Cross-sector collaboration
The Family Team
The Family Team is a new cross-sectional collaboration model, meant to create a coherent course of treatment across municipalities and Child and Adolescent Mental Health Services.
A key principle is that the direction and actions of a course of treatment are determined in collaboration with the child or youth and the family. The family must feel like they are a clear and active part of the Family Team, and the various professionals need to be able to collaborate across disciplines, guided by the family’s needs and perspectives.
The model is developed through co-creation with children, young people, parents, and professionals. It is based on five key components:
The Family’s Digital Toolbox: A closed digital space that gives the family and professionals the opportunity to communicate, share information, and create a joint overview between municipality and mental health services.
Read more about The Family’s Digital Toolbox here.
Early notification: The municipality is informed when the child or young person begins their psychiatric assessment in Child and Adolescent Mental Health Services. This creates the opportunity to establish collaboration between the municipality, mental health services, and the family from the beginning.
Coherence and coordination: coordinators from both the municipality and mental health services help to create continuity and help organize the course of treatment across sectors. A shared plan joins perspectives from the family and professionals, appointments, and a shared direction. The plan is accessible through the Family’s Digital Toolbox.
Balanced perspectives: The perspectives of the child, adolescent, or family should have a prominent place alongside the ones of the professionals. From the beginning, the family describes in the Family’s Perspective what is important to them. At the same time, the questionnaire My Well-Being is used to incorporate the child’s, youth’s and parents’ own assessments into the course of treatment.
Peer support: Peer workers have their own experiences with mental health services – either as a former young patient or as a relative. They can support young people and parents through one-on-one conversations, group sessions, and supporting activities. They help the family to be better prepared and involved in the course of treatment.
PROM – My Well-Being
My Well-being is a digital questionnaire in which children, adolescents, and their parents answer questions about the well-being of the child or adolescent in care. The questionnaire can be used by both municipalities and mental health services and can be integrated into existing IT systems.
The goal is for the child’s or young person’s own sense of well-being to become an active part of the process, and for the family and professionals to use the responses to monitor well-being over time and as a starting point for dialogue and follow-up.
Like the Family Team, My Well-Being is developed through collaboration with children, adolescents, parents, and professionals.
Best for Us panel
At Best for Us, young people and their families are considered key experts when it comes to finding new ways to improve well-being and the quality of care in mental health services. Therefore, all work packages must provide opportunities to involve young people and their families in the development and testing of the project’s solutions.
Young people and their families can sign up for the Best for Us panel if they would like to share their experiences and perspectives and help improve the support and assistance that children, young people, and their families receive within the mental health services in the North Denmark Region.
Current Status
In the fall of 2026, The Family Team will be tested in Child and Adolescent Mental Health Services in the North Denmark Region in collaboration with the municipalities of Aalborg, Hjørring, Mariagerfjord, and Thisted.
During the same period, My Well-Being will be tested as both part of the Family Team and independently regarding follow-ups on psychopharmacological treatment in the Child and Adolescent Mental Health Services.
The tests are intended to provide information on how the Family Team and My Well-Being work and are implemented in practice and how children, young people, families and professionals experience the solutions.
Responsible
The overall responsible for work package 2 is Malene Østergaard Terp, ph.d. and head of the Center for Recovery and Co-Creation, Psychiatry - North Denmark Region.