, screening, assessment and referral procedures across agencies to reduce duplication of efforts, especially for the person seeking help to avoid retelling their story.
A strong NWDSDM that integrates a focus on a community pathway ensures services are tailored to the individual's unique needs, goals and preferences (Image #). The community pathway also ensures there is a strong emphasis on empowering individuals to make informed choices and maintain control over their care and support.
About the No Wrong Door
Service Delivery Model
Key Elements of the
No Wrong Door Service Delivery Model
Initial
communit
y member
Contact
Universal
Initial Intake
and Screening
Service
Coordination
Service
Delivery
Follow-up and
Progress
Monitoring
Evaluation,
Outcomes and
Continuous
Improvement
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Maecenas sagittis justo id nunc commodo, quis auctor ex rutrum.
Creating Opportunity Pathways for Children and Youth through San José’s System of Care 4 NWDSDM: A model developed to ensure seamless, person-centered services across access points.
Entry Points and Demonstration Sites: An introduction to the key entry points and demonstration sites where the NWDSDM is tested and refined.
Service Delivery: A step-by-step guide to how individuals are connected to the right services through intake, assessment and personalized care planning.
Service Coordination: An overview of how multiple agencies and providers work together to deliver comprehensive, integrated support for individuals and families.
Continuous Improvement: A look at how data and feedback are used to refine services, ensuring services remain effective and responsive to community needs.
This Handbook Details:
Guided by the values of accessibility, equity and collaboration, the NWDSDM is designed to ensure every individual receives the support they need when and where they need it.
Clarity: Clear insights to support understanding of the NWDSDM model.
Consistency: A unified guide to the model’s components, processes and procedures.
Support: A practical resource for navigating challenges and questions during implementation.
Purpose: To ensure all pilot locations understand and consistently implement the NWD approach.
Audience: Frontline staff, service providers, supervisors and community partners involved in the implementation.
This handbook is a living document, updated periodically to reflect changes. Familiarizing yourself with its contents supports our shared success.
This Handbook Provides:
Creating Opportunity Pathways for Children and Youth through the No Wrong Door Service Delivery Model City of San José System of Care: No Wrong Door Service Delivery Model 5 SYSTEM OF CARE
The System of Care, in San José, is a
coordinated network of services and
supports designed to promote well-being,
equity and belonging.
At its core, the Service Pathway Entry
(SPE) begins with a physical location that
fosters a culture of care and inclusion.
6 08
04 09
City of San José System of Care
A brief overview of the No Wrong Door Resource Training Guide, its purpose, and background.
Community Design
13 No Wrong Door Service Delivery Model
19 How It Work - System of Support
Process and Implementation Steps
Table of Contents
24 Introduction
42 Driving Results and Ensuring Accountability
An overview of the city’s coordinated approach to supporing children, youth and families.
A look at how collaboration and stakeholder engagement shape the No Wrong Door Model.
An explanation of the model’s core components and how it streamlines access to services.
A breakdown of the service navigation approach and the roles of key stakeholders.
A step-by-step guide for putting the No Wrong Door model into action.
Key performance metrics and strategies for continuous improvement. 43 Appendix and Glossary
Creating Opportunity Pathways for Children and Youth through the No Wrong Door Service Delivery Model © 2025 Collective Impact Solutions. All rights reserved. DRAFT 1 This document may not be reproduced, distributed, or used without prior written permission from Collective Impact Solutions. 7 The CSJ System of Care simplifies and improves access, integration, coordination, and efficiency of service delivery and enhances outcomes.:
Simplifies access: Provides clear, consistent pathways to support.
Improves efficiency: Reduces duplication of efforts and maximizes resources.
Enhances outcomes: Focuses on holistic, coordinated care for better results.
Promotes equity: Ensures universal access to quality services regardless of the entry point.
The city and its partners report annually on progress toward the goals of the Children and Youth Services Master Plan, including system transformation and the development of a comprehensive system of care using a no wrong door approach. Rather than duplicating efforts, CSJ unifies and leverages existing initiatives across San José and Santa Clara County.
NWD HANDBOOK AND RESOURCE GUIDE
Benefits of the CSJ System of Care
City of San José System of Care
The City of San José System of Care is rooted in the County of Santa Clara Community Pathway of the Family First Prevention Services, reflecting the county’s and city’s commitment to a collaborative collective impact approach that creates a seamless system of care. This system bridges city and county services, ensuring families and children receive the support they need across multiple sectors. In partnership with the County of Santa Clara, collaborative partners integrate the goals and principles of the Family First Prevention Services Act and Assembly Bill 2083 throughout the design, development, implementation and evaluation of the CSJ System of Care. This framework reduces barriers, promotes equity and enhances the delivery of culturally responsive services, fostering a more accessible and effective multi-tier and cross-sector network.
The CSJ System of Care reflects the assets, needs,
and lived experiences of the community. Through a
“Community Co-Design” approach, community
members, families, and youth serve as co-creators,
ensuring the system are responsive, intentional,
and accessible. The vision established a seamless
person-centered system where individuals and
families could access services without barriers.
CSJ System of Care: A Collaborative Path Forward
Creating Opportunity Pathways for Children and Youth through San José’s System of Care 8 mmunity -Design
mmunity -Design
The co-design process began with a commitment to listening and learning from those directly impacted. Thus, community-based organizations (CBOs), youth, families, school districts, and service providers were all engaged in shaping the model.
We held listening sessions, engagement meetings, and design workshops, where community members shared their lived experiences, challenges, and aspirations.
Youth participation was integral. Their perspectives, captured in graphics and visuals like the iceberg model (which illustrated systemic challenges), helped shape the approach.
The design process prioritized cultural responsiveness, ensuring that the NWD model reflected the diverse needs of San José families.
NWD HANDBOOK AND RESOURCE GUIDE
Creating Opportunity Pathways for Children and Youth through the No Wrong Door Service Delivery Model The City of San José remained committed to ensuring the CSJ System of Care reflected the assets, needs and lived experiences of the community. To achieve this, it was essential to engage all sectors throughout the design, implementation and evaluation process. The system was not only designed for the community but with the community—positioning residents as cocreators rather than just participants.
Understanding that equitable access starts with
communication, we developed materials in both English
and Spanish (Vietnamese was also available upon
request) to ensure that every community member could
participate.
Flyers and promotional materials were created to
recruit families and community members into the
process.
CBOs played a critical role in outreach, using flyers,
social media, and in-person outreach to invite families to engage in discussions about how services should
be structured.
A registration process was implemented to make
participation easy and accessible, ensuring that all
voices—regardless of language, literacy, or digital
access—were included.
The vision was clear: to create a seamless, person-centered system where individuals and families could access services without barriers, no matter where they entered the system.
Achieving this vision required deep community engagement to ensure the model was not only theoretically effective but also practically meaningful to the people it aimed to serve. 9 mmunity -Design
Key Actions:
Flyers were translated and distributed through trusted community partners, supporting grassroots recruitment rather than solely top-down outreach.
Community members were compensated for their time and lived experience.
The CSJ System of Care was developed through extensive co-design sessions with community members, youth, service providers, and various stakeholders. These sessions emphasized lived experiences and community voice to identify system gaps and co-create solutions.
NWD HANDBOOK AND RESOURCE GUIDE
Community Mapping and Engagement:
Community Mapping and Engagement: Participants engaged in exercises to map out current service delivery models, identifying barriers and best practices. One impactful exercise with community participants was the Aspirational Iceberg. It was used to dig deep into the underlying values, structures, and mental models that show the service delivery experience of the community. This activity helped community members envision what they wanted from their city and collaboratively identify the visible and invisible factors that contribute to the culture and success of the service system.
Creating Opportunity Pathways for Children and Youth through the No Wrong Door Service Delivery Model 10
NWD HANDBOOK AND RESOURCE GUIDE PAGE NUMBER
NWD HANDBOOK AND RESOURCE GUIDE
Creating Opportunity Pathways for Children and Youth through San José’s System of Care Visual: Sobrato Youth Engagement Visioning
The Aspirational Iceberg reveals a profound community vision for a healing and equitable system.
This story is about moving beyond surface-level changes and focusing on the root causes of inequity, creating a service delivery model driven by compassion, cultural sensitivity, and shared accountability. By aligning values, patterns, and structures with this vision, the CSJ System of Care promises to be more than a system—it becomes a community-driven culture of care and belonging.
mmunity -Design
This was a story about building a service model driven by compassion, cultural sensitivity, and shared accountability. By aligning values, patterns, and structures with this vision, the CSJ System of Care became more than a system—it transformed into a community-driven culture of care and belonging.
Youth participation was integral to the co-design process. Their perspectives were captured in graphics and visuals—a model that illustrated systemic challenges and helped uncover the underlying values and structures that needed transformation. This exercise allowed youth to reimagine their city and co-identify the visible and invisible factors contributing to the culture and success of the service system. These activities revealed a profound community vision for a healing and equitable system, focusing on moving beyond surface-level changes to address root causes of inequity.
Along with the efforts of incorporating family stories and experience, the work also had an inspiring chapter to highlight youth voices. The Sobrato Youth Engagement effort was driven by a clear vision: fostering a future where every child and youth in San José can thrive—becoming resilient, self-sufficient adults with access to abundant opportunities to live, work, and prosper in the vibrant landscape of Silicon Valley. To achieve this vision, the City of San José, in partnership with Sobrato Philanthropy and Collective Impact Solutions, made a bold decision to center youth as key stakeholders in the transformation of the service delivery system. They understood that the voices of young people—those most affected by these services—had to be heard and acted upon. 11 mmunity -Design
The CSJ System of Care integrated the County of Santa Clara’s Community Pathway, emphasizing collaboration under the Family First Prevention Services Act and Assembly Bill 2083. This alignment ensured: A continuum of services from prevention to intervention, meeting families’ needs at every stage. Reduced child welfare involvement through early intervention strategies that mitigated risks. Enhanced community well-being by providing culturally responsive supports that built resilience.
NWD HANDBOOK AND RESOURCE GUIDE
No Wrong Door Service Delivery Model
City of San José
The City of San José System of Care, designed with a No Wrong Door Service Delivery Model (NWDSDM), ensured multiple agencies and service providers worked together to maintain continuity of care, reduce fragmentation and address service gaps. Developed in collaboration with community-based organizations, school districts, city and county departments and other stakeholders, the system continued refining shared databases and communication systems through its pilot phase in spring 2025.
Creating Opportunity Pathways for Children and Youth through the No Wrong Door Service Delivery Model County of Santa Clara System of Care Alignment
Integrated System of Care
By aligning CSJ and Santa Clara County’s systems of care, the framework:
Ensured accessibility by reducing bureaucratic hurdles for families.
Promoted equity by addressing systemic barriers.
Strengthened partnerships through cross-sector collaboration. 12 mmunity -Design
The No Wrong Door Service Delivery Model followed a cyclical process that emphasized continuous, integrated service delivery to ensure families experienced seamless transitions between services with ongoing feedback loops:
Initial contact and engagement
Intake and screening
Multidimensional assessment
Service coordination and delivery
Follow-up and monitoring
Outcome evaluation and continuous improvement
NWD HANDBOOK AND RESOURCE GUIDE
Creating Opportunity Pathways for Children and Youth through the No Wrong Door Service Delivery Model No Wrong Door Service Delivery Model (continued)
13 A demonstration site provides an opportunity
to pilot new programs, models or strategies in
real-world settings. he key elements, and
tools, processes, best practices, services,
and strategies of the City of San José No
Wrong Door Service Delivery Model are
tested and refined by addressing challenges
and barriers through scalable solutions.
NWD HANDBOOK AND RESOURCE GUIDE PAGE NUMBER
The City of San José Children and Youth Services Master Plan served as a strategic roadmap to guide policy priorities, investments and service alignment, aiming to improve health outcomes and economic mobility for children, youth and young adults.
Demonstration Site and Entry Point Implementation
The City of San José System of Care
alignment with the County of Santa Clara
centers the voices and lived experience of
youth and families throughout the design,
implementation, and delivery of services.
This partnership created a communitywide service pathway, leveraging county resources beyond the city’s scope.
What is a demonstration site ?
NWD HANDBOOK AND RESOURCE GUIDE
The CSJ System of Care ensured children, youth and families could access services through multiple entry points, regardless of where they sought help. City departments, school districts and community partners played vital roles in coordinating support within an integrated service network.
Overview of NWDSDM Entry Points
Demonstration Site Implementation
The City of San José established two demonstration sites in partnership within community-based organizations, school districts, county departments, families, youth and other community stakeholders to test and refine the No Wrong Door Service Delivery Model. These sites served as multi-functional hubs providing:
Central intake points to streamline referrals
On-site support services to address diverse needs
Community input sessions to ensure responsiveness
By integrating intake, assessment and coordinated service delivery, the model eliminate systemic barriers and builds sustainable solutions for underserved communities.
Creating Opportunity Pathways for Children and Youth through San José’s System of Care 14 Demonstration Site and Entry Point Implementation
NWD HANDBOOK AND RESOURCE GUIDE
Demonstration Sites Matter
Provide real-time
insights to
improve services
Offer a space to
test innovative
ideas
Create a model
for removing
barriers to care
The goal is to build
a model that can be replicated
citywide to make services
more accessible, effective and
family-friendly.
Collaboration and Continuous Improvement
The success of the CSJ System of Care relies on collaboration with cross-sector stakeholders to create an integrated, measurable service delivery approach. Each demonstration site conducted real-time evaluations of infrastructure, data and services to identify challenges, refine processes and highlight best practices.
By fostering ongoing assessment and
adaptation, the System of Care remains
responsive to the evolving needs of San José
children, youth, and families while developing a
replicable framework for seamless access to
services.
Assessment and Evaluation Process
Throughout the implementation of the City of San José System of Care with a No Wrong Door Service Delivery Model an assessment and evaluation process will be ongoing. Thus far it included reviewing reports, district and community data; conducting school site learning walks to observe current practices; and holding empathy interviews and listening sessions to capture lived experiences. These assessments ensure demonstration sites are guided by real-time data, community feedback and systemic analysis, providing a foundation for sustainable improvements.
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Entry
Points
The CSJ System of Care No Wrong Door Service Delivery Model – Community Pathway includes a centralized intake system that serves as the initial point of contact for community members. The Single Point of Entry (SPE) can take various forms, including a physical location, hotline, or online portal, ensuring accessibility and convenience. For the CSJ System of Care Community Pathway, the SPE begins with a physical location that fosters a culture of care and belonging, and uses a Universal Initial Intake and Screening Form to efficiently streamline access to services and support for those entering the System of Care.
A key component of this model was the Unified Information System, a secure, shared database accessible to all participating agencies. This system improved cross-agency collaboration, ensured integrated care and complied with privacy regulations such as HIPAA.
By centralizing intake, information-sharing and service coordination, the SPE model reduced barriers, improved efficiency and ensured timely, well-coordinated support for individuals and families.
Single Point of Entry (SPE) Overview
Visual: The CSJ System of Care No Wrong
Door Service Delivery Model streamlines
access to services through a centralized
intake system, unified information sharing
and coordinated support, ensuring
seamless and equitable care for
individuals and families.
NWD HANDBOOK AND RESOURCE GUIDE
City of San José Departments
CSJ Libraries
PRNS
Pilot School Districts
Eastside Union High School District
Alum Rock Union School District
Franklin McKinley Elementary School District
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During installation and initial implementation, sites will establish a core planning team, assess existing systems, data and practices and refine service delivery models. Each demonstration site will function as a multi-functional hub, integrating centralized intake, referrals, multidimensional assessments and coordinated service delivery. Cross-sector collaboration will ensure families access services seamlessly, from universal support to intensive wraparound care.
Ongoing Assessment and Improvement
A planning team of city leaders, school district representatives and community members will align structures with the System of Care framework, facilitate provider training and strengthen cross-agency communication. Ongoing assessments will evaluate service delivery, partnerships and staff capacity, using data-driven strategies to improve access and coordination.
Pilot Sites
Installation and Implementation
The CSJ System of Care and No Wrong Door Service
Delivery Model will follow a multi-phased
implementation outlined in the Children and Youth
Services Master Plan. Two demonstration sites will
serve as learning communities to refine the model and
remove systemic barriers for underserved communities.
NWD HANDBOOK AND RESOURCE GUIDE
Building a Sustainable Model
Demonstration sites will transform services into a unified, responsive system. A centralized intake process will include:
Standardized intake forms
Screening tools
Shared data platforms
Coordinated service delivery protocols
Through co-design and capacity-building, pilot sites will refine the model to ensure equitable, sustainable and accessible services for all..
Creating Opportunity Pathways for Children and Youth through San José’s System of Care 17 Process and
Implementation
Steps
How It Works:
and
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CSJ NWDSDM Sustainability
Equitable
System
of Care
Coordinated
Support
Seamless
Access
The community member’s journey begins with a welcoming, non-judgmental environment at the entry points, including city departments, school districts or demonstration sites. Staff greet community members warmly, ensuring they feel safe and supported from the very first interaction. During this step, basic information is collected to create a community member profile and prioritize urgent needs. Individuals can connect through multiple access points, such as phone lines, in-person visits or online portals. Implementing the CSJ System of Care and No Wrong Door Service Delivery Model requires a structured approach to reduce barriers, improve efficiency and ensure timely, well-coordinated support for individuals and families. Providers play a critical role in aligning structures and frameworks necessary for the Single Point of Entry model, creating a seamless, accessible system of care.
This section outlines the key elements and essential steps providers take to integrate standardized processes, enhance cross-agency collaboration and streamline service delivery. By establishing centralized intake, shared data systems and coordinated service protocols, providers foster a responsive, equitable and sustainable support network for the community.
NWD HANDBOOK AND RESOURCE GUIDE
Opening Doors with Care: A Safe and Supportive Start
Visual: An interconnected network of service providers working together ensures a seamless access, coordinated support and an equitable system of care within the CSJ No Wrong Door Service Delivery Model.
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The City of San José Department of Parks, Recreation and Neighborhood Services and Public Library provide inclusive environments that offer a variety of programs and services for children, youth and families. To effectively serve community members in need, the No Wrong Door Service Delivery Model (NWDSDM) ensures a seamless, coordinated approach where individuals seeking support are welcomed, assessed and connected to appropriate resources—whether through city departments or external partners.
Similarly, schools and school districts function as key access points, integrating health and human services with education through a Single System of Support Framework grounded in upstream prevention and collective impact. Schools serve as a single point of entry, ensuring that families and students receive the services they need without barriers such as insurance or diagnostic requirements.
NWD HANDBOOK AND RESOURCE GUIDE
Overview
Creating Opportunity Pathways for Children and Youth through San José’s System of Care Visual: The flowchart outlines the key elements and essential steps providers take to integrate standardized processes, enhance cross-agency collaboration and streamline service delivery. A larger version can be found in the appendix 20 NWD HANDBOOK AND RESOURCE GUIDE PAGE NUMBER
1.Initial Contact
Visitors are greeted by trained staff or volunteers in a safe, welcoming and traumainformed environment.
Staff members are equipped with cultural humility training to provide empathetic and responsive support.
2.Universal Intake and Screening
A brief intake process helps individuals articulate their needs.
Staff use standardized universal intake and screening tools to assess needs across multiple domains, including: Health, Housing, Employment, Education and Social support.
Immediate needs such as housing insecurity, food access or urgent health concerns are prioritized.
3.Determining Level of Need
After intake, staff assess whether the individual requires basic referrals or more comprehensive support.
Individuals needing further assistance are connected to external service providers.
4.Warm Hand-Off and Service Navigation
Staff coordinate a warm hand-off to the appropriate service provider or tier of need.
Support includes scheduling appointments, assistance with completing forms and navigation to specialized resources such as legal aid, financial assistance or mental health services
To prevent fragmentation, staff work closely with external partners to ensure individuals do not need to retell their stories multiple times.
5.Creating a Community Hub
Libraries and community centers act as more than just service gateways—they foster community connections and empowerment.
Services are tailored to meet individual goals and enhance overall well-being.
NWD HANDBOOK AND RESOURCE GUIDE
Creating Opportunity Pathways for Children and Youth through San José’s System of Care City of San José Department Entry Points
City of San José Department Entry Points
Libraries and community centers serve as natural entry points where trained staff and volunteers facilitate connections to needed services. The NWDSDM process follows key steps that support the City’s System of Care.
21 1.School-Based Support Teams
Multi-disciplinary teams (MDTs), also known as Coordinated Care Teams or Coordination of Services Teams (COST),
use data to implement evidence-based interventions.
These teams focus on academic, behavioral, health and
social-emotional needs at Tier 2 and Tier 3 levels.
2.Identification and Referral Process
Students requiring additional support are identified through COST meetings.
If family support or external services are needed beyond school-based interventions, a referral is made to a School Link Services (SLS) coordinator.
NWDSDM Process in Schools: The SLS coordinator facilitates the following steps, mirroring the city department process:
3. Initial Contact: Families are engaged with care and cultural humility, ensuring a welcoming and stigma-free experience.
Universal Intake and Screening: The coordinator
assesses needs across domains such as education, health, mental health and social services. Immediate needs are
prioritized.
Determine Level of Need: The coordinator determines
whether the student and family require basic support or more intensive services.
Warm Hand-Off to Appropriate Tier of Need: The
coordinator ensures a seamless transition to necessary
services, reducing barriers to access. Families receive clear next steps and assistance in navigating external support systems.
NWD HANDBOOK AND RESOURCE GUIDE
Creating Opportunity Pathways for Children and Youth through San José’s System of Care City of San José Department Entry Points
School Sites – Initial Contact with Students and Families Schools and school districts serve as an essential single point of entry, integrating educational, health and mental health services to support students and families. 22 NWD HANDBOOK AND RESOURCE GUIDE PAGE NUMBER
NWD HANDBOOK AND RESOURCE GUIDE
Creating Opportunity Pathways for Children and Youth through San José’s System of Care City of San José Department Entry Points
Ensuring a Seamless and Equitable Process
Both city department entry points and school sites align their processes with the CYS Master Plan values:
1. Accessibility and inclusion for all youth
Cross-sector collaboration
Investment and accountability
Equity
Outcomes and results-driven services
Youth and community voice-driven approach
1.Both =
The No Wrong Door Service Delivery Model ensures that children, youth and families receive the right support without unnecessary barriers, making essential services available within the community and for the community.
2. 23
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Tier 1 – Universal Supports: Immediate referral to
services that promote general well-being and
strengthen communities. These preventive services
are designed for the general population.
Tier 2 – At-Risk Services: Referral to a site navigator or promotora for targeted interventions that help
prevent emerging challenges from escalating.
Tier 3 – Intensive Supports: Assignment to a care
coordinator and care team for comprehensive, longterm support tailored to complex needs.
The community member’s journey begins in a welcoming, nonjudgmental environment at entry points, including city departments, school districts or demonstration sites. Staff greet community members warmly, ensuring they feel safe and supported from the first interaction. During this step, staff collect basic information to create a community member profile and prioritize urgent needs. Individuals can connect through multiple access points, such as phone lines, in-person visits or online portals.
NWD HANDBOOK AND RESOURCE GUIDE
Key Elements of the CSJ NWDSDM: Steps 1 and 2
Step 1: Initial community member Contact
Determining the level of need is essential for connecting individuals to services that match their unique circumstances. The CSJ System of Care classifies needs into the following tiers:
Step 2: Universal and Initial Intake and Screening
Visual: The City of San José System of Care Intake Form streamlines community member access by standardizing information collection, ensuring efficient service coordination and seamless support delivery.
Single Point of Entry: A centralized
system ensures all initial contact follows a
consistent process, regardless of where
the individual first enters.
Clear Communication: Staff explain that
assistance is available across multiple
services and that community members
receive support throughout their journey.
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Key Elements of the CSJ NWDSDM: Step 2
For individuals needing more targeted support, a multi-dimensional assessment evaluates financial stability, mental and physical health, housing, employment and social support systems. community member-Centered Approach: Individuals actively participate in the assessment process, ensuring their voices are heard and their preferences respected.
State Requirements: For children and youth, the Child and Adolescent Needs and Strengths (CANS) Assessment Tool informs care coordination and service planning.
Continuum of Service Delivery: A no wrong door framework structures tiered services to match individuals' varying needs and complexities. This approach ensures community members receive appropriate interventions, with intensive services reserved for those with higher needs.
Visual: Multi-Tiered System of Supports (MTSS) is a three-tiered framework illustrating the levels of support provided to community members. Each tier narrows as the intensity of support increases, illustrating the progressive levels of intervention within framework.
Guided service-planning for children, youth and families while ensuring they receive the right level of support at the right time.
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My Notes
NWD HANDBOOK AND RESOURCE GUIDE
Key Elements of the CSJ NWDSDM: Step 2
Tier 1: Universal supports
Direct referral to Service Provider
Tier 1 supports and services are directed at the general population to strengthen communities and improve child well-being by focusing on the social determinants of health. State Definition:
These activities are directed at the general population to strengthen communities and improve child well-being by focusing on the social determinants of health, defined as the conditions into which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.
Target Group
State Definition
All community members, regardless of specific needs
These activities are focused on the general population to strengthen communities and improve child well-being by addressing the social determinants of health. These determinants include the conditions into which people are born, grow, work, live, and age, as well as the wider set of forces and systems shaping the conditions of daily life.
Step 1: The family or individual is determined to be a “light touch” and is directly referred to the Service Provider.
Step 2: Referral to Service Provider and appointment scheduled within 36 hours or when family/individual available.
Step 3: All information and data of family/individuals is shared with the Service Provider. All information and data is reviewed by the Service Provider prior to engaging with family and/or individuals.
Step 4: Initial contact with Service Provider and family or individual.
Establish trust and rapport
Family/individual is provided with a welcoming environment.
Service Providers will complete their internal assessment with Family/Individual.
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These activities are offered to populations with one or more risk factors associated with compromised wellbeing or child maltreatment. These risk factors include poverty, parental substance abuse, young parental age,
parental mental health concerns, exposure to violence,
and parental or child disabilities. Programs seek to
build protective factors and mitigate risk factors.
community members with identified needs that require more than universal services but do not need intensive intervention.
NWD HANDBOOK AND RESOURCE GUIDE
Key Elements of the CSJ NWDSDM: Step 2
Tier 2: At-risk
Referral to Demonstration Site
Navigator/Promotora or Service Guide
Tier 2 services aim to alleviate emerging problems and prevent escalation by addressing specific, moderate needs identified through assessment and providing focused support.
Target Group
State Definition
Step 1: The Family or Individual is determined to be “At-Risk” and resides in the zip codes of the demonstration sites
Step 2: Referral to Site Navigator/Promotora or Service Guide (SN/SG) and appointment scheduled within 36 hours or when family/individual available.
Step 3: All information and data of family and individuals are shared with SN/SG. All information and data is reviewed by SN/SG prior to engaging with family and/or individuals.
Step 4: Initial contact with Service Provider and Family/Individual.
Establish trust and rapport
Family/individual is provided with a welcoming environment.
Service Providers will complete their internal assessment with Family/Individual.
Steps of Interventions and Support
Early support can make a
lasting difference.
Tier 2 services help
families build resilience by
addressing concerns
before they escalate.
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Step 5: SN/SG determines if a family/individual is “At-Risk” or/and needs more intensive services.
If Yes, refer to Tier 3/Care Coordinator
If No, skip to Step 6.
Step 6: N/SG continues to work with the family/individual on developing a plan with the Self Sufficiency Assessment determining the best services/programs that will meet the needs of the family/individual.
Goal Setting: Work with the family to identify their goals and desired outcomes.
Action Plan: Develop a personalized service plan that outlines the specific services and supports needed to achieve the goals. Include clear timelines and responsibilities.
Resource Identification: Identify available resources and services that match the family/individual's needs, including internal and external providers.
Step 7: Option of referral of a Triage Team
If SN/SG determines that they need more support for a family/individual, they can refer a family/individual to a triage team to receive more guidance of services/programs to keep families and individuals from escalating into Tier 3.
NWD HANDBOOK AND RESOURCE GUIDE
Key Elements of the CSJ NWDSDM: Step 2
Tier 2: At-risk (continued)
Referral to Demonstration Site
Navigator/Promotora or Service Guide
The warm handoff builds
trust. When families meet
service providers with
familiar support by their
side, they feel more
confident engaging with
new resources.
Step 8: Service Referral
SN/SG makes formal referrals to the identified
services and providers and ensures that referral
documentation is complete and accurate.
Note: Referrals are to Health and Mental Health
Health: Referral to call center will vary
depending on the insurance provider held by
the family or individual.
Mental Health: Referral directly to Behavioral
Health Call Center
Warm Handoff: SN/SG facilitates a warm handoff by introducing the family to the service providers, ensuring a smooth transition.
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Step 1: The family/individual is determined to be “At-Risk” and intensive supports and resides in the zip codes of the demonstration sites.
Step 2: Referral to Care Coordinator (CC) and appointment scheduled within 36 hours or when family/individual available.
NWD HANDBOOK AND RESOURCE GUIDE
Key Elements of the CSJ NWDSDM: Step 2
Tier 3: Intensive/Tertiary
Referral to Care Coordinator and Care Team
Tier 3 is implemented when limited progress with Tier 2 interventions indicates the need for more intensive, specific and intentional interactions. Interventions at this level are individualized based on collected data and provide comprehensive, sustained support for individuals with complex or multiple needs. These services require a higher level of coordination to address the unique challenges faced by community members.
Target Group
State Definition
community members with significant needs that require long-term and coordinated intervention. Individualized services and interventions are provided for children and families with established problems.
These activities focus on families where child maltreatment has occurred, seeking to mitigate its trauma, reduce the negative consequences of the maltreatment, and prevent its recurrence.
Step 3: All information and data of family and
individuals are shared with CC. All information
and data is reviewed by the CC prior to
engaging with family and/or individuals.
Step 4: Initial contact with Care Coordinator and
family/individual.
Establish trust and rapport
Completion of assessments
Comprehensive Assessment (CANS)
Tier 3 interventions go beyond
surface-level support.
They provide the intensive,
personalized care needed to
help individuals and families
overcome complex challenges.
Creating Opportunity Pathways for Children and Youth through San José’s System of Care 29 My Notes
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Step 5: CC works with family/individual to develop a care plan determining the best services/programs that will meet the needs of the family/individual.
Goal Setting: Work with the family to identify their goals and desired outcomes.
Action Plan: Develop a personalized service plan that outlines the specific services and supports needed to achieve the goals. Include clear timelines and responsibilities.
Resource Identification: Identify available resources and services that match the family/individual's needs, including internal and external providers.
Step 6: Coordination of a Care Team
If CC determines the family/individual needs additional support, a Care Team is established to provide comprehensive, coordinated care by bringing together professionals from various fields to address the complex needs of individuals or families. The team works collaboratively to develop and implement a holistic care plan.
Step 7: Service Referral
The CC makes formal referrals to identified services and providers and ensures all referral documentation is complete and accurate.
Note: Referrals to Health and Mental Health
Health: Referral to call center will vary depending on the insurance provider held by the family or individual.
Mental Health: Referral directly to Behavioral Health Call Center Warm Handoff: Facilitate a warm handoff by introducing the family to the service providers, ensuring a smooth transition.
NWD HANDBOOK AND RESOURCE GUIDE
Key Elements of the CSJ NWDSDM: Step 2
Tier 3: Intensive/Tertiary (continued)
Referral to Care Coordinator and Care Team
Creating Opportunity Pathways for Children and Youth through the No Wrong Door Service Delivery Model 30 My Notes
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Key Elements of the CSJ NWDSDM: Step 2
Specialized and Crisis Services
Immediate Referral to Demonstration Site
Step 1: The family/individual is determined to be Intensive support and resides in the zip codes of the demonstration sites.
Step 2: Referral to Care Coordinator (CC) and appointment scheduled within 36 hours or when family/individual available.
Follow steps for Tier 3.
Step 3: All information and data of family and individuals are shared with CC. All information and data is reviewed by the CC prior to engaging with family and/or individuals.
An immediate needs assessment is conducted to identify any critical or emergency needs that require urgent attention and to provide referrals or direct assistance as needed.
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1.Identify Stakeholders
Engage key stakeholders, including community leaders, service providers, families, and youth. Ensure representation from various sectors such as education, healthcare, social services, and local government.
2.Define Goals and Objectives
Clearly outline the goals and objectives of the Care Team. Focus on improving access to services, enhancing coordination among providers and ensuring families receive comprehensive support.
3.Develop a Framework
Create a framework for the No Wrong Door model, which includes streamlined intake processes, centralized information systems, and a coordinated referral network.
4.Train Staff
Provide training for staff on the principles of the No Wrong Door model, person-centered care, and effective communication and collaboration techniques.
5.Establish Partnerships
Form partnerships with other organizations, agencies, and service providers to ensure a seamless network of support. This includes schools, healthcare providers, social service agencies, and community-based organizations.
6.Implement Technology Solutions
Utilize technology to create a centralized database and communication system that allows for easy access to information and coordination among team members.
7.Create a Referral System
Develop a referral system that ensures families can access the services they need without having to navigate multiple agencies. This system should be easy to use and accessible to all families.
8.Monitor and Evaluate
Continuously monitor and evaluate the effectiveness of the Care Team and the No Wrong Door model. Collect feedback from families and service providers to make necessary adjustments and improvements.
9.Sustain and Expand
Work on sustaining the Care Team by securing ongoing funding and resources. Explore opportunities to expand the model to other communities or service areas.
NWD HANDBOOK AND RESOURCE GUIDE
Key Elements of the CSJ NWDSDM: Step 2
Establishing a Care Team
Creating Opportunity Pathways for Children and Youth through San José’s System of Care Establishing a Care Team for a No Wrong Door service delivery model within a communitybased organization involves several key steps. Here’s a general outline:
32 NWD HANDBOOK AND RESOURCE GUIDE PAGE NUMBER
The Triage and Care Team includes professionals from various disciplines to address the diverse needs of individuals and families:
Mental Health Professionals: Counselors, psychologists, and therapists for emotional and psychological support.
Social Services Staff: Social workers to provide assistance with social and economic challenges.
NWD HANDBOOK AND RESOURCE GUIDE
Key Elements of the CSJ NWDSDM: Step 2
The Composition of the Care Team
Education Representatives: School staff and educational specialists to support learning needs.
Housing Specialists: Experts to assist with housing-related issues and stability.
Healthcare Providers: Nurses and medical staff to address physical health concerns.
Community-Based Organizations: Representatives from local organizations offering specialized services.
Family Representatives and Advocates: To ensure family voices are heard and their needs are prioritized.
No family should navigate complex
challenges alone. The Triage and Care
Team ensures support is coordinated,
compassionate and customized for
each family’s unique needs.
Creating Opportunity Pathways for Children and Youth through San José’s System of Care Establishing a Triage Team
Purpose: The primary role of a triage team is to
conduct initial assessments of individuals or
families to determine the level of support and
intervention required. They act as the first point
of contact to quickly identify urgent needs and
prioritize cases for appropriate services.
Key Functions:
Initial Assessment: Quickly evaluates the needs and urgency of each case.
Prioritization: Determines the severity of needs and prioritizes cases based on urgency.
Resource Allocation: Directs individuals or families to the appropriate services or support within the system.
Coordination: Works to ensure that families are connected to the right resources without having to navigate complex systems.
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Process to Coordinate a Triage Team
1. Define Objectives and Scope
Clearly outline the objectives of the triage team, such as assessing the needs of families, prioritizing cases, and connecting them to appropriate services.
Determine the scope of the triage team’s work, including the types of cases they will handle and the criteria for triage.
2. Assemble the Triage Team
Identify and recruit team members with diverse expertise, such as social workers, case managers, health professionals, and intake specialists.
Provide comprehensive training on assessment tools, triage protocols, and the “No Wrong Door” approach.
3. Develop Triage Protocols and Tools
Create standardized assessment tools to evaluate the needs and urgency of each case.
Establish clear protocols for prioritizing cases based on severity and urgency. Include guidelines for decision-making and escalation.
4. Establish Communication Channels
Set up effective communication channels within the triage team for sharing information and coordinating efforts.
Develop procedures for communicating with other service providers and stakeholders to ensure seamless referrals.
5. Intake and Initial Contact
Implement an intake process for receiving referrals from various entry points, such as community organizations, schools, and self-referrals.
Ensure that the triage team makes timely initial contact with families to explain the process and gather preliminary information.
6. Needs Assessment and Prioritization
Use the standardized assessment tools to evaluate the needs of each family.
Apply the triage protocols to prioritize cases based on urgency and severity. Categorize cases into different levels of priority (e.g., high, medium, low).
7. Resource Identification and Referral
Identify appropriate services and resources that match the needs of each family.
Make formal referrals to the identified services. Ensure that referral documentation is complete and accurate.
Facilitate a warm handoff by introducing the family to the service providers and ensuring a smooth transition.
NWD HANDBOOK AND RESOURCE GUIDE
Key Elements of the CSJ NWDSDM: Step 2
Triage Team Composition:
Typically, social workers, intake specialists, and case managers who are trained in assessment and resource coordination.
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Once the assessment is complete, a personalized service plan is developed, and the individual is connected to the appropriate services.
Service Guides/Navigators (Tier 2): Help
individuals access short-term, immediate services.
Care Coordinators (Tier 3): Provide long-term case management and coordinate multiple services for complex cases
.
Cross-Agency Coordination: Agencies collaborate to ensure seamless service delivery without duplication or service gaps. Regular communication among providers helps adjust services as needed.
Prevention Plan: For at-risk individuals, a prevention plan is created to avoid escalation into crisis situations.
NWD HANDBOOK AND RESOURCE GUIDE
Key Elements of the CSJ NWDSDM: Step 3
Service coordination within the CSJ System of Care with a no wrong door service delivery model is the process of managing and organizing services for an individual across multiple agencies or providers to ensure they receive comprehensive and integrated support. Different roles within the collaborative cross-sector partners of the CSJ System of Care provide different services to an individual or family. Case coordination focuses on providing personalized, continuous care across different sectors, preventing gaps or overlaps in services.
Step 3: Service Coordination
Assigned Navigators or Care Coordinators
(Tier 1 or 2):
Creating Opportunity Pathways for Children and Youth through San José’s System of Care Collaboration across agencies
helps build trust, streamline
services, and improve outcomes.
8. Follow-Up and Monitoring
Schedule regular follow-ups with families to monitor their progress and address any emerging issues.
Make necessary adjustments to the service plan based on feedback and changing needs.
9. Documentation and Reporting
Maintain accurate and up-to-date records of all interactions, assessments, and referrals.
Prepare reports as required by funding agencies, management, or other stakeholders.
10. Continuous Improvement
Collect feedback from families and service providers to identify areas for improvement in the triage process.
Implement changes to improve efficiency and effectiveness based on feedback and outcomes.
35 NWD HANDBOOK AND RESOURCE GUIDE PAGE NUMBER
1. Service Coordination: Initial Assessment and Prioritization Conduct thorough assessments to understand the full scope of an individual's or family's needs.
Use standardized tools to evaluate the urgency and complexity of each case.
Collect data from various sources, including interviews, surveys and existing records.
Categorize cases into priority levels—high, medium or low—and determine the appropriate level of intervention.
j2. Resource Identification and Referral
Identify services and resources that match the needs of individuals or families.
Submit formal referrals with complete and accurate documentation.
Facilitate a warm handoff to service providers to ensure a smooth, supported transition.
3. Holistic Care Planning
Develop and implement a holistic care plan that addresses psychological, social, educational and other needs.
Incorporate community member input to ensure their preferences and goals are reflected in the plan.
4. Ongoing Support and Monitoring
Provide continuous support and adjust care plans as needed based on community member progress and feedback.
Schedule regular follow-ups to track outcomes and address emerging needs.
NWD HANDBOOK AND RESOURCE GUIDE
Key Elements of the CSJ NWDSDM: Step 3
Service Coordination Process
When individuals help shape their care plans, they are
more motivated and engaged.
The best systems evolve with the communities they
serve. Feedback fuels growth.
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Key Elements of the CSJ NWDSDM: Step 3 and 4
5. Coordination and Collaboration
Maintain clear, consistent communication with community members, school districts, community-based providers and system partners.
Establish partnerships with other organizations, agencies and service providers to create a robust support network.
6. Documentation and Reporting
Track community member information using a shared database to improve service coordination while ensuring privacy compliance.
Maintain accurate records of interactions, assessments and referrals.
Prepare reports to meet funding requirements and support ongoing process evaluation.
7. Continuous Improvement
Provide ongoing support and make necessary adjustments to care plans.
Collect feedback from families and service providers to identify areas for improvement.
Implement changes to enhance the triage and care process, ensuring the model remains responsive to community needs.
Service Coordination Process (continued)
Creating Opportunity Pathways for Children and Youth through San José’s System of Care Service delivery focuses on executing the personalized service plan developed during the service coordination process. The individual or family receives appropriate services based on their identified tier level and needs, whether through short-term interventions or long-term intensive support.
Step 4: Service Delivery
37 NWD HANDBOOK AND RESOURCE GUIDE PAGE NUMBER
"Our goal is to
learn, adapt, and
improve —
ensuring every
family receives
the best possible
support.
Step 2 – Monitor Service Delivery
Continuously monitor the quality and effectiveness of services provided. Address any issues or barriers that arise during service delivery.
Step 3 – Case Management and Ongoing Support
The assigned Service Guide, Navigator or Care Coordinator oversees the implementation of the service plan and serves as the primary point of contact for individuals and families.
Conduct regular check-ins to assess progress and address new needs.
Adjust service plans as necessary based on feedback and changing circumstances.
Step 4 – Cross-System Coordination
Ensure seamless integration and cooperation between different systems, such as healthcare, education and social services, to provide holistic support.
Establish inter-agency agreements and protocols for information sharing and collaboration.
Identify and address potential gaps or overlaps in services.
Facilitate joint training and capacity-building activities for staff across systems.
NWD HANDBOOK AND RESOURCE GUIDE
Key Elements of the CSJ NWDSDM: Step 3 and 4
Step 1 – Initiate Services
The Service Guide, Navigator or Care Coordinator helps the individual connect with identified service providers based on the personalized service plan. This may involve scheduling appointments, making introductions and ensuring the individual understands what to expect from each service provider.
The Service Guide, Navigator or Care Coordinator also
ensures all necessary documentation and information are shared with service providers to facilitate a smooth transition.
Creating Opportunity Pathways for Children and Youth through San José’s System of Care Service Delivery (continued)
Ongoing support ensures individuals continue
receiving the services they need to achieve their
goals. Regular follow-ups are scheduled to track
progress and address emerging challenges.
Step 5: Follow-Up and Monitoring
38 NWD HANDBOOK AND RESOURCE GUIDE PAGE NUMBER
NWD HANDBOOK AND RESOURCE GUIDE
Key Elements of the CSJ NWDSDM: Step 5
Check-Ins: Case managers review individual progress and update the care plan as needed.
Referral to Higher Tiers: If progress stalls, individuals may be referred to higher-level services for more intensive support.
Flexible Service Models – Create flexible service models that allow smooth transitions between tiered service levels without gaps or delays.
Regular Reassessments – Implement regular reassessments to ensure individuals receive the appropriate level of support and can be stepped up or down as needed.
Step 1: Initial Follow-Up Contact
Schedule Follow-Up
Arrange an initial follow-up contact with the community member shortly after service delivery begins. Ensure the timing is appropriate to gauge early progress and address any immediate concerns.
Individual/Family Check-In:
Contact the community member to check on their well-being and assess their satisfaction with the services received. Discuss any initial challenges or barriers they may be facing.
Step 2: Regular Monitoring and Check-Ins
Establish a Follow-Up Schedule
Develop a regular follow-up schedule based on the community member's needs and the nature of the services provided. Include both in-person meetings and phone or virtual check-ins as appropriate.
Conduct Regular Check-Ins
Reach out to the community member at predetermined intervals to monitor their progress and assess their ongoing needs. Ensure consistent communication to build trust and rapport.
Step 3: Progress Assessment and Documentation
Gather Feedback
Solicit feedback from the community member about their experiences with the services and any changes in their circumstances. Use surveys, interviews, or informal conversations to gather comprehensive information.
Document Progress
Record the community member's progress, noting any achievements, challenges, or changes in their situation. Update the community member's care plan and case file with relevant information.
Key Support Actions:
Creating Opportunity Pathways for Children and Youth through San José’s System of Care Follow-Up and Monitoring (continued)
39 NWD HANDBOOK AND RESOURCE GUIDE PAGE NUMBER
Ongoing support is not just
about monitoring progress.
It's about fostering trust,
promoting independence and
ensuring individuals have the
tools they need to thrive.
NWD HANDBOOK AND RESOURCE GUIDE
Key Elements of the CSJ NWDSDM: Step 5
Follow-Up and Progress Monitoring (continued)
Step 4: Adjustments to Care Plan
Review and Evaluate
Regularly review the community member's care plan in collaboration with the community member and service providers. Evaluate the effectiveness of the services and identify areas for improvement.
Modify Care Plan
Make necessary adjustments to the care plan based on the community member's feedback and progress. Ensure that the modified plan addresses any emerging needs or challenges.
Step 5: Coordination with Service Providers
Communicate with Providers
Maintain open lines of communication with all service providers involved in the community member's care. Share relevant updates and information to ensure coordinated service delivery.
Address Barriers
Work with service providers to address any barriers or issues that may arise during the community member's progress. Develop joint strategies to overcome challenges and support the community member's goals.
Step 6: Ongoing Support and Resources
Provide Continuous Support
Offer ongoing support to the community
member, including additional resources or
referrals as needed. Ensure that the
community member feels supported
throughout their journey.
Empower community member
Equip and support the community member
by involving them in decision-making and
encouraging self-advocacy. Provide tools
and resources to help the community
member build their capacity and
resilience.
Creating Opportunity Pathways for Children and Youth through San José’s System of Care 40
NWD HANDBOOK AND RESOURCE GUIDE PAGE NUMBER
NWD HANDBOOK AND RESOURCE GUIDE
Key Elements of the CSJ NWDSDM: Step 6
Evaluating service outcomes ensures the effectiveness of care and supports continuous improvement. Data collection and community member feedback help refine care plans and enhance service delivery.
Step 6: Final Evaluation and Outcome Measurement
Data Collection: Gather feedback from individuals and track key performance indicators.
Plan Adjustments: Refine care plans based on evaluation results to better meet individual needs.
Key Support Actions:
Conduct Final Evaluation: Once a community member has achieved their goals or completed the service, conduct a final evaluation to measure outcomes. Use standardized tools to assess the impact of the services on the community member's well-being.
Document Outcomes: Record the final outcomes in the community member's case file, noting any key achievements or areas for further support. Use this information to inform future service delivery and program improvements.
Closure or Transition: Provide a formal closure when appropriate, ensuring the community member understands how to access future support if needed. If transitioning to another service or support, facilitate a smooth handover to ensure continuity of care.
Schedule appointments and follow-ups.
Regular check-ins by the case manager or agency staff.
Update the community member's profile and care plan as necessary.
Address any emerging needs or challenges.
Outcome evaluation isn't just about measuring success. It's about learning, adapting and improving care for the future.
Creating Opportunity Pathways for Children and Youth through San José’s System of Care 41
NWD HANDBOOK AND RESOURCE GUIDE
Driving Results
Driving Results and Ensuring Accountability
The CSJ System of Care prioritizes continuous improvement to create a seamless, responsive service delivery system that evolves alongside the community's needs. Regular evaluation, open communication and shared responsibility help ensure services remain accessible, effective and equitable for all.
Continuous improvement is not a fixed endpoint but an ongoing journey—one that reinforces the system's core values of accessibility, equity and community member-centered care.
Unified Information System
A key component of the CSJ System of Care is the Unified Information System—a shared, secure database that stores community member information and facilitates real-time collaboration across participating agencies.
This system supports integrated, high-quality care by:
Centralizing community member Information: Ensuring all authorized providers can access up-to-date information to deliver informed, coordinated support.
Improving Cross-Agency Collaboration: Allowing agencies to work together more effectively, preventing duplication of services and ensuring continuity of care.
Ensuring Data Security & Privacy: Complying with federal, state and local regulations— including the Health Insurance Portability and Accountability Act (HIPAA)—to protect community member confidentiality.
Creating Opportunity Pathways for Children and Youth through San José’s System of Care 42 Appendix
Creating Opportunity Pathways for Children and Youth through San José’s System of Care 43 Initial Contact and Engagement
Warm Welcome: Staff create a welcoming nonjudgmental environment.
Basic Information Collection: Gather demographic data and identify immediate needs.
Initial Intake/Screening
Single Point of Entry: Centralized system via location, hotline or portal.
Unified Information System: Secure database for cross-agency access.
Comprehensive Screening Process
Standardized Tools: Consistent data collection across housing, health and education domains.
Determining Level of Need
Tier 1 - Universal Supports: Community-wide services targeting social determinants of health.
Tier 2 - At-Risk: Targeted interventions for emerging issues.
Tier 3 - Intensive/Tertiary: Individualized services for established problems.
Specialized/Crisis Services: Immediate assessments for urgent needs.
Multi-Dimensional Assessment
Holistic Approach: Address all aspects of community member well-being. community member-Centered: Engage community members actively in the process.
CANS Tool: Required for assessing child and adolescent needs.
Service Coordination and Delivery
Service Guides/Navigators (Tier 2): Short-term goal-oriented support.
Care Coordinators (Tier 3): Long-term comprehensive case management.
Cross-Agency Collaboration: Ensuring continuity and avoiding service gaps.
Follow-Up and Monitoring
Regular Check-ins: Assess progress and adjust plans.
Outcome Evaluation: Measure service impact, collect feedback and refine processes.
Universal Intake and Screening
Common Intake Data: Name, contact info, demographics, housing, income and family structure.
Screening Questions: Emergency needs, risk factors and developmental concerns.
Assessments
Ages & Stages Questionnaire (ASQ-3): Early childhood developmental screening.
Child and Adolescent Needs and Strengths (CANS): Comprehensive youth assessment tool.
Capacity Building & Training
Staff Training: Emotional intelligence, trauma-informed care and cultural competency.
Environment: Accessible welcoming spaces with multilingual resources.
Communication: Authentic community member-centered engagement strategies.
Continuous Improvement
Feedback Loops: Incorporate community member and community input.
Data Analysis: Identify trends and improve service delivery.
Key considerations for practitioners to support consistent, high-quality care through structured processes and collaborative frameworks.
NWD HANDBOOK AND RESOURCE GUIDE PAGE NUMBER
NWD HANDBOOK AND RESOURCE GUIDE
Creating Opportunity Pathways for Children and Youth through San José’s System of Care 44 N
WDHANDBOOKANDRESOURCEGUIDEPAGENUMBER
NWDHANDBOOKANDRESOURCEGUIDE
CreatingOpportunityPathwaysforChildrenandYouththroughSanJosé’sSystemofCare Visual: Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitationullamco laboris nisi ut aliquip ex ea commodo consequat. 45
California IP-CANS
0 = No evidence
2 = Interferes with functioning;
action needed
0 = No evidence
2 = Interferes with functioning;
action needed
0 = No evidence
2 = Interferes with functioning;
action needed
1 = History or suspicion; monitor
3 = Disabling, dangerous;
immediate or intensive action
needed
1 = History or suspicion; monitor
3 = Disabling, dangerous;
immediate or intensive action
needed
1 1 = History or suspicion; monitor
3 = Disabling, dangerous;
immediate or intensive action
needed
0 = Centerpiece strength
2 = Identified strength
0 = No evidence
2 = Interferes with functioning;
action needed
1 = Useful strength
3 = No evidence
0 = No evidence; this could be a strength
1 = History or suspicion; monitor; may be an opportunity to build 2 = Interferes with functioning; action needed
3 = Disabling, dangerous; immediate or intensive action needed February 2019
1 = History or suspicion; monitor
3 = Disabling, dangerous;
immediate or intensive action
needed
CALIFORNIA INTEGRATED PRACTICE—CHILD AND ADOLESCENT NEEDS AND STRENGTHS CA IP-CANS Child’s Name:
Caregiver(s):
21. Suicide Risk
22. Non-Suicidal Self-Injurious Behavior
23. Other Self-Harm (Recklessness)
24. Danger to Others
25. Sexual Aggression
26. Delinquent Behavior
27. Runaway
28. Intentional Misbehavior
10. Family Functioning 11.
Living Situation 12. Social
Functioning 13.
Developmental/Intellectual 14.
Decision Making 15. School
Behavior 16. School
Achievement 17. School
Attendance 18.
Medical/Physical 19. Sexual
Development 20. Sleep
RISK BEHAVIORS
0 0
0 1. Psychosis (Thought Disorder)
2. Impulsivity/Hyperactivity
3. Depression
4. Anxiety
5. Oppositional
6. Conduct
7. Anger Control
8. Substance Use
9. Adjustment to Trauma
LIFE FUNCTIONING DOMAIN
1 1
Assessor:
BEHAVIORAL/EMOTIONAL NEEDS DOMAIN
2 2
2 3
3 3
32. Family Strengths
33. Interpersonal
34. Educational Setting
35. Talents and Interests
36. Spiritual/Religious
37. Cultural Identity
38. Community Life
39. Natural Supports
40. Resiliency
41a. Supervision 42a.
Involvement with Care 43a.
Knowledge 44a. Social
Resources 45a. Residential
Stability 46a.
Medical/Physical 47a.
Mental Health 48a.
Substance Use 49a.
Developmental 50a. Safety
0 29. Language
30. Traditions and Rituals
31. Cultural Stress
STRENGTHS DOMAIN
0 0
1 1
1 DOB:
Form Status:
Case Name:
Case Number:
Date of Assessment (dd/mm/yyyy)
Gender: Race/Ethnicity:
Initial Reassessment Discharge
CULTURAL FACTORS DOMAIN
2 2
2 3
Youth has no known caregiver. Skip Caregiver Resources
and Needs Domain.
CAREGIVER RESOURCES AND NEEDS
A. Caregiver Name:
Relationship:
3 3
This document contains both information and form fields. To read information, use the Down Arow from a form field. 46
California IP-CANS
NO = No evidence of any trauma of this type.
YES = Exposure/experienced a trauma of this type.
0 = No evidence; this could be a strength 1 = History or suspicion; monitor; may be an opportunity to build 2 = Interferes with functioning; action needed 3 = Disabling, dangerous; immediate or intensive action needed
41b. Supervision 42b. Involvement with Care 43b.
Knowledge 44b. Social Resources 45b. Residential Stability 46b. Medical/Physical 47b. Mental Health 48b. Substance Use 49b. Developmental 50b. Safety
0 = No evidence; this could be a strength
1 = History or suspicion; monitor; may be an opportunity to build 2 = Interferes with functioning; action needed
3 = Disabling, dangerous; immediate or intensive action needed NO = No evidence of any trauma of this type.
YES = Exposure/experienced a trauma of this type.
0 = No evidence; this could be a strength
1 = History or suspicion; monitor; may be an opportunity to build 2 = Interferes with functioning; action needed
3 = Disabling, dangerous; immediate or intensive action needed February 2019
41c. Supervision 42c.
Involvement with Care 43c.
Knowledge 44c. Social
Resources 45c. Residential
Stability 46c.
Medical/Physical 47c.
Mental Health 48c.
Substance Use 49c.
Developmental 50c. Safety
T1. Sexual Abuse
T2. Physical Abuse
T3. Emotional Abuse
T4. Neglect
T5. Medical Trauma
T6. Witness to Family Violence
0 CAREGIVER RESOURCES AND NEEDS
B. Caregiver Name:
Relationship:
1 0 1
CAREGIVER RESOURCES AND NEEDS
C. Caregiver Name:
Relationship:
NO
2 2
POTENTIALLY TRAUMATIC/ADVERSE CHILDHOOD EXPERS.
YES
3 3
41d. Supervision 42d.
Involvement with Care 43d.
Knowledge 44d. Social
Resources 45d. Residential
Stability 46d.
Medical/Physical 47d.
Mental Health 48d.
Substance Use 49d.
Developmental 50d. Safety
0 T7. Witness to Community/School Violence
T8. Natural or Manmade Disaster
T9. War/Terrorism Affected
T10. Victim/Witness to Criminal Activity
T11. Disruption in Caregiving/Attachmnt Losses
T12. Parental Criminal Behaviors
CAREGIVER RESOURCES AND NEEDS
D. Caregiver Name:
Relationship:
1 NO
2 POTENTIALLY TRAUMATIC/ADVERSE CHILDHOOD EXPERS.
YES
3 47
California IP-CANS
0 = No evidence
2 = Interferes with functioning;
action needed
0 = No evidence
2 = Interferes with functioning;
action needed
(12 months to 5 years old)
NO =no evidence
YES = Exposure/experienced a trauma of this type.
1 = History or suspicion; monitor
3 = Disabling, dangerous;
immediate or intensive action
needed
1 = History or suspicion; monitor
3 = Disabling, dangerous;
immediate or intensive action
needed
2 0 = Centerpiece strength
2 = Identified strength
0 = No evidence
2 = Interferes with functioning;
action needed
0 = No evidence
2 = Interferes with functioning;
action needed
0 = No evidence
2 = Interferes with functioning;
action needed
1 = Useful strength
3 = No evidence
February 2019
1 = History or suspicion; monitor
3 = Disabling, dangerous;
immediate or intensive action
needed
0 1 2 3
(12 months to 5 years old)
1 = History or suspicion; monitor
3 = Disabling, dangerous;
immediate or intensive action
needed
1 = History or suspicion; monitor
3 = Disabling, dangerous;
immediate or intensive action
needed
2 EC1. Impulsivity/Hyperactivity
EC2. Depression
EC3. Anxiety
EC4. Oppositional
EC5. Attachment Difficulties
EC6. Adjustment to Trauma
EC7. Regulatory
EC8. Atypical Behaviors
EC9. Sleep
FUNCTIONING
EC10. Family Functioning
EC11. Early Education
EC12. Social and Emotional Functioning
EC13. Developmental/Intellectual
EC14. Medical/Physical
0 1
0 T1. Sexual Abuse
T2. Physical Abuse
T3. Emotional Abuse
T4. Neglect
T5. Medical Trauma
T6. Witness to Family Violence
T7. Witness to Community/School Violence
T8. Natural or Manmade Disaster
T9. War/Terrorism Affected
T10. Victim/Witness to Criminal Activity
T11. Disruption in Caregiving/Attachmnt Losses
T12. Parental Criminal Behaviors
CHALLENGES
1 NO
3 2
POTENTIALLY TRAUMATIC/ADVERSE CHILDHOOD EXPERS.
YES
3 EC15. Self-Harm
EC16. Exploited
EC17. Prenatal Care
EC18. Exposure
EC19. Labor and Delivery
EC20. Birth Weight
EC21. Failure to Thrive
CULTURAL FACTORS
EC22. Language
EC23. Traditions and Rituals
EC24. Cultural Stress
STRENGTHS
RISK BEHAVIORS & FACTORS
EC32. Caregiver Emot. Responsiveness
EC33. Caregiver Adj. to Traumatic Exper.
EC25. Family Strengths
EC26. Interpersonal
EC27. Natural Supports
EC28. Resiliency (Persist. & Adaptability)
EC29. Relationships Permanence
EC30. Playfulness
EC31. Family Spiritual/Religious
DYADIC CONSIDERATIONS
0 0
0 1
1 1
2 2
EARLY CHILDHOOD MODULE
This section is to be completed when the child is birth to 5 years old. The Potentially Traumatic/Adverse Childhood Experiences (#T1- T12 below) must also be completed for this age group. This section can also be completed for youth of any age who are experiencing developmental challenges.
3 3
3 48
California IP-CANS
0 = No evidence; this could be a strength
1 = History or suspicion; monitor; may be an opportunity to build 2 = Interferes with functioning; action needed
3 = Disabling, dangerous; immediate or intensive action needed 0 = No evidence; this could be a strength
1 = History or suspicion; monitor; may be an opportunity to build 2 = Interferes with functioning; action needed
3 = Disabling, dangerous; immediate or intensive action needed 0 = No evidence; this could be a strength
1 = History or suspicion; monitor; may be an opportunity to build 2 = Interferes with functioning; action needed
3 = Disabling, dangerous; immediate or intensive action needed 0 = No evidence; this could be a strength
1 = History or suspicion; monitor; may be an opportunity to build 2 = Interferes with functioning; action needed
3 = Disabling, dangerous; immediate or intensive action needed February 2019
EC34b. Supervision EC35b.
Involvement with Care EC36b.
Knowledge EC37b. Social
Resources EC38b. Residential
Stability EC39b. Medical/Physical
EC40b. Mental Health EC41b.
Substance Use EC42b.
Developmental EC43b. Safety
EC44b. Family Rel. to the System
EC45b. Legal Involvement EC46b.
Organization
EC34a. Supervision EC35a.
Involvement with Care EC36a.
Knowledge EC37a. Social
Resources EC38a. Residential
Stability EC39a. Medical/Physical
EC40a. Mental Health EC41a.
Substance Use EC42a.
Developmental EC43a. Safety
EC44a. Family Rel. to the System
EC45a. Legal Involvement EC46a.
Organization
CAREGIVER RESOURCES AND NEEDS
B. Caregiver Name:
Relationship:
0 0
1 1
2 2
Child has no known caregiver. Skip Caregiver Resources
and Needs Domain.
CAREGIVER RESOURCES AND NEEDS
A. Caregiver Name:
Relationship:
3 3
EC34d. Supervision
EC35d. Involvement with Care
EC36d. Knowledge
EC37d. Social Resources
EC38d. Residential Stability
EC39d. Medical/Physical
EC40d. Mental Health
EC41d. Substance Use
EC42d. Developmental
EC43d. Safety
EC44d. Family Rel. to the System
EC45d. Legal Involvement
EC46d. Organization
EC34c. Supervision EC35c.
Involvement with Care EC36c.
Knowledge EC37c. Social
Resources EC38c. Residential
Stability EC39c. Medical/Physical
EC40c. Mental Health EC41c.
Substance Use EC42c.
Developmental EC43c. Safety
EC44c. Family Rel. to the System
EC45c. Legal Involvement EC46c.
Organization
CAREGIVER RESOURCES AND NEEDS
D. Caregiver Name:
Relationship:
CAREGIVER RESOURCES AND NEEDS
C. Caregiver Name:
Relationship:
0 0
1 1
2 2
3 3
49 Economic Mobility
EmpathName ofMeasure DeterminantsmentHousing Access & SecurityCCSCC Debts
Safety
Savings
Housing
Income/
Earnings
Levels
Employment
Public Benefits
Legal
(Immigration
Status)
1 2 3 4 5
Score/N/A orDK
Participant goal? (✓)
ASSMASSMCCSCCCCSCCEmpathEmpath
Home or residence is notsafe; immediate level oflethality is extremely high;possible CPSinvolvement. Not permanently housed (in In transitional, temporary or In stable housing that is Household is in safe, adequate subsidized housing. car, on the street, shelter etc.) substandard housing; and/or safe but only marginally current rent/mortgage payment is unaffordable (over 50% of income). Safety is threatened/temporary protection is available; level of lethality is high. adequate. Current level of safety is minimally adequate; Environment is safe, however, future of such is ongoing safety planning is uncertain; safety essential. planning is important. Household is safe, adequate, unsubsidized housing. Environment is apparently safe and stable. No income. Earnings<30% AMI Earnings = 30% - 49% AMIEarnings = 50% - 79% AMI Earnings of >=+AMI (Family-Sustaining Wage)Household Size of: 2:>=$116,000 3:>=$130,5604:>=$145,040 *Income ranges from HUD, Household Size of: Household Size of:
2: $43,500 - $72,499 3:$48,960 - $81,5994: $54,390 - $90,649 Household Size of:2: $72,500 - $115,999 3:$81,600 - $130,5594: $90,650 - $145,039 Santa Clara County,effective June 15,2023/Source:https://siliconvalleyathome .org/resources/finding- affordable-housing/No job. 2:< $43,499 3: < $48,959 4:< $54,389 Temporary, part-time or seasonal; inadequate pay, no inadequate pay; few or no adequate pay and benefits. Working full time; Working full time with Maintains permanent employment with adequate income andNo debt other than
benefits. Behind in payments of 1 ormore debts and makingpayments on at least 1 debt benefits. Making minimumpayments on all debts Has debts; currently not making any payments
Current in all debts andmaking more than minimum mortgage, education,payments on one or moredebtsSavings of more than 2months' expenses, but lessthan 3 months' expensesReceiving all eligible public Public Benefits not required and/or car loans, andcurrent in all debtsSavings of 3 months'expenses or more No savings Savings of less than one mont's expenses
Savings of at least onemonth's and up to 2months expenses No public benefits (noincome and/or not eligible)public benefits, but not Applied for eligible sources of Enrolled to eligible
benefits, but not sufficientbenefits for self sufficiency receiving benefits
No immigration status/No Eligible to apply for remedies Immigration Statusremedies currently available and/or Immigration Petition provides stability with NO stability and can lead to Immigration status provides Permanent Status: Green
Card (LPR) or US Citizen
[ex. Temporary ProtectiveStatus has lapsed or DACAInitial] Filed path to citizenship:
Temporary ProtectiveStatus (TPS) granted;Parolees; DACAStatus/Renewals citizenship: U-Visa, T-Visa,SIJS (Special ImmigrantJuvenile visa), VAWA, SIV(Special Immigrant Visa),Asylum/Refugee Status CCSCC Self-Sufficiency Matrix Participant Name DOB / / Assessment Date / / Program Name
CCSCC Self Sufficiency Matrix Version 11; Date: 1.17.2024 1 of 4 50 Name of
Measure DeterminantsmentLearning & EmpowermentASSMChildcare & Family SupportsConnected Neighborhoods & Safe Communities Networks
Children's
Education
Educational
Attainment
Child Care
Community
Involvement
Family StabilityParenting Skills
Family/Social
Relations
1 2 3 4 5
Score/N/A orDK
Participant goal? (✓)
CCSCC Self-Sufficiency Matrix Participant Name DOB / / Assessment Date / / Program Name
ASSMASSMASSMASSMEmpathEmpathEmpath
Not applicable due to crisis Socially isolated and/or nosituation; in “survival”mode. social skills and/or lacks motivation to become involved. Can never rely on networks Can rarely rely on networks to provide useful advice, guidance and support to provide useful advice, guidance, and support Lack of necessary supportfrom family or friends;abuse (DV, child) is present resources to help; family Family/friends may besupportive, but lack ability or family/friends; family Some support frommembers acknowledgeand seek to changenegative behaviors; arelearning to communicateand support. or there is child neglect. members do not relate well with one another; potential for abuse or neglect. Can sometimes rely onnetworks to provideuseful advice, guidance,and supportLacks knowledge of ways Some community Can often rely on networksto provide useful advice,guidance, and support to become involved. involvement (advisory
group, support group), buthas barriers such astransportation, childcareissues. Can always rely on netowrks to provide useful advice, guidance, and support; adocates for others Actively involved in community. One or more school-aged children not enrolled in school. One or more school-aged children enrolled in school, but not attending classes. Enrolled in school, but oneEnrolled in school and All school-aged children or more children only occasionally attending classes. Job training or certificate complete (beyond high school) attending classes most of the enrolled and attending on a time. regular basis. Less than High School Diploma or GED/HiSET High School Diploma or GED/HiSET complete Associate's degree or professional certification complete Bachelor's degree or higher complete Needs childcare, but none is Childcare is unreliable or available/accessible and/or unaffordable, inadequate Affordable subsidized childcare is available, but limited. Parenting skills are apparent but not adequate. Reliable, affordable childcare is available and subsidies are available Parenting skills are adequate. Able to select quality childcare of choice, no need for subsidies Parenting skills are well developed. child is not eligible. There are safety concerns regarding parenting skills. supervision is a problem for Parenting skills are minimal. Not able to engage in work, Barely able to engage in work, Somewhat able to engage Mostly able to engage in Fully able to engage in school, and family life because of children or family needs school, and family life because of children or family life because of children or children or family needs in work, school and family work, school, and family life; work, school, and family life; children or family needs don't get in the way (OR) No children or dependent family members needs family needs rarely get in the way Strong support from family Has healthy/expanding or friends. Household members support network; household is stable and support each other’s efforts.communication is consistently open. CCSCC Self Sufficiency Matrix Version 11; Date: 1.17.2024 2 of 4 51 Name of
Measure DeterminantsmentMental & Physical Wellness and Belonging 1 Food
Access
Life Skills
Disabilities
Substance
Abuse
Mental Health
Physical Health
Health Care
Coverage
2 3 4 5
Score/N/A orDK
Participant goal? (✓)
CCSCC Self-Sufficiency Matrix Participant Name DOB / / Assessment Date / / Program Name
ASSMASSMASSMASSMASSMASSMUnitedWaySSM
No medical coverage withimmediate need. No medical coverage and great difficulty accessing medical care when needed. Some household membersmay be in poor health. Chronic medical conditions, Some members (e.g. Children) have medicalcoverage. All members can get medical All members are covered care when needed, but may by affordable, adequate strain budget. health insurance. Untreated and chronic medical and life threatening potentially life threatening, Chronic illness generallywell managed andattempting to make andkeep routine medical and preventative medical and No chronic illness or stablechronic illness andmaintaining good No chronic illness andmaintaining proactivepreventative medical anddental care practices conditions, withinconsistent to minimalfollow-up careNo food or means toprepare it. Relies to asignificant degree on othersources of free or low-costfood. Unable to meet basic needs Can meet a few but not all with inconsistent follow-upcare
dental appointments dental care practices
Can meet basic food needswithout assistance. Household is on food stamps Can meet basic food or accessing sources of free or needs, but requires Can choose to purchase any food household desires. low-cost food. occasional assistance. Can meet most but not all Able to meet all basic needs Able to provide beyond such as hygiene, food,activities of daily living. needs of daily living without daily living needs without of daily living without basic needs of daily living for self and family. assistance. assistance. assistance. Danger to self or others; recurring suicidal ideation; symptoms that may affect
Recurrent mental health Mild symptoms may be
present but are transient;
Minimal symptoms that are Symptoms are absent orexpectable responses to life rare; good or superior functioning in wide rangeof activities; no more thanevery day problems orconcerns. experiencing severe difficulty in day-to-day life self/others; persistent behavior, but not a danger to only moderate difficulty in stressors; only slight functioning due to mental impairment in functioning. health problems. due to psychological problems. problems with functioning due to mental health symptoms. Meets criteria for dependence; Use within last 6 months; Client has used during last 6 No drug use/alcohol abuse Meets criteria for severe abuse/dependence;resulting problems sosevere that institutionalliving or hospitalizationmay be necessary. preoccupation with use and/or obtaining evidence of persistent or recurrent social, months, but no evidence of persistent or recurrent social, in last 6 months. drugs/alcohol; withdrawal or occupational, emotional or occupational, emotional, or withdrawal avoidance physical problems related physical problems related to behaviors evident; use results to use (such as disruptive use; no evidence of recurrent in avoidance or neglect ofessential life activities. behavior or housing problems); problems have persisted for at least onemonth. Safe – rarely has acute orchronic symptomsaffecting housing,employment, socialinteractions, etc. dangerous use. In crisis – acute or chronic symptoms affecting housing, employment, social interactions, etc. Vulnerable – sometimes or periodically has acute or chronic symptoms affecting housing, employment, social interactions, etc. Building Capacity – asymptomatic – condition controlled by services or medication Thriving – no identified disability. CCSCC Self Sufficiency Matrix Version 11; Date: 1.17.2024 3 of 4 52 Name of
Measure DeterminantsmentMiscellaneous - Potential Barriers to Measure 1 Legal (Justice
System)
Transportation
Access
(Mobility)
2 3 4 5
Score/N/A orDK
Participant goal? (✓)
CCSCC Self-Sufficiency Matrix Participant Name DOB / / Assessment Date / / Program Name
ASSMASSM
No access to transportation, Transportation is available,public or private; may have but unreliable, unpredictable, and reliable, but limited Transportation is available Transportation is generally Transportation is readily available and affordable;car is adequately insured. accessible to meet basic travel needs. car that is inoperable. unaffordable; may have care and/or inconvenient; but no insurance, license, etc. drivers are licensed and minimallyinsured. Fully compliant with Current outstanding tickets Current charges/trial Has successfully completed No active criminal justice involvement in more that12 months and/or nofelonycriminal history. or warrants. pending, noncompliance with probation/parole terms. probation/parole. probation/parole within past 12 months, no new charges filed. CCSCC Self Sufficiency Matrix Version 11; Date: 1.17.2024 4 of 4 53 1.
Highest EducationDegreeyou received:
Is anyone pregnant in the immediate family/household? Yes City of San José Children and Youth Services Master Plan, System of Care Participant Intake Form
No
First Name:Mailing Address:
Last Name:
Street Apt# City State Zip Code
☐ Currently DO NOT have an addressDate of Birth:E-mailI consent to have my information shared as part of the system of care navigation to direct me to the correct services: ☐ Yes ☐ No ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Are you unhoused/homeless? ☐ Yes ☐ No Phone # Cell Phone #Race/Ethnicity:ChineseRaces ☐ Decline to State ☐ Black/African Ancestry ☐ Latino/a/x ☐ White ☐ Vietnamese ☐ ☐ Filipino ☐ Pacific Islander ☐ American Indian/Indigenous ☐ Two or More ☐ Other Asian:☐ Male☐ Female☐ Unknown
☐ Other Latino/a/x:☐ Transgender Male Gender: ☐ Gender non-binary ☐ Questioning☐ Prefer Not to Answer
☐ Transgender Female ☐ Two-Spirit
☐ Another Gender Identity (Please list):
Preferred Language: ☐ English ☐ Spanish ☐ Vietnamese ☐ Chinese/Mandarin ☐ Tagalog ☐ Other languages:☐ Decline to State☐ Bachelor's Degree ☐ Master’s Degree ☐ Doctorate Degree☐ Do you have a degree from another country? Yes / No ☐ Decline to State
☐ Elementary ☐ Middle School ☐ High School/GED ☐ Associate's ☐ Vocational/Technical☐ Other:
DEMOGRAPHIC INFORMATION
HOUSEHOLD MEMBER INFORMATION
☐ ☐
City of San José, Children and Youth Services Master Plan – Intake Form12/2024 1 54 Does this child have Medi-Cal or health insurance (Blue Cross, Kaiser, CHAMPUS, etc.) paid for by a parent or parent’s employer? *
☐ Yes
☐ No
Child 2Does this child have Medi-Cal or health insurance (Blue Cross, Kaiser, CHAMPUS, etc.)paid for by a parent or parent’s employer? * ☐ Yes
☐ No
Child 3Does this child have Medi-Cal or health insurance (Blue Cross, Kaiser, CHAMPUS, etc.)paid for by a parent or parent’s employer? * ☐ Yes
☐ No
Child 4Does this child have Medi-Cal or health insurance (Blue Cross, Kaiser, CHAMPUS, etc.)paid for by a parent or parent’s employer? * ☐ Yes
☐ No
No
Yes (write it in):
No
Yes (write it in):
No
Yes (write it in):
U.S CitizenshipLegal ResidencyOther: please indicateU.S CitizenshipLegal ResidencyOther: please indicateU.S CitizenshipLegal ResidencyOther: please indicate
2.3. # of adults in the household (18 years or older): Do adults in the household have insurance? ☐ Yes
☐ No
Do any adults have identified disabilities or functional needs? ☐ None☐ Developmentally disabled☐ Prefer not to answer. ☐ Visual
☐ Mental Health
☐ Mobility☐ Other:
☐ Hearing
☐ Speech
4. # of children in the household (17 years and younger): if children present, complete screening ☐ No children in the home
☐ Decline to state
To determine all services that could be available due to funding restrictions, please let us know:
Name of childChild 1
Relationship Age Identified Disability Immigration Status ☐ No☐ Yes (write it in):
☐U.S Citizenship☐Legal Residency☐Other: please indicate ☐☐☐☐☐☐
☐☐☐☐☐☐☐☐☐
City
of S
a
n
J
o
s
é, C
hildre
n
a
n
d
Yo
uth
S
ervic
e
s
M
a
ster Pla
n
– Inta
ke
Form12/2
0 2
4 2
55 1.
2.3.4.5.6.7. Does anyone in your household have a personal emergency (T2)? ☐ No ☐ Yes (check all that apply)☐ Pregnancy☐ Elder AbuseHave your utilities been shut off, or do you have a shut-off notice (T2)? ☐ YesDo you need help with transportation to get food, clothing, medical care or other emergency items? ☐ Immediate Medical Need ☐ Child Abuse ☐ Domestic Abuse☐ Other emergencies that threaten health or safety (Explain) ☐ No
☐ Yes ☐ No
Do you need essential clothing, such as diapers or clothing needed for cold weather?Anyone in the Household Associated and/or Impacted by Gangs ☐ Yes ☐ No ☐ Yes ☐ No
Are you a Veteran? ☐ Yes ☐ No
Is your household a migrant/seasonal farm worker? ☐ Yes ☐ No Two or more services needed or T2 answered will be referred to Tier 2 Service Guide/Navigator HOUSING:☐ Housing Information☐ An eviction or a notice (T2) EMPLOYMENT SERVICES: ☐You are currently employed ☐Seeking Vocational Training ☐ Emergency Housing
☐ Low-income Housing
☐ Seeking a Job
☐ Career Counseling
☐ Unaccompanied Youth (25 yrs or below w/out family)EDUCATION SERVICES:☐ K-12 Education of a Child☐ Special Needs of a ChildHEALTH/MEDICAL SERVICES:☐ Health Insurance SupportCHILDCARE SERVICES:☐ Extra services outside of child development centers☐ Services for child/ren not enrolled FOOD:
☐ High School, College or Vocational ☐ CalFresh (food stamps) ☐ Will your food run out (T2) ☐ Literacy/ESL Classes ☐ Foodbank info
MENTAL HEALTH/COUNSELING SERVICES:
☐ Specific Health Needs ☐ You
OTHER SERVICES:☐ Parenting Education
☐ Your child/children
☐ Legal Services
8. Are you currently receiving any public assistance: ☐ No ☐ Yes (mark all that apply):
☐ CalFresh☐ Other:
☐ Cash Aid ☐ Health Coverage ☐ Housing Voucher ☐ WIC(Women, Infants and Children) Program
SCREENING TOOL
City of San José, Children and Youth Services Master Plan – Intake Form12/2024 3 I would like to be connected to the following services: (Check all that applies) 56 Amount When will it be received How often? Will Income continue
9. Yes
Yes
Does anyone in the household receives or expect to receives any income from the following (mark all that apply):☐ Supplemental Security Income/State Supplementary Payment (SSI/SSP),☐ Earnings (from a job)☐ Foster Care Payment, ☐ Social Security Benefits, ☐ Child Support,☐ Veterans Benefits ☐ Other (explain):
If any income box was checked, complete below:
No
No
10. What is the Annual Household Income (check one):
☐ $20,000 or less☐ $81,000 to $100,000
☐ $21,000 to $40,000☐ $100,000 to$160,000
☐ $41,000 to $60,000☐ $161,000 or more
☐ $61,000 to $80,000
11. Is your household's combined gross income and liquid resources less than the combined rent/mortgage and utilities? ☐ Yes ☐ No Consent to Share InformationBy signing below, I understand and agree that the information I provide during this intake and screening process may be shared with relevantentities, including City departments, County agencies, nonprofit organizations, and other service providers, to address my needs and provideappropriate services and support. I understand that this information sharing is a part of the City of San Jose’s system of care and the "No WrongDoor" service delivery model, designed to ensure I receive coordinated and comprehensive assistance.I acknowledge that my information will be shared only with those entities directly involved in providing services or support relevant to mysituation and needs. I understand that my information will be handled confidentially and only shared with those authorized to assist inaddressing my needs.By providing my consent, I authorize sharing my information as described above. I understand that I may revoke my consent at any time byproviding written notice, though I acknowledge that doing so may affect the services I receive. ___________________________________________________ Your Printed Name Your SignatureDate: ______________________________City of San José, Children and Youth Services Master Plan – Intake Form ☐☐
☐☐
12/2024 4
57 NWD HANDBOOK AND RESOURCE GUIDE PAGE NUMBER
Access Point: A location or platform where individuals can seek assistance and be connected to services.
California Family First Prevention Services Act (FFPSA): Legislation focusing on providing preventive services to keep children out of the foster care system.
Care Coordinator: A professional responsible for managing and coordinating an individual's care plan and services.
Care Plan: A personalized plan outlining the services and supports an individual will receive.
Case Management: Ongoing support provided to individuals including monitoring progress and adjusting care plans as needed.
City of San José Children and Youth Services Master Plan (CSJ CYSMP): A strategic plan guiding policies, investments and services for children and youth in San José.
Collaboration: Working together across organizations, sectors and communities to achieve common goals.
Community-Based Organizations (CBOs): Nonprofit groups that provide services and support within the community.
Community Co-Design: A collaborative process involving community members in the development and implementation of programs and services.
Community Engagement: The process of involving community members in decision-making and service planning to ensure programs meet their needs.
Community Pathway: A coordinated network of services designed to guide individuals through the support system effectively.
Continuous Improvement: The ongoing process of evaluating and enhancing services to improve outcomes.
Co-Design: The collaborative development of programs and services with active participation from community members and stakeholders.
Cross-System Coordination: Collaboration among different systems (e.g., education, healthcare, social services) to provide comprehensive support.
Cultural Responsiveness: The practice of recognizing and respecting the cultural backgrounds and needs of individuals when providing services.
NWD HANDBOOK AND RESOURCE GUIDE
Glossary A-C
Creatng Opportunity Pathways for Children and Youth through San José’s System of Care 58
NWD HANDBOOK AND RESOURCE GUIDE PAGE NUMBER
Demonstration Site: A pilot location where new service delivery models are tested and refined before broader implementation.
Entry Point: Any location or platform where individuals can access services such as community centers, schools or online portals.
Equity: The practice of ensuring fair access to opportunities and resources for all individuals regardless of their background or circumstances.
Feedback Collection: The process of gathering input from service recipients and providers to improve programs and services.
Holistic Care Plan: A comprehensive plan that addresses an individual's physical, emotional, social and educational needs.
Initial Assessment: The process of evaluating an individual's needs to determine the level of support required.
Initial Contact: The first interaction an individual has with the service system, often involving basic information collection and needs assessment.
Multi-Tiered System of Supports (MTSS): A framework that provides varying levels of support based on the intensity of an individual's needs.
Navigator/Promotora: A community-based professional who guides individuals through the service system, often focusing on cultural responsiveness.
No Wrong Door (NWD): A service delivery model ensuring individuals receive the support they need regardless of the entry point into the system.
Outcome Measurement: Evaluating the effectiveness of services in achieving desired results for individuals and communities.
Prioritization: Determining the severity of needs to ensure urgent cases receive prompt attention.
Resource Allocation: The process of directing individuals to appropriate resources based on their assessed needs.
Risk Assessment: The process of identifying factors that may pose a threat to an individual's well-being.
NWD HANDBOOK AND RESOURCE GUIDE
Glossary D-R
Creating Opportunity Pathways for Children and Youth through San José’s System of Care 59
NWD HANDBOOK AND RESOURCE GUIDE PAGE NUMBER
Self-Sufficiency Assessment: A tool used to evaluate an individual's ability to meet their basic needs independently.
Service Delivery Model: A structured approach outlining how services are provided to individuals including processes, protocols and pathways.
Service Provider: An organization or individual responsible for delivering specific services or supports to individuals.
Shared Data and Feedback Loops: Systems that allow for the exchange of information among service providers to enhance coordination and continuous improvement.
Single Point of Entry (SPE): A centralized system where individuals can access multiple services through one contact point.
Stakeholders: Individuals or groups with an interest or role in the development and implementation of programs and services.
System of Care: A coordinated network of services designed to meet the diverse needs of individuals and families within a community.
Triage Team: A group of professionals responsible for assessing the urgency of needs and directing individuals to appropriate services.
Universal Assessment: A standardized evaluation used to determine an individual's needs across multiple service areas.
Universal Intake: A standardized form or process used across agencies to collect initial information from individuals seeking services.
Warm Handoff: A direct, personal introduction from one service provider to another to ensure continuity of care.
NWD HANDBOOK AND RESOURCE GUIDE
Glossary S-Z
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