The transition workbook includes information about 1) Introduction to the Medical Home; 2) Discussion of Medical Conditions and Medications; and 3) Transferring Care to use as a resource and workbook with the primary care provider on an ongoing basis during transition preparation, and to support a new patient visit with an adult primary care physician.
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CMC CoIIN Webinar: Putting Families First: Shared Plan of Care and Care Coordination
WA State Birth to One Roadmap
This care roadmap provides families with contact information for each of their providers and services along with family support resources.
Patient Touchpoints Graphic
These graphics visually depict a patient’s contacts with different services within the health system.
Intake Visit Care Coordinator Cue Card
This document contains question prompts for care coordinators to ask during the intake visit. These questions help the care team to get a good picture of the child and their family, along with their strengths and needs.
Family Intake Form
This form prompts families to think about concerns, priorities, and unmet needs for their child before their care coordination intake visit.
Team Indiana Care Coordination ConverSketch
This graphic recording shows Team Indiana’s experience with care coordination and integration.
Goal Cards
Team Wisconsin created goal cards as a tool to spark ideas for families when they are asked about goals.
Creating a Shared Plan of Care
These instructions from Team Wisconsin outline their process for creating a SPoC in their EMR system.
Shared Plan of Care EPIC Template
This is the template Team Wisconsin uses in their EMR system.