CHW National Library

Team Oregon summarizes their project focus and major learnings related to healthcare transition for young adults with medical complexity.

This PDF SPoC document includes a contact sheet and action plan.

This slide presentation describes characteristics and standards for care coordination, care coordination models, and Minnesota’s approach to care coordination.

This document shows a fictional example of an All About Me sheet, including the child’s likes, dislikes, hopes and dreams, strengths, and goals.

This document was created by Team Massachusetts to ask parents for feedback on the Get to Know Me form, the Pain Scale form, and the Surgical Shared Plan of Care. The document also includes sheets for recording themes in parent responses throughout the week.

This document is used to record important things to know at the pre-surgical appointment to improve care coordination.

This document allows patients and families to inform the surgical team of important things to know about the child.

This tip sheet provides advice to families and caregivers for preparing for a telehealth visit with their child.

Team Alabama’s SPoC document includes a ‘Get to Know Me’ section, medical history, and goal planning sheets.

A comprehensive, functional, living shared plan of care for children with medical complexity.