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Case · 69

Youth Transitioning from Incarceration

A dual-status youth, one coordinated team

Member

Aaliyah (15)

Service line

Youth Transitioning from Incarceration

Location

Sacramento County, CA

Duration

12-month coordination

01 —

The outcome

A 15-year-old crossing juvenile probation and foster care had been in three placements in six months. One care team synchronized the social worker, probation officer, and school — and she stayed put.

1 placement in 12 months

Headline result for Aaliyah (15).

1

Placement in 12 months

Down from 3 in the prior 6 months.

0

Self-harm episodes

In the last 9 months of care.

1

School enrollment

Full year of continuous schooling.

12

Multi-agency case conferences

Monthly cadence sustained.

02 —

Background

Where the member started.

Aaliyah was on informal probation for a status offense and simultaneously a dependent of the court. Prior placement disruptions had cost her a full semester of consistent schooling.

In their words —

“For the first time, everyone in the room was on the same page — and I didn't have to be the messenger.”

— Aaliyah, Youth Reentry Member

03 —

The challenge

What stood in the way.

  1. 01

    Three placement moves in six months; two school changes.

  2. 02

    Untreated depression with self-harm history.

  3. 03

    PO and social worker communicating through Aaliyah, not each other.

  4. 04

    Resource family overwhelmed and considering a 7-day notice.

04 —

Our approach

How we built the plan.

Move 01

Single care manager holding the pen across probation, child welfare, school, and clinic.

Move 02

Adolescent DBT skills group + weekly individual therapy.

Move 03

Resource family respite and coaching to prevent placement disruption.

05 —

The solution

Step by step, what we actually did.

  1. 01

    Weeks 1–4 — Stabilization

    Joint case conference with PO, social worker, resource family, and school; one shared care plan produced.

  2. 02

    Months 2–6 — Skills + supports

    DBT skills group weekly; resource family coaching biweekly; mentor pairing through a community partner.

  3. 03

    Months 7–12 — Continuity

    Placement preserved through two crisis points using respite and rapid clinical response instead of disruption.

06 —

Services involved

The full network on this case.

Enhanced Care ManagementAdolescent Behavioral Health (DBT)Child Welfare CoordinationSchool Advocacy

Next —

More stories

Other members, other outcomes.

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