1. It Takes a Village: Shared Plans of Care HCP: A Program for Children & Youth with Special Health Care Needs

2. It Takes a Village: Shared Plans of Care HCP: A Program for Children & Youth with Special Health Care Needs

3. Reason for Referral Despite accessing several medical and community resources, Mary’s family continues to operate in crisis mode. Mary’s provider feels that her family could benefit from coordinated services and supports.

4. FOC --- MOC 6yo Genome

5. History: Child & Family 1.Mary is a 6 year old first grader. lives with tuberous sclerosis 2.Problem List: seizures significant sleep issues aggression self-harm behaviors (biting self, pulling out hair, pulling eyelashes, head banging) unsafe behaviors (bolting out of the house) incessant screaming and tantrums 3.Mary is missing a lot of school and struggling academically. 4.Family is stressed and reports missing lots of work. Dad frequently misses appointments. Mom could use more support. 5.Mary is frequently hospitalized and accessing therapies is a challenge. 6.Parents feel that communication is fragmented and often conflicting.

6. Strengths Family Strengths:

7. Culture & Beliefs Xxxxxxxxxxxxxx Xxxxxxxxxxxxxxxxxxxxxxxxxxxxx Xxxxxxxxxxx xxxxxxxxxxxx

8. Other (safety concerns, meds, etc.) limited access to psychiatry overuse of crisis resources (police, mobile crisis team) med management (med errors - poor communication)

9. Services & Supports (Brainstorm)

10. Potential Goals (Brainstorm)

11. Health Care Team (Brainstorm)

12. 1 Genome Other (Safety, Meds, etc) Services & Supports History Culture & Beliefs Strengths Care Team

13. Plan of Care Goal Activities Person(s) Responsible Timeline

14. Plan of Care Goal Activities Person(s) Responsible Timeline

15. Plan of Care Goal Activities Person(s) Responsible Timeline

16. Outcomes