Care Plans

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Care Plans

Essential Components and Sample Care Plans to Be Used in Practice

Care planning is an effective tool to assist in care coordination and managing patients with special health care needs. Patients with FASDs and their families often require multiple providers and partners to assist in their management. As such, employing care plan development and maintenance can assist primary care providers in combining necessary information into one document.

Essential Components of Medical Home Care Plan/Portable Medical Summary

Care plans are an essential part of the medical home. Every patient can benefit from a care plan (or medical summary) that includes all pertinent current and historic, medical, and social aspects of a child’s and family's needs. It also includes key interventions, each partner in care, and contact information. A provider and family may decide together to also create an action plan, which lists imminent next health care steps while detailing who is responsible for each referral, test, evaluation, or other follow-up. If needed, emergency plans provide explicit instructions for prepared actions to be taken by the family, other caregivers or teachers, and all health care professionals. Below are the essential components/fields of an effective care plan.

Primary Elements:

  • Name
  • Date of Birth
  • Insurance (primary and secondary)
  • Phone number and emergency contact information
  • Parents’ names
  • Diagnoses to be considered (see ICD code list)
  • Medications
  • Allergies with doses
  • Specialists and phone numbers
  • Hospitalizations and surgeries

Support Services:

  • Equipment (tracheostomies, gastrostomy tubes, wheelchair, orthotics, etc)
  • Therapies (speech, physical therapy, occupational therapy)
  • School/child care
  • School information (grade, teacher, Individualized Education Program, Individual Family Service Plan, 504) in school services
  • Home care/nursing services
  • Pharmacy information
  • Mental health agencies and providers
  • Dental care
  • Community agencies
  • Transition care plan elements if applicable (office of vocational rehab, etc.)

Secondary Elements:

  • Past medical history and review of systems
  • Communication devices
  • Home modifications
  • Activities of daily living (challenges, toileting, hygiene)
  • Respite
  • Supplemental security income
  • Feeding, diet, nutrition
  • Housing and transportation needs
  • Hearing and vision services
  • Child’s strengths and likes

Sample Office Documents

  • Sample Care Plan
    Use of this care planning format may require additional pages to address behavior management strategies, including an Individualized Education Program (IEP)–based plan for school for children with FASDs. Consistency of actions and close communication across settings and providers may be essential to success for such plans. Incorporating relevant portions of the care plan into the IEP may facilitate addressing all relevant issues so that outside resources are identified.
  • Integrated Services Care Plan
    This document can be individualized in the pediatric medical home as it expands the key components of a care plan for an individual with special needs. This document outlines the key components all care plans should have so practices can easily develop their own care plans for the child with an FASD. Practices can use their electronic health records to create care planning with fields that are populated from fields from the medical records. Care plans should be created in partnership with families and caregivers.
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