Care Coordination Plan (Neurodevelopmental Disorders)

Document Title: Care Coordination Plan (Neurodevelopmental Disorders)

Author/Role: [Author name and role]

Date Created: [Date] | Last Updated: [Date] | Next Review Date: [Date]

Encounter Type: [in-person / telehealth / care coordination only]

Distribution Status: [Draft / Shared with: [authorized recipients]]

Patient Name: [Legal name] | Preferred Name: [Name] | DOB: [DOB] | MRN: [MRN]

Primary Language: [Language] | Interpreter Needed: [Yes / No]

Guardian(s)/Decision-Maker(s): [Names and legal role(s)]

Preferred Contact Method & Best Times: [Method and availability]

Reason for Plan

[Trigger for plan initiation] (Document why this plan is being created: new diagnosis, new referrals, transition point, new safety concern, or transition to adult care.)

Family/Youth Priorities:

• [Family/youth priority #1]
• [Family/youth priority #2]
• [Family/youth priority #3]

[Scope statement] (Include only if sharing externally. Clarify what this plan covers and does not cover.)

Executive Summary

(Keep to one page or less. Label sources throughout. Do not infer diagnoses or eligibility.)

[Clinical-functional synopsis] (One paragraph: primary diagnoses and key comorbidities; communication modality/AAC; learning/adaptive needs; behavior/safety considerations. Include sensory/feeding/sleep only if driving services or accommodations. Label sources.)

Current Supports Snapshot:

• [Active therapies with type and frequency]
• [School plan status: IEP / 504 / none] — Last meeting: [Date]
• [Key community supports or benefits]
• [Highest-risk coordination vulnerabilities: missed referrals, long waitlists, service gaps]

Top Goals (2–5):

• [Prioritized goal]

Most Time-Sensitive Next Actions (2–5):

• [Critical next step] — Owner: [Owner] | Due: [Date]

Care Team Directory

(If a key role is unknown, enter "Unknown - needs identification.")

Name	Role	Organization	Phone	Email/Fax	Best Contact Method	Notes
Core Care Team
[Name]	[Role]	[Organization]	[Phone]	[Email/Fax]	[Phone / Portal / Email]	[Notes]
Specialty/Behavioral Health Providers
[Name]	[Role]	[Organization]	[Phone]	[Email/Fax]	[Best contact]	[Notes]
Therapy Providers
[Name]	[Role]	[Organization/Setting]	[Phone]	[Email/Fax]	[Best contact]	[Frequency and focus]
School Partners
[Name]	[Role]	[School/District]	[Phone]	[Email/Fax]	[Best contact]	[Notes]
Community Agencies
[Name]	[Role]	[Agency]	[Phone]	[Email/Fax]	[Best contact]	[Notes]

Information Sharing & Consent

• ROI Status: [Yes / No / Partial] — Authorized parties: [List]. Restrictions: [If any]
• Communication Preferences: [Preferred method] | [Preferred cadence for check-ins]

(Label all information throughout this plan: "Family-reported," "School-reported," "Verified from [document] dated [date]," or "Per record dated [date]." Do not infer diagnoses, IEP eligibility, guardianship status, or consent permissions.)

Diagnoses & Functional Profile

• Primary Neurodevelopmental Diagnoses: [List] (Source: [source])
• Co-occurring Conditions Affecting Planning: [List] (Source: [source])
• Allergies/Medication Considerations: [List if relevant to school/therapy; otherwise omit]
• Strengths & Protective Factors: [Patient interests/motivators, family strengths, effective strategies] (Source: [source])

Functional Domains: (Include only domains with known information. If a central domain is not assessed, note "Not assessed - needs [type] evaluation" and add to Action Item Tracker.)

• Communication: [Expressive/receptive profile; AAC use] (Source: [source])
• Learning/Executive Functioning: [Key needs] (Source: [source])
• Adaptive Skills: [Daily living skills relative to age] (Source: [source])
• Social Interaction: [Peer/adult interaction profile] (Source: [source])
• Behavior Regulation: [Triggers; effective strategies] (Source: [source])
• Sensory Profile: [Include if affecting supports] (Source: [source])
• Motor/Coordination: [Include if PT/OT relevant] (Source: [source])
• Sleep: [Include if driving services/accommodations] (Source: [source])
• Feeding: [Include if driving services/accommodations] (Source: [source])
• Safety Risks: [Elopement / self-injury / aggression / exploitation risk / none identified] (Source: [source])

Goals & Outcomes

(List 2–6 prioritized goals. Use family/youth-centered language. Make goals operational with measurable outcomes.)

1. Goal: [Goal statement]

   Target Timeframe: [Timeframe] | Owner(s): [Primary coordinator(s)]

   Progress Measure: [Observable metric and tracking method]

   Systems Addressing Goal: [Therapies / School / Home / Medical / Community]

2. Goal: [Goal statement]

   Target Timeframe: [Timeframe] | Owner(s): [Owner]

   Progress Measure: [Metric]

   Systems Addressing Goal: [List]

Current Services & Supports

(For each service: type, provider, frequency, barriers. Label sources. State "None documented" if a subsection is empty.)

Medical & Behavioral Health

• [Clinician] — [Role]. Follow-up: [Cadence]. Medication management: [Prescriber; monitor]. Barriers: [If any]. (Source: [source])

Therapies

• [Therapy type] — [Setting]. Frequency: [Frequency]. Goals: [Primary goals]. Next re-eval: [Date]. Barriers: [If any]; Mitigation: [Plan]. (Source: [source])

School Supports

• Plan type: [IEP / 504 / MTSS / informal / none]. Related services: [List]. Safety/health supports: [If any]. (Source: [source])

Community Supports

• [Service type]. Status: [Active / Pending / None]. Notes: [Insurance/benefit considerations]. (Source: [source])

School Coordination Plan

School/District: [Name] | Grade: [Grade] | Program: [General ed / Special ed / Inclusion / Other] (Source: [source])

Key Dates: Last IEP/504 meeting: [Date] | Next meeting: [Date] | Last evaluation: [Date, domains evaluated] (Source: [source])

Pending School Steps: (Duplicate each in Action Item Tracker.)

• [Action step] — Owner: [Owner] | Due: [Date] | Status: [Not started / In progress / Completed / Deferred / Blocked]

Clinician-to-School Deliverables Needed: [Diagnosis confirmation letter / Medication orders / Functional impact summary / None] (Send only per ROI.)

Action Item Tracker

(Operational core of the plan. Assign one owner per task. Use action verbs. Track referrals: placed → scheduled → results received → integrated. If no owner can be assigned, document as risk.)

Goal	Action	Owner	Due Date	Status	Contingency/Barrier Plan
[Linked goal]	[Specific action]	[Single owner]	[Date]	[Not started / In progress / Completed / Deferred / Blocked]	[Mitigation if blocked]
[Linked goal]	[Specific action]	[Owner]	[Date]	[Status]	[Plan]

Barriers & Family Support Needs

• Access Barriers: [Transportation / cost / waitlists / language / digital access / caregiver work constraints] (Source: [source])
• Family/Caregiver Support Needs: [Behavior support training / AAC training / home program support / respite / caregiver stress supports] (Source: [source])

(Convert solvable barriers into tasks in Action Item Tracker.)

Safety & Crisis Planning

(Include only if meaningful risk exists or sharing with partners who need this information. Omit entirely if no identified safety risks.)

• Relevant Safety Risks: [Elopement / self-injury / aggression / suicidal ideation / exploitation risk] (Source: [source])
• Crisis Plan: Call: [Contact]. Go to: [Location]. Bring: [Med list, emergency form]
• De-escalation Strategies: [Strategies that work for this patient]
• Emergency Information Form: [Location/reference]

Transition Planning

(Include for adolescents/young adults or when planning independence supports. Omit for younger children.)

• Self-Management Skills to Build: [Medication knowledge / appointment participation / self-advocacy]
• Systems Transitions: [Pediatric to adult care / school transition services / vocational supports]
• Legal Planning Considerations: [Decision-making supports / guardianship exploration] (Use neutral language; refer to appropriate experts.)

Follow-up & Plan Maintenance

Next Care Coordination Touchpoint: [Date/Timeframe] | Follow-up By: [Name/Role]

Plan Review Triggers: New evaluation results; major school change; hospitalization/ED visit; new safety concern; insurance change affecting services

Change Log:

Date	Author	Summary of Changes	What Was Newly Verified
[Date]	[Name/Role]	[Brief edit summary]	[Items with source and date]

Attachments

• [IEP/504/behavior plan] — [Date]
• [Therapy evaluations] — [Date]
• [ROI forms] — [Date]
• [Referral letters] — [Date]
• [Emergency information form] — [Date]

Family/Youth Reviewed and Agrees with Priorities: [Yes / No / Partial] | Date: [Date]