Checklists and Tools

This list highlights some of the major tools available to help health care providers and families provide family-centered, coordinated primary care for children and youth with special needs. 

These tools, primarily developed or adapted for use in Washington State, are described in more details in other parts of this or linked websites.  They are provided here for quick access.

NOTE: Many of these resources were developed or adapted by organizations funded by the Washington State Department of Health Children with Special Health Care Needs.  The Washington State Medical Home Leadership Network and Washington State Medical Home Website, the Adolescent Health Transition Project, the Center for Children with Special Needs have all developed tools to support medical home partnerships that are linked to below.  Products developed with support from DOH-CSHCN are noted with a (DOH) following the title.

Search by category:

Provider Tools	Resource Lists	Transition
Family Tools	School Tools

You can also search the Medical Home Website for other tools.

Provider Tools

Referral Form for Birth to Five Early Intervention

A Universal Referral form created jointly by the AAP and the Training, Referral and Assessment Center for Excellence (TRACE).   Includes release of information from parents for provider to share with EI program and checkbox for information you would like returned to you from the EI program.

http://www.medicalhomeinfo.org/screening/DPIP/Early Intervention Referral Form.doc

Care Coordination Resources and Information

Medical Care Plans/Assessment Forms  - National Center of Medical Home Initiatives for Children with Special Needs

• Medical Information Plans
• Emergency Plans
• Working (action) Care Plans and Medical Summaries
• Child History and Fact Sheet

www.medicalhomeinfo.org/tools/assess.html

Dr. Stephens' Chronic Case Management Forms

 

Family-Initiated Care Planning Forms - Center for Children with Special Needs

• Getting to Know Me (2 pg family-completed form introduing child)
• What's the Plan - Versions A and B (One page worksheet to organize questions and concerns)
• In Case of Emergency (One page form)
• View sample care plans:

  http://cshcn.org/planning-record-keeping/care-plans-parents/parents-create-care-plan

Care Coordination - Medical Home Portal

Care plans, visit focus sheets and more...

www.medicalhomeportal.org/clinical-practice/building-a-medical-home/care-coordination

 

Healthy and Ready to Work Website

Care plans, emergency plans, medical summaries, transition summary 

http://www.hrtw.org/tools/check_care.html

Continuous, Comprehensive, Coordinated Care Resources

Fact Sheets, Policy Statements, Articles and Reports

National Center of Medical Home Initiatives for Children with Special Needs

www.medicalhomeinfo.org/publications/continuous.html

Emergency Preparedness for Children with Special Health Care Needs

Emergency Care Plans

To facilitate prompt and appropriate emergency care for children with special health care needs, the American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP) have developed an Emergency Information Form (Adobe Acrobat PDF File - 84K) which can be used as a tool to transfer critical information about these children. Link to blank form, interactive form, sample form, parent information, policy statements and more.

www.aap.org/advocacy/emergprep.htm

Guidelines for Emergency Medical Care in School

Committee on School Health
Pediatrics 107 (2):435-436,  Feb 2001. [PDF]

Tips for First Responders

Information on how to assist persons with a wide range of disabilities, including: People with Mobility Challenges, People with Mental Illness, Blind or Visually Impaired People, Deaf or Hard of Hearing People, and People with Cognitive Disabilities.

You can use this information during routine encounters as well as emergencies. While not meant to be comprehensive, this is specific information you can read quickly either before or while you are actually responding to an incident.

http://cdd.unm.edu/products/TipsForFirstResponders.htm

Medical Consultation

MEDCON

University of Washington Medical Consultation for Medical Providers in Washington, Alaska, Montana, and Idaho. Toll-free education and referral service of the UW School of Medicine and its primary teaching hospitals.

The line is open 24 hours a day, seven days a week. A MEDCON operator will connect community primary care providers with the appropriate faculty physician with expertise in any particular area.

Local: 206-543-5300  Long Distance Toll free: 1-800-326-5300,

email: medcon@washington.edu

MEDCON Website

Diagnoses-Specific Care Guidelines and Patient Education Materials

For specific conditions
Go to: www.medicalhome.org/diagnoses
See the sections, "Diagnoses" and "Child Health Notes" for current content.

Information for adult providers

http://depts.washington.edu/healthtr/Providers/adult.htm

 

See also:

"Tools for Providers"
The National Center of Medical Home Initiatives for Children with Special Needs at the American Academy of Pediatrics

www.medicalhomeinfo.org/tools/providerindex.html

Healthy and Ready to Work Tools and Checklists

www.hrtw.org/tools/check.html

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Family Tools

Care Notebook / Organizer (DOH)

Notebook for families to help organize and keep in one place notes, medical records, treatment plans etc for.  Expandable file folder Organizer version as well.  Available in Spanish.

http://cshcn.org/planning-record-keeping/care-notebook

Emergency Care Plan for Children with Special Health Care Needs

From the American Academy of Pediatrics

• Blank Emergency Information Form
• Blank Interactive Emergency Information Form
• Sample Emergency Information Form
• Emergency Preparedness Instructions for Parents (how to use the form)

MedlinePlus

Website directs patients/families to information to help answer health questions. MedlinePlus brings together authoritative information from the National Libraries of Medicine, the National Institutes of Health (NIH), and other government agencies and health-related organizations. Preformulated MEDLINE searches are included and give easy access to medical journal articles.  Also: extensive information about drugs, an illustrated medical encyclopedia, interactive patient tutorials, and latest health news.  In English and Spanish.

www.nlm.nih.gov/medlineplus/medlineplus.html

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Resource Lists

County-Specific Resources for Children with Special Health Care Needs and Their Families in Washington

www.medicalhome.org/resources/resource_info.cfm

List of Quick Key Contacts

Key organizations or people who know about resources in each community and can help you quickly find and access needed resources for children with special health care needs and their families (Family Health Hotline, CSHCN public health nurse coordinator, Birth to three early intervention family resources coordinator, parent support)

www.medicalhome.org/resources/local_contacts.cfm

Guide to Care Coordinators in Washington State (DOH)

http://cshcn.org/planning-record-keeping/guide-care-coordinators-wa

Summer Camp Directory for Children with Special Needs- Washington (DOH)

http://cshcn.org/resources-contacts/summer-camp-directory

Starting Point Resource Guide: 

Resources for Children with Special Health Care Needs in Washington State
English and Spanish version (DOH)
English: http://cshcn.org/sites/default/files/webfm/file/StartingPointGuide.pdf
Spanish: http://cshcn.org/sites/default/files/webfm/file/GuiaParaPadres.pdf

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School Tools

Committee on School Health
Pediatrics 112 (3):697-699, Sep 2003. [PDF]

Provision of Educationally-Related Services for Children and Adolescents With Chronic Diseases and Disabling Conditions

Committee on Children With Disabilities
Pediatrics 105 (2):448-451, Feb 2000. [PDF]

The Pediatrician's Role in the Development and Implementation of an Individual Education Plan (IEP) and/or an Individual Family Service Plan (IFSP) (RE9823)

American Academy of Pediatrics, Committee on Children With Disabilities Pediatrics. 1999;104(1):124-127

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;104/1/124

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Transition

Adolescent Autonomy Checklists (DOH)

www.depts.washington.edu/healthtr/Checklists/intro.htm

Adolescent Health History Summary (DOH)

www.depts.washington.edu/healthtr/healthhistory/default.html

Adolescent Health Transition Notebook (DOH)

www.depts.washington.edu/healthtr/notebook/default.html

Transition Timelines for Children and Adolescents with Special Needs: (DOH)

• Developmental Disabilities/Delays
• Chronic Illnesses/Disabilities

Both available in English, Spanish, Russian, Chinese, and Vietnamese

Overview: www.depts.washington.edu/healthtr/Timeline/timeline.htm

Downloads: www.depts.washington.edu/healthtr/Timeline/timeline_instr.htm

 

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