Comprehensive Care Planning - Tennessee
Comprehensive CarePlanningCMHI
Comprehensive Care PlanChildren with Special Health Care NeedsThis folder contains information about the essentials of comprehensive care planning for childrenwith special health care needs (CSHCN). Three distinct types of documents present medicalinformation plans, emergency plans, and working (action) care plans. When combinedappropriately for CSHCN (based upon need), these tools make up a comprehensive care plan. Afew of the care plan examples offer a combination of the three types of care plans (ie. anemergency plan and a medical information plan). These combined care plans are marked with anasterisk and will appear in both folders.Table of ContentsIntroduction to Essential Care Plan Components- the Comprehensive Care PlanSection One: Medical Information Care Plans Medical Summary – EPIC-IC PA Gifford Medical Care Plan CMHI Chronic Conditions Management Plan* Hitchcock Clinic Pediatric Care Plan*Section Two: Specialized Emergency Information (Medical Information/Emergency Care Plan) Emergency Care Plan (Blank Form) Hitchcock Clinic Pediatric Care Plan*Section Three: Working (Action) Care Plans CMHI Chronic Conditions Management Plan* Actionable Care Plan
Introduction toEssential Care PlanComponentsThe ComprehensiveCare PlanCMHI
The Comprehensive Care Plan:Medical Summary, Emergency Treatment Plan andWorking Care PlanFor Children with Special Health Care NeedsChildren with special health care needs, their families, physicians, practice teams and communityproviders will benefit from having a clear, written medical summary, emergency treatment planand plan of care. These components can be combined or developed separately. When combinedthe Medical Summary, Emergency Treatment Plan and Working Care Plan are the componentsof a Comprehensive Care Plan. The medical summaries, emergency treatment and care plans canbe on paper, disk or if possible web-based. There are multiple purposes of the medicalsummary/care plans. These include: An available source of information for parents to provide to the medical, educational andother care teams, A quick reference with child-specific information in a medical emergency, An action plan that the entire care team, including the family and patient develop, use toprioritize, assign tasks, implement and assess care.In the beginning remember that your practice team will decide who needs a medical summary oran emergency care plan depending on the complexity of the condition. The summary and/oremergency treatment plan will take some time to develop in the beginning, but the family, theclinicians and the community providers will find them very helpful. Your parent partners will bea great resource here with family friendly language.The working care plan is a written framework combining the goals of the patient/family/teamwith the treatment plan. It is best to keep it simple at the start. Remember to start small withlittle steps. The Center for Medical Home Improvement Action Care Plan (working care plan) isa practical tool to get you started.The major components of the comprehensive care plan include a medical summary with anemergency treatment plan and a working care plan:1. The Medical Summary: The child’s medical summary contains a short synopsis of thechild’s current diagnosis, problem list, treatment including medications and recurrentproblems, past medical history and community based care. The specific components of themedical summary include: Identifying and family contact (including emergency contact) information Allergies and Medications Diagnosis and Active Problem List (including critical equipment) Consultants--Specialist and their contact information Transport/Equipment Needs Past History (Summary) Review of Systems (Degree of current involvement)
Coverage Concerns/Recurrent ProblemsCommunity Providers/AgenciesHospitalizationsAssets and challenges unique to the individual childOther information the family wants caregivers to know about their childExamples are available online at the AAP Medical Home website, the Center for Medical HomeImprovement website, the PACC website (see links for these on the extranet), NICHQ MedicalHome website, the EPIC-IC website and others.2. The Emergency Treatment Plan: The medical summary can include information foremergency treatment and in many instances can serve as both the summary and theemergency plan. However, some parents and practices may want a separate EmergencyTreatment Plan. The child with multiple, complex conditions and/or recurrent life threateningevents may need an emergency treatment plan in addition to or in place of the medicalsummary. The AAP / ACEP emergency treatment plans are very similar to the medicalsummary and it would be duplicative to fill out both. The Emergency Treatment Plans dohave more baseline physical/lab data. The AAP and the ACEP have approved them. Theform is available on the AAP web site with links from the NICHQ website and others. (Someteams have found it helpful to use a medical summary and check of a box indicating anattached emergency plan).3. The Working Care Plan: A care plan for a child with special health care needs can be assimple as a written, organized note developed during a visit, a more detailed plan of caredeveloped during a meeting of the family, care coordinator and clinician or a comprehensive,integrated care plan developed by the child/family’s multidisciplinary team. This plan helpsdirect the role/focus of the practice-based care coordinator. The critical components of thecare plan include: A prioritized list of main concerns/goals with The current clinical/educational/social information pertinent to the concern/goal. The current plan/intervention for that concern/goal The person(s) responsible for that intervention The due date for the intervention.The working or action care plans are available on the NICHQ Medical Home web site, the AAPMedical Home web site and others.Note: Some care planning examples combine two or more of the three components in thedocument. When this is the case an * indicates so in the table of contents for that documents.
Section One: MedicalInformation CarePlansCMHI
MEDICAL SUMMARY - EPIC-ICDate updatedPatient Name DOBParent’s Name Phone(H) (W)AddressE-mailOther Emergency Contact Phone RelationshipInsurancePrincipal DiagnosisPCPSecondary Diagnosis PCP PhonePCP Fax/E-mailEmergency Plan Yes No Immunizations up-to-date Yes No DateAllergies/Rxns (meds/foods/procedures)Problem List (with critical equipment)Medications / DoseMedications / DoseSpecialistsPhone Number/Fax/E-mail
Equipment/Transport InformationHistoryReview of Systems & general/baseline physical/lab dataHEENT lSkinNeuroPsychEndoImmuneCoverage Concerns/Recurrent Presenting ProblemsProblemDiagnostic StudiesSupport ServicesServiceHome CarePT/OTDMESchool/Child roceduresTreatmentContact Information
MEDICAL CARE PLANGIFFORD MEDICAL CENTERRANDOLPH, VERMONT 05060Name:Allergies:Parent/Guardian:PCP:PCP Phone #:Nick Name:Complexity:Phone #:Insurance:Parent Emergency #:DOB:Special Instructions:Unique Family Needs/Assets:Antibiotic Prophylaxis:PROBLEM LISTIndications:MEDY/NSPECIALISTINVOLVEDMedication & Dose:OUTCOMEHOWOFTENHealth Maintenance(*) – See Med Sheet in ChartPage 1 of 2LASTVISIT
MEDICAL CARE PLANPatient Name:Page 2 of 2PROCEDURESTESTSLABSLASTDONEVALUEOther Services:TYPE OF SERVICEDEVICES**Unique Immunization Needs:InfluenzaPneumococcalRSVOther(**) For full record see chart.SERVICE GIVEN BYDATE STARTEDFREQUENCY
List of Health Care and Other Service ProvidersChild’s Name: DOB:Dx: 1 Dx: 2 Dx:3Health Care:Name/LocationPhone #Fax #ReferralDateName/LocationPhone #Fax #EffectiveDatesPhone #Fax #Specialists:Special Clinics:(coordinators)Other:School Services:Early Intervention:School attending:School Principal(s):Classroom teachers:School nurse(s):Spec. ed. Coordinator:Other personnel:Community services:Name/LocationFamily Support coordinator:Visiting nurse:Mental Health Provider:HMO/Insurance contact:DCYF case worker:Other service providers:Informal supports: minister, friend, etc.
CHRONIC CONDITION MANAGEMENT (CCM)IN PRIMARY CARECare PlanningParent’s NamesChild’s NamePhones (H) /Best Time / Place To Call/Diagnosis (s)(W) /FAX # if availableCCM Monitoring: Questioning & Inverventions in the following areas:Date:Family’s #1 IssueHealth Provider’s #1IssueChronic ConditionUpdate (meds, acuteepisodes, etc.)Child’s Life/RecentAccomplishments:Family LifeComm/Family SupportIssuesFinancial Issues(insurance, SSI, etc.)School NeedsSpecialist ContactsPatient Education/SelfCareOtherPARENT NOTEBOOK GIVEN (DATE) OFFICE CONTACT PERSON
CHRONIC CONDITION MANAGEMENT (CCM) IN PRIMARY CARENEXT STEPS NEEDEDChild’s Name Phone NumberDiagnosis (s)DateTaskWhoDateDoneNotesNext appointment needed/Next CCM monitoring visit:Date Care Plan Last Revised://///////
CHRONIC CONDIDTION MANAGEMENT (CCM) IN PRIMARY CARECARE PLANNINGNOTES:
Hitchcock Clinic—ConcorddPediatric Care Plan Part IChild’s NameNicknameParent (Caregiver)DOB(Relationship)AddressPhone #(home)(Blocked? Y N ) Best time to reachE-mailMom Alternate PhoneDad Alternate PhoneEmergency ContactPhoneRelationshipEmergency ContactPhoneRelationshipHealth Insurance/PlanIdentification #Diagnose(s):Emergency PlanYesNoComplexity dications/dose:PCP#1 MailOther (fax, e-mail, etc.):#2Other (fax, e-mail, etc.):#3Other (fax, e-mail, etc.):#4Other (fax, e-mail, etc.):Nursing Service/RespitePhoneMedical Home Improvement Project, 7-29-02
SPECIALIZED EMERGENCY INFORMATIONHitchcock Clinic- ConcordChild’s Name:Nickname:Date:Common Presenting Problems/Findings with Specific Suggested ManagementsProblem #1( ) See specialist letter(s) attachedPresenting Signs & SymptomsSuggested Diagnostic Studies:Problem #2Suggested Diagnostic Studies:Problem #3Suggested Diagnostic Studies:Treatment Considerations:Presenting Signs & SymptomsTreatment Considerations:Presenting Signs & SymptomsTreatment Considerations:Comments on child, family, or other specific medical issues:XPhysician/Provider SignaturePrint Name aboveFamily/guardian signature giving consent for release ofthis information to the emergency roomPrint Name aboveXMedical Home Improvement Project, 7-29-02
Care Plan Part II: Child DescriptionNameNicknameDOBChild’s Assets & StrengthsVital Sign (baselines)HtWtTempOtherChallenges (check all that apply, please explain on lines onOrthopedic/MusculoskeletalRespiratoryFeed & SwallowingPhysical /foods/activities to be avoided:Prior surgeries/procedures:DateDateDateDateDateDateMost recent labs/diagnostic studies:LabsEEGEKGX-raysDrug levelsC-SpineOtherOtherMRI/CTMedical Home Improvement Project 7-29-02
Care Plan Part II: Child DescriptionEquipment/appliances/assistive TechnologyPlease check all that apply and use the lines below to explain:GastrostomyAdaptive SeatingWheelchairTracheostomyCommunication DeviceOrthoticsSuctionMonitors: ( ) Apnea O2CrutchesNebulizerCardiac GlucoseWalkerOtherSchool System/Child Care:Contact Person/Role:Phone:Family Information:CaregiversSiblingsOther important factsSpecial Circumstances/Comment/What you would like us to knowParent /Caregiver Signature & DatePrimary Care Provider Signature & DateMedical Home Improvement Project 7-29-02
Section Two:Specialized EmergencyInformation(Medical Information / Emergency Care Plan)CMHI
Date formcompletedRevisedInitialsRevisedInitialsBy WhomName:Birth date:Home Address:Home/Work Phone:Parent/Guardian:Emergency Contact Names & Relationship:Signature/Consent*:Primary Language:Phone Number(s):Physicians:Primary care physician:Emergency Phone:Fax:Current Specialty physician:Specialty:Emergency Phone:Fax:Current Specialty physician:Specialty:Emergency Phone:Fax:Anticipated Primary ED:Pharmacy:Anticipated Tertiary Care Center:Diagnoses/Past Procedures/Physical Exam:1.Baseline physical findings:2.3.Baseline vital signs:4.Synopsis:Baseline neurological status:*Consent for release of this form to health care providersNickname:Last name:Emergency Information Form for Children With Special Needs
Medications:Significant baseline ancillary findings (lab, x-ray, ECG):1.2.3.4.Prostheses/Appliances/Advanced Technology Devices:5.6.Management Data:Allergies: Medications/Foods to be avoidedand why:1.2.3.Procedures to be avoidedand why:1.2.3.ImmunizationsDatesDatesDPTHep BOPVVaricellaMMRTB statusHIBOtherAntibiotic prophylaxis:Indication:Medication and dose:Common Presenting Problems/Findings With Specific Suggested ManagementsProblemSuggested Diagnostic StudiesTreatment ConsiderationsComments on child, family, or other specific medical issues:Physician/Provider Signature:Print Name: American College of Emergency Physicians and American Academy of Pediatrics. Permission to reprint granted with acknowledgement.Last name:Diagnoses/Past Procedures/Physical Exam continued:
Hitchcock Clinic—ConcordPediatric Care Plan Part IChild’s NameNicknameParent (Caregiver)DOB(Relationship)AddressPhone #(home)(Blocked? Y N ) Best time to reachE-mailMom Alternate PhoneDad Alternate PhoneEmergency ContactPhoneRelationshipEmergency ContactPhoneRelationshipHealth Insurance/PlanIdentification #Diagnose(s):Emergency PlanYesNoComplexity dications/dose:PCP#1 MailOther (fax, e-mail, etc.):#2Other (fax, e-mail, etc.):#3Other (fax, e-mail, etc.):#4Other (fax, e-mail, etc.):Nursing Service/RespitePhoneMedical Home Improvement Project, 7-29-02
SPECIALIZED EMERGENCY INFORMATIONHitchcock Clinic- ConcordChild’s Name:Nickname:Date:Common Presenting Problems/Findings with Specific Suggested ManagementsProblem #1( ) See specialist letter(s) attachedPresenting Signs & SymptomsSuggested Diagnostic Studies:Problem #2Suggested Diagnostic Studies:Problem #3Suggested Diagnostic Studies:Treatment Considerations:Presenting Signs & SymptomsTreatment Considerations:Presenting Signs & SymptomsTreatment Considerations:Comments on child, family, or other specific medical issues:XPhysician/Provider SignaturePrint Name aboveFamily/guardian signature giving consent for release ofthis information to the emergency roomPrint Name aboveXMedical Home Improvement Project, 7-29-02
Care Plan Part II: Child DescriptionNameNicknameDOBChild’s Assets & StrengthsVital Sign (baselines)HtWtTempOtherChallenges (check all that apply, please explain on lines onOrthopedic/MusculoskeletalRespiratoryFeed & SwallowingPhysical /foods/activities to be avoided:Prior surgeries/procedures:DateDateDateDateDateDateMost recent labs/diagnostic studies:LabsEEGEKGX-raysDrug levelsC-SpineOtherOtherMRI/CTMedical Home Improvement Project 7-29-02
Care Plan Part II: Child DescriptionEquipment/appliances/assistive TechnologyPlease check all that apply and use the lines below to explain:GastrostomyAdaptive SeatingWheelchairTracheostomyCommunication DeviceOrthoticsSuctionMonitors: ( ) Apnea O2CrutchesNebulizerCardiac GlucoseWalkerOtherSchool System/Child Care:Contact Person/Role:Phone:Family Information:CaregiversSiblingsOther important factsSpecial Circumstances/Comment/What you would like us to knowParent /Caregiver Signature & DatePrimary Care Provider Signature & DateMedical Home Improvement Project 7-29-02
Section Three:Working (Action)Care PlansCMHI
List of Health Care and Other Service ProvidersChild’s Name:DOB:Dx:1 Dx2 Dx3Health Care:Name/LocationPhone #Fax #ReferralDateName/LocationPhone #Fax #EffectiveDatesSpecialists:Special clinics:(coordinators)Other:School Services:Early intervention:School attending:School principal(s):Classroom teacher(s):School nurse(s):Spec. ed. coordinator:Other personnel:Community services:Name/LocationPhone #Family support coordinator:Visiting nurse:Mental health provider:HMO/Insurance contact:DCYF case worker:Other service providers:Informal supports: minister,friend, etc.) Center for Medical Home Improvement 2001.146AFax #
CHRONIC CONDITION MANAGEMENT (CCM)IN PRIMARY CARECare PlanningParent's NamesChild's NamePhones(H) /Best Time / Place To Call/Diagnosis(s)(W) /FAX # if availableCCM Monitoring: Questioning & Interventions in the following areas:Date:Family's #1 IssueHealth Provider's#1 IssueChronic ConditionUpdate(meds, acute episodes, etc.)Child's Life/ RecentAccomplishments:Family LifeComm/FamilySupport IssuesFinancial Issues(insurance, SSI, etc.)School NeedsSpecialist ContactsPatient Education/Self CareOtherPARENT NOTEBOOK GIVEN (DATE) Center for Medical Home Improvement 2001.OFFICE CONTACT PERSON146B
CHRONIC CONDITION MANAGEMENT (CCM) IN PRIMARY CARENEXT STEPS NEEDEDChild's NamePhone NumberDiagnosis(s)DateTaskWhoDateDoneNotesNext appointment needed/Next CCM monitoring visit:Date Care Plan Last Revised: Center for Medical Home Improvement 2001.//146C//////
CHRONIC CONDITION MANAGEMENT (CCM) IN PRIMARY CARECARE PLANNINGNOTES: Center for Medical Home Improvement 2001.146D
Medical Home Learning CollaborativeAction Care PlanChild’s name:Primary diagnosis:Original Date of plan:Main ConcernsDOB:Secondary Diagnosis:Parents/Guardians:Secondary diagnosis(s)Updated Plan://Related Current ClinicalCurrentInformation (sx, labs, etc)Plans/Interventions//Person(s) ResponsibleParent/Caregiver Signature:Clinician Signature:/Name Care Coordinator:Due Date& DateCompleted
Medical Home Learning CollaborativeAction Care PlanChild’s name:Primary diagnosis:Matthew StoneDown SyndromeOriginal Date of plan:Main ConcernsFalling asleep at schoolAttention spanShort, distractible? ADHDDOB:8-13-98Parents/Guardians:Secondary Diagnosis: Congenital Heart DiseaseSecondary diagnosis(s)Hypothryoidism6/3/03Updated Plan/Related Current ClinicalCurrentInformation (sx, labs, etc)Plans/InterventionsLog & observe sleep forL-thyroxine 50 mcgapneaT4 6.5TSH 1.0Arrange for nap studyWaking at nightSnoresCheck with cardiologistSleeps sitting upConner scaleHome & schoolReview last triennelevaluation and testing//Due Date & DateCompletedPerson(s) ResponsibleMrs. S.6/10/03Care Coordinator6/10/03Dr. C.6/08/03Mrs. S.6/14/03Care coordinator for school6/14/03Dr. C6/21/03see aboveSee #1 aboveParent/Caregiver Signature:Clinician Signature:/Name Care Coordinator:
Jul 29, 2002 · The Working Care Plan: A care plan for a child with special health care needs can be as simple as a written, organized note developed during a visit, a more detailed plan of care developed during a meeting of the family, care coordinator and clinician or a comprehensive, integrated care plan
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to establish the history, theory and purpose of comprehensive planning. Comprehensive planning is compared to strategic planning in this section to differentiate it. Other planning methods could be used for comparison; however, the practice of comprehensive planning is evolving toward its strategic counterpart.
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