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. Families are encouraged to review the cards online in advance of the visit and/or look through the actual cards during an in-person clinic visit to help the team focus their efforts on actions that are meaningful for the child and family.

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.

Shared Plan of Care Summary

This template can be used to summarize the SPoC for the family and identify follow-up actions for each member of the care team.

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