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High Utilizer Care Plans

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Does anyone out there have a template that they use for care plans that are disseminated to field crews on high-utilizer patients to help assist with clinical decision making? 

Trying to deploy a care plan template here and not super interested in reinventing the wheel if it already exists.

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In areas where I've worked these types of care plans have been individualized for the person in question.  There was no template used as a basis for patient interactions.  And honestly?  Most of these care plans were "ensure patient and crew safety, transport to the ED".  For some of these folks social work at the receiving hospital has had to get involved as the ER was seeing these folks as often, if not more often, than we were.  If that's not a resource you've looked at yet they may be of help.

Sorry this is not of more help.  These are tough cases that usually don't follow a global script or fit into a neat template.

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