Health Homes Serving Children - 10 Elements of a Plan of Care

  • Table also available in the following format (PDF)

Updates to the "10 Elements" of a Plan of Care

Updated: January 2024

The below table outlines the previous "10 Elements" required of a Plan of Care for the Health Home Serving Children's (HHSC) program and indicates whether the element is incorporated in the updated Health Home Plan of Care policy or within another location where the information should reside. Unless otherwise noted, the information for each element is still required. Please note that the Department will be issuing a "Guide to Edits" of the various policies effected by this change.

Previous 10 Elements Required of a Plan of Care New Location of
Previous 10 Elements
  1. The child's Emergency Contact and disaster plan for fire, health, safety issues, natural disaster, other public emergency (safety plan).
 The child's/youth's record
  1. The child's History and Risk Factors related to services and treatment, well-being, and recovery.
 Incorporated in a Plan of Care per the updated POC policy and the child's/youth's record
  1. The child's Functional Needs related to services and treatment, well-being and recovery.
 Incorporated in a Plan of Care per the updated POC policy and Relevant Assessment Tools
  1. The child's and caregivers' identified Strengths and Preferences related to services and treatment, well-being, and recovery.
 Incorporated in a Plan of Care per the updated POC policy
  1. Medicaid State Plan and Non-Medicaid services identified to meet child's needs –must be person-centered, comprehensive, and integrated to include Physical, Behavioral Community and Social Supports. Plan must also document the indication of choice of (A) Service Provider, (B) Reason for the Service and (C) Intended Goals.
 Incorporated in a Plan of Care per the updated POC policy
  1. Key Informal Community Supports. This would include any supports in place for the child/family that address identified needs (Ex. Family's neighbor is available for support as needed and is aware of child/family's needs but is not assigned a specific task to reach a goal).
 The child's/youth's record unless the child/family identifies as part of the Plan of Care or safety plan.
  1. Description of planned Care Management Interventions (including Services Care Management, Referral, Access, Engagement, Follow Up, and Service Coordination) and Timeframes.
 Incorporated in a Plan of Care per the updated POC policy
  1. The child's Transition Plan including circumstances/services needed to transition from Health Home Care Management as needed (e.g., education, living situation, employment, community functioning, hospital, treatment facility, foster care)
 The child's/youth's record unless a transitional goal needs to be incorporated in the Plan of Care

Ex: a youth who turns 14 must have an independent living goal in their Plan of Care
  1. Documentation of participation by inter-disciplinary team (all Key Providers) in the development of the plan of care.
 The child's/youth's record
  1. The child/adolescent and or parent/guardian/legally authorized representative's signature documenting agreement with the Plan of Care. (Referencing DOH 5201 Health Home Consent/Information Sharing/For Use with Children Under 18 Years of Age).
 Incorporated in a Plan of Care per the updated POC policy