Care coordination resources, including a sample patient care plan can be found at:
https://www.aap.org/en-us/professional-resources/practice-transformation/managing-patients/Pages/Care-Coordination.aspx
National Center for Medical Home Implementation Building Your Medical Home Guide:
https://medicalhomes.aap.org/Pages/Managing-Your-Patient-Population.aspx
https://medicalhomes.aap.org/Documents/PediatricCarePlan.pdf
NICHQ Care Plan Template: https://www.nichq.org/resource/nichqs-care-plan-template