A care plan shared across organizations gives the patient and participating teams an agreed account of goals, responsibilities and next steps. Its usefulness depends on whether people can find the current plan, understand their roles and communicate changes.
AHRQ's Integration Academy describes a shared care plan as a patient-centered record that supports communication among the patient and care team. Its guidance, written for integrated behavioral and primary care, emphasizes shared information, team roles and ongoing updates.
Start with the person's goals
Ask what matters to the person and how the proposed actions relate to those priorities. Explain which organizations are involved and what each can contribute.
ACL's person-centered planning approach identifies strengths, goals, preferences and desired outcomes, then uses a written plan to organize support. It also calls for monitoring progress and making adjustments.
A shared plan should not be only a collection of professional task lists. Make the connection between the person's goal and each agreed action visible.
Name responsibilities precisely
Identify who will perform the action, who can answer questions and when it should be reviewed. Distinguish an accepted responsibility from a request sent to another organization.
For example, in a fictional plan, one clinic orders a test and a community team helps arrange attendance. The record should separately identify who will interpret the result and communicate the next clinical decision. Helping schedule the test does not automatically transfer those responsibilities.
When different teams give conflicting instructions, preserve the uncertainty and seek clarification from the responsible clinicians. Do not silently select one instruction or combine incompatible plans.
Keep the current version identifiable
Use the local process to record the plan's date, author or responsible team and review status. Make important changes visible to the people who need to act on them.
AHRQ notes that the feasibility of a fully integrated electronic plan varies with technology and workflow, particularly when teams work in different locations. A shared record should not be assumed to update every organization's system automatically.
Where systems cannot share a live version, agree on an authorized method to communicate changes and confirm receipt. Avoid treating an old downloaded copy as proof of the current plan.
Define access and information sharing
Discuss information-sharing concerns with the person and follow the applicable privacy and consent processes. Access to a plan, authority to edit it and authority to issue clinical instructions are separate questions.
Include the relevant community-service contacts and the limits of what has been arranged. A referral awaiting acceptance should remain visible as an open task.
Review after meaningful changes
Revisit the plan when needs, preferences, responsible teams or service arrangements change. Confirm that the patient can obtain and understand the parts they need.
At review, ask which goals remain relevant, which actions are complete and what is still unresolved. Close tasks with a clear outcome rather than deleting them without explanation.
Use warm handoffs to introduce the receiving team when possible. Record outstanding tests and referrals, check their acceptance through closed-loop referrals, and define what would count as completion when measuring care coordination.
Sources
- Develop a Shared Care Plan (accessed 2026-09-17) — AHRQ Integration Academy.
- Person-Centered Planning (accessed 2026-09-17) — Administration for Community Living.