Shared Plans of Care

Shared care planning is a process for coordinating care for select children and youth with special health needs. OCCYSHN contracts with partners around the state to implement shared care planning in their communities.


WEBINARS:
On the third Thursday of every month from 9:00-10:00 AM there is a web-based meeting about implementing shared care planning, for all OCCYSHN partners. The meetings include discussion, instruction, and technical support. An email reminder with a link to the next webinar goes out monthly. 

INTRODUCTION TO SHARED PLANS OF CARE: On September 21, 2017 Jeanne McAllister (BSN, MS, MHA, Research Associate Professor IUSM Pediatrics) presented to OCCYSHN's SPOC partners across the state. This webinar offers an introduction to the theory and practice of SPOC.
Shared Plans of Care as Centerpiece of Real Family-Centered Care Coordination
(video of the webinar presentation.)
SLIDES: Shared Plans of Care as Centerpiece of Real Family-Centered Care Coordination
(PDF of the PowerPoint slides.)

 

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: A POWERPOINT PRESENTATION: A brief slide presentation describing shared care planning to potential professional partners.

Forms and Materials

(arranged in the order in which they are typically used)

Shared Care Planning: Information for Families (English)
Shared Plans of Care: Information for Families (Spanish)
Shared Plans of Care: Information for Families (Russian)
Shared Plans of Care: Information for Families (Chinese)
Shared Plans of Care: Information for Families (Vietnamese)
A two-page flyer that describes shared care planning to family members of CYSHCN.
Shared Care Planning: An Overview
A one-page flyer that describes shared care planning to professionals.
Care Map
A fillable template for "mapping" the care and services a child and family are currently getting.
Definition of "Complex" for Shared Plans of Care
Used to determine whether a CYSHCN qualifies as "complex" to meet OCCSYHN shared care planning contract requirements.

Shared Care Planning Template (English -  landscape)
Template (English - portrait)
Template (Spanish)
Template (Russian)
Template (Chinese)
Template (Vietnamese)

The required tool for developing and recording shared care plans.

Reporting

Shared Care Planning Evaluation and Data Collection Procedures  This document details required evaluation procedures. 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, martial@ohsu.edu.

 

WHAT

WHEN

HOW

SPOC Information Form
After every SPOC meeting, and re-evaluation
A link to an online data collection tool is emailed monthly.

SPOC Mid-Year Report
Date to be determined. SPOC partners will be notified by email.
A link to an online data collection tool will be emailed.
Study Interest Form
As soon as possible after initiating a SPOC meeting or re-evaluation (if the family wants to participate).
If the family chooses to sign this form, fax it to OCCYSHN at 503-494-2755. (OCCYSHN administers the actual survey. Fax ONLY the signed Study Interest Form.)
SPOC End of Year Report
Date to be determined. SPOC partners will be notified by email.An online data collection tool will be emailed.

Selected Resources

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. http://www.gottransition.org/  

 

Literature Informing Shared Care Planning

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.


2017-18 Shared Care Planning Webinars

  • October 19, 2017 - What Does Next Year Look Like for SPOC? Click HERE for the slides.
  • November 16, 2017 - Facilitating a Shared Care Planning Meeting  Click HERE for the slides.
  • December 21, 2017 –SPOC Information Form  Click HERE for the webinar recording. Click HERE for the slides.
  • January 18, 2018 - Discharge Planning Click HERE for the slides.
  • February 15, 2018 - Engaging with Primary Care Click HERE for the slides. Click HERE for the One Minute Paper.
  • March 15, 2018 - Health Literacy and Shared Plans of Care Click HERE for the slides.
  • April 19, 2018 - Addressing Transition Goals Click HERE for the slides.
  • May 17, 2018 - Partnering with Developmental Disabilities Services on SPOC Click HERE for the slides.
  • July 19, 2018 - What We Learned - 2018 OCCYSHN Regional Meetings Click HERE for the slides.