Shared Care Planning

Shared care planning is a process for coordinating care for children and youth with special health care needs. OCCYSHN contracts with partners around Oregon to implement shared care planning in their communities. OCCYSHN's public health partners convene teams of families and professionals to create care plans for individual children and youth with special health needs.

NEW! The Family-Centered Shared Care Planning Assessment Tool

The Family Centered Shared Care Planning Assessment Tool is a quality-improvement tool that teams can use to assess their integration of the ten core values of patient- and family-centered shared care planning. The tool was identified as a "Cutting Edge Practice" by the national Association of Maternal & Child Health Programs.

Find a PDF of the tool HERE.

Contact us if you prefer a Microsoft Excel version of the document, which automatically scores the tool.

Shared Care Planning: Information for Families
two-page document describing shared care planning to family members of CSYCHN

Shared Care Planning: An Overview
one-page document describing shared care planning to professionals

Shared Care Planning: A PowerPoint Presentation
brief, customizable slide presentation describing shared care planning to potential professional partners

Shared Care Planning for Youth and Young Adults
one-page document (aimed at professionals) describing shared care planning with young adults

Definition of "Complex" for Shared Care Planning
defines "complex" for purposes of OCCYSHN shared care planning contract requirements

Shared Care Planning Template
the required tool for developing and recording shared care plans
English (portrait) - Microsoft Word
English (portrait) - fillable PDF
English (landscape) - fillable PDF
English (landscape) - Microsoft Word
Chinese - Microsoft Word
Russian - Microsoft Word
Vietnamese - Microsoft Word
Spanish - Microsoft Word

Care Map
fillable template for "mapping" a child and family's current care and services

Shared Care Planning Handbook: Implementing Shared Plans of Care for Children and Youth with Special Health Care Needs This handbook provides detailed instructions on how to implement shared care planning. It also includes background information and context for the work.

Shared Care Planning 102: Health Care Transition

The Shared Care Planning Evaluation and Data Collection Procedures details evaluation requirements. It includes information about which reports are submitted when, and how to submit them. Questions about reporting can be directed to OCCYSHN's Evaluation and Assessment Coordinator, Alison Martin, PhD: 503.494.5435,

Shared Care Plan Information Form After every SPOC meeting, and re-evaluation A link to an online data collection tool is emailed monthly.
Shared Care Planning End of Year Report Shared care planning partners will be notified by email towards the end of the contract year. An online data collection tool will be emailed.

Care Mapping:  Boston Children's Hospital provides an overview of care mapping, including background information and care mapping tools for families and providers.

Culturally and Linguistically Appropriate Services (CLAS):  The U.S. Department of Health and Human Services' CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities.

Family Support: The Oregon Family to Family Health Information Center provides information, resources, and peer support for families of children with special health needs. 

Health Literacy:  The U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality developed the "Health Literacy Universal Precautions Toolkit." The toolkit aims to help health care providers "reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels."

Disability Rights Oregon is a non-profit law office that provides advocacy and legal services to Oregonians with disabilities who have an issue related to their disability.

Arc Oregon advocates for Oregonians with intellectual and developmental disabilities. They provide guardianship, advocacy and health care representation services.

Releases of Information: The Oregon Department of Education offers information about the relationship between education and health care as it pertains to sharing information. Their Release of Information template can be used for SPOC.

Transition to Adult Health Care: Got Transition, Center for Health Care Transition Improvement works to improve the transition from pediatric to adult health care through the use of new and innovative strategies for health professionals and youth and families.

Achieving a Shared Plan of Care with Children and Youth with Special Health Care Needs: An Implementation Guide Jeanne W. McAllister, BSN, MS, MHA (2014). Lucile Packard Foundation for Children's Health.

Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms Taylor EF, Lake T, Nysenbaum J, Peterson G, Meyers D. (2011). Agency for Healthcare Research and Quality.

Guiding Principles for Team-Based Pediatric Care Katkin, Julie, Kressly SJ, Edwards AR, et al. (2017). American Academy of Pediatrics Policy Statement.

Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework Antonelli, R.C., McAllister, J.W., Popp, J. (2009). The Commonwealth Fund. 

National Standards for Systems of Care for Children and Youth with Special Health Needs (Version 2.0) VanLandeghem, K., Sloyer, P., Gabor, V., &Helms, V. (2017). The National Standards were developed by the Association of Maternal &Child Health Programs and the National Academy for State Health Policy. Lucile Packard Foundation for Children's Health.

Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth across Multiple Systems Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee (2014). American Academy of Pediatrics Policy Statement.

Developing and Sustaining Child Health Teams - A Toolkit (rev. March 2019) - Oregon Center for Children and Youth with Special Health Needs