Care Plans and Care Maps: Innovative Tools to Improve the

Care of Children with Special Health Care Needs

Sherri Adams, MSN,NP-Peds, CPNP-AC/PC, Joanna Soscia, MEd, MN, NP-Peds

Needs of CSHCN

Strategies for implementation

Care Map Examples

Care Plan --Identify appropriate software if needed to create document.

• Ensure you include a description about the child’s development,

functional status, social situation and communication strategies.

• Collaborate with parents throughout to ensure that information is

accurate, valuable and consistent with information they wish to share.

• Update care plan regularly and share with appropriate providers.

Care Map --Work with family to support them in care map creation.

• Review care map with creator to ensure full understanding.

• Use care map content to support care coordination and advocacy work.

• Children with Medical Complexity and the broader

population of Children with Special Health Care Needs

(CSHCN) are a diverse patient population who may depend

on highly specialized care from multiple providers, in

numerous settings to optimize their quality of care.

• Improved communication and care coordination is an

essential component of delivering family centered care that

is of high quality and efficiency for CSHCN.

• Objective evidence to support the use of care plans and

care maps is evolving and supports the development and

use of care plans and care maps that are child and family

centered.

• This poster will: Review the care coordination needs of

CSHCN, define what care plans and care maps are, review

potential formats, and identify strategies for implementation.

Understanding Care Plans

• A Care Plan is a written document that outlines the major

medical issues and care needs for a specific child and is created

by the health care provider in collaboration with the family. The

document can be modified to meet a variety of needs, including

an emergency care plan and advanced directives.

• They facilitate transition through the health care system, enhance

care coordination and manage health information across sites of

care.

• They are a useful tool for health care providers and parents that

centralizes and focuses care of the child and centralizes

exchange of information.

http://durgastoolbox.com/2013/07/09/care-mapping-as-

reflection-and-celebration/

Understanding Care Maps

• A Care Map depicts complexity of care and life for CSHCN

and their families. It is a pictorial way to describe the

individual needs, strengths and assets of a family and to

provide the holistic view of a child in their family and

community

• Practitioners may be able to use the family created care map

to help avoid duplications or gaps in services, prioritize among

multiple activities, and identify care coordination and

communication needs.

• Care Maps provide a visually compelling tool to advocate for

improved integration of services for CSHCN and their families.

References

Adams S, Cohen, E., Mahant, S., Friedman, J.N., MacCulloch, R., Nicholas, D.B. (2013). Exploring the usefulness of

comprehensive care plans for children with medical complexity (CMC): a qualitative study. BMC Pediatrics, 13(10).

Antonelli R.C. & Lind C. (2012b). Care mapping: A how-to guide for professionals. Retrieved May 7th, 2013 from Boston Children’s

Hospital website: http://www.childrenshospital.org/clinicalservices/Site3508/ Documents/ Care-Mapping-forprofessionals-2-

18-13.pdf.

American Academy of Pediatrics, Committee on Pediatric Emergency Medicine and Council on Clinical Information

Technology, American College of Emergency Physicians, Pediatric Emergency Medicine Committee: Policy statement--

emergency information forms and emergency preparedness for children with special health care needs. Pediatrics 2010,

125(4):829-837.

American Academy of Pediatrics Council on Children with Disabilities: Care coordination in the medical home: integrating

health and related systems of care for children with special health care needs. Pediatrics 2005, 116(5):1238- 1244.

Belkin L. (26 January, 2013b). Care maps: Special needs mom inspires others to illustrate their own support networks. Retrieved

May 7th,2013 from The Huffington Post website: http://www.huffington post.com/2013/01/26/care-maps-for-special-needs

families_n_2557855.htmlfdsf

Cohen E, Kuo D, Agrawal R et al. Children with Medical Complexities: An emerging population for clinical and research

initiatives. Pediatrics. 2011;127(3): 529-538.

Looman WS, Presler E, Erickson MM, et al. Care coordination for children with complex special health care needs:

The value of the advance practice nurses enhanced scope of knowledge and practice. Journal of Pediatric Health Care.

2012; 27(4): 293- 303.

Adams S et al (2013)

http://durgastoolbox.com/2012/09/19/durga-tool-9-my-care-

map-or-the-picture-that-tells-a-thousand-words/