LONG-TERM CARE MAP FOR CLEFT LIP/PALATE CLEFT PALATE ONLY CLEFT LIP PALATE AGE NEWBORN
ACTION/INTERVENTION
RESPONSIBLE PERSON
OUTCOME
1) Assessment-born at Scott and White
1) Plastic surgeon, clinical team coordinator, speech pathologist
2) Newborn--follow-up-born at Scott and White 3) Well baby check up 1-2 weeks follow-up 4) Assessment-not born at Scott and White 7-10 (15-30) days
2) Primary pediatrician (to be scheduled by parent) 3) Primary pediatrician (to be scheduled by parent) 4) Plastic surgeon, clinical team coordinator, speech pathologist
1 MONTH
1) Well baby check up
1) Primary pediatrician (to be scheduled by parent)
1) Feeding and weight check
2 MONTHS
1) Annual team visit.
1) plastic surgeon, dentist, audiologist, ENT, speech pathologist, Clinical team coordinator 2) Primary pediatrician (to be scheduled by parent)
1) Establishment of comprehensive Treatment Plan. Schedule surgery and follow-up appointments
2) Well baby check up
1) Distribution of packet about diagnosis and financial assistance. Address concerns, feeding instructions explanation of team process and lip adhesion if indicated 2) Pediatrician recommendations 3) Pediatrician recommendations 4) Set up team day
2) Pediatrician recommendations
3 MONTHS
1) Lip adhesion or definitive lip repair/ possible tube placement
1) Plastic surgeon and ENT
1) Post-op follow-up
4 MONTHS
1) Well baby check up 2) Medical record review
1) Primary pediatrician (to be scheduled by parent) 2) Clinical team coordinator
1) Pediatrician recommendations
1) Primary pediatrician (to be scheduled by parent) 2) Plastic surgeon, ENT (if
1) Pediatrician recommendations
5-6 MONTHS
1) Well baby check up 2) Definitive Lip repair if not
Scott and White TDH/CHD Continuation Application/ 09-10
2) Tracking/monitoring
2) Post-op follow-up
AGE
ACTION/INTERVENTION already done, tubes (if necessary)
RESPONSIBLE PERSON necessary)
1) Well baby check up
1) Primary pediatrician (to be scheduled by parent) 2) Clinical team coordinator
1) Pediatrician recommendations
1) Primary pediatrician (to be scheduled by parent) 2) Plastic surgeon, dentist, speech pathologist, ENT, audiologist, clinical team coordinator 3) Plastic surgeon (dentist, audiology, and ENT if necessary)
1) Pediatrician recommendations
13 MONTHS 1) Post-op visit/follow-up
1) Plastic surgeon, dentist, audiology, and ENT (all that apply)
1) Schedule therapy (if necessary)
15 MONTHS 1) Well baby check up
1) Primary pediatrician (to be scheduled by parent) 2) Clinical team coordinator
1) Pediatrician recommendations
1) Primary pediatrician (to be scheduled by parent) 2) Primary dentist (to be scheduled by parents)
1) Pediatrician recommendations
20 MONTHS 1) Medical record review
1) Clinical team coordinator
1) Tracking/monitoring
24 MONTHS 1) Medical record review
1) Clinical team coordinator.
1) Tracking/monitoring
28 MONTHS 1) Medical record review
1) Clinical team coordinator
1) Tracking/monitoring
32 MONTHS 1) Medical record review
1) Clinical team coordinator
1) Tracking/monitoring
9 MONTHS
2) Medical record review 12 MONTHS/ 1 YEAR
1) Well baby check up 2) Team visit
3) Surgery pre-op/ palate repair (if necessary)
2) Medical record review 18 MONTHS 1) Well baby check up 2) Dental check-up
Scott and White TDH/CHD Continuation Application/ 09-10
OUTCOME
2) Tracking/monitoring
2) Establishment of the Comprehensive Treatment Plan 3) Palate repair/other repairs 9id necessary)
2) Tracking/team recommendations
2) Dentist recommendations
AGE ACTION/INTERVENTION 3 YEARS/ 1) Annual team visit 36 MONTHS
RESPONSIBLE PERSON 1) Plastic surgeon, dentist, audiologist, ENT, speech pathologist, clinical team coordinator 2) Primary pediatrician (to be scheduled by parent) 3) Clinical team coordinator
OUTCOME 1) Establish Comprehensive Treatment Plan, Lip/palate revision surgery if needed
1) Dentist/hygienist (to be scheduled by parent) 2) Clinical team coordinator
1) Follow-up/cleaning
1) Establish Comprehensive Treatment Plan
4) Post-op visits
1) Plastic surgery, dentist, audiologist, ENT, speech pathologist, clinical team coordinator 2) Primary pediatrician (to be scheduled by parent) 3) Plastic surgeon, ENT, dentist (all those that apply) 4) All doctors that apply
5) Medical record review
5) Clinical team coordinator
5) Tracking/team recommendations
1) Follow-up dental 2) Medical record review
1) Dentist/hygienist 2) Clinical team coordinator
1) Follow-up/cleaning 2) Tracking/monitoring
1) Annual team visit
1) Plastic surgery, dentist, audiologist, ENT, speech pathologist, clinical team coordinator
1) Establish Comprehensive Treatment Plan
2) Dental and medical check up
2) Primary pediatrician and dentist (to be scheduled by
2) Pediatrician and dentist recommendations
2) Well child check up 3) Medical record review 3 YEARS1) Dental check-up 42 MONTHS 2) Medical record review 4 YEARS
1) Annual team visit.
2) Well child check up 3) Surgery intervention/pre-op
4–4½ YEARS 5 YEARS
Scott and White TDH/CHD Continuation Application/ 09-10
2) Pediatrician recommendations 3) Tracking/monitoring
2) Tracking/monitoring
2) Pediatrician recommendations 3) Repairs (if necessary) 4) Lip/palate revision, possible pharyngeal flap, splinter pharyngoplasty, speech therapy
AGE
ACTION/INTERVENTION 3) Medical record review
RESPONSIBLE PERSON parent) 3) Clinical team coordinator
3) Tracking/monitoring
5-5 ½ YEARS
1) Dental check-up 2) Medical record review
1) Dentist/hygienist 2) Clinical team coordinator
1) Follow-up/cleaning 2) Tracking/monitoring
6 YEARS
1) Annual team visit
1) Establish Comprehensive Treatment Plan
2) Orthodontic evaluation 3) Medical record review
1) Plastic surgery, dentist, audiologist, ENT, speech pathologist, clinical team coordinator 2) Orthodontist 3) Clinical team coordinator
6-6 ½ YEARS
1) Dental check-up 2) Medical record review
1) Dentist/hygienist 2) Clinical team coordinator
1) Follow-up/cleaning 2) Tracking/monitoring
7 YEARS
1) Annual team visit
1) Establish Comprehensive Treatment Plan.
2) Dental check-up
1) Plastic surgery, dentist, audiologist, ENT, speech pathologist, clinical team coordinator 2) Dentist/hygienist
7- 7 1/2 YEARS
1) Medical record review
1) Clinical team coordinator
1) Tracking/monitoring
8 YEARS
1) Annual team visit
1) Plastic surgery, dentist, audiologist, ENT, speech pathologist, clinical team coordinator
1) Establish Comprehensive Treatment Plan
8-8 1/2 YEARS
1) Dental check-up 2) Medical record review
1) Dentist/hygienist 2) Clinical team coordinator
1) Follow-up/cleaning 2) Tracking/team recommendations
9 YEARS
1) Annual team visit
1) Plastic surgery, dentist, audiologist, ENT, speech pathologist, clinical team
1) Establish Comprehensive Treatment Plan, consideration of alveolar bone graft
Scott and White TDH/CHD Continuation Application/ 09-10
OUTCOME
2) Orthodontist recommendations 3) Tracking/monitoring
2) Follow-up/cleaning
AGE
ACTION/INTERVENTION 2) Medical record review
9-9 1/2 YEARS 10 YEARS
3) Pediatrician and dentist recommendations
1) Dental check-up 2) Medical record review
1) Dentist/hygienist 2) Clinical team coordinator
1) Follow-up/cleaning 2) Tracking/monitoring
1) Annual team visit
1) Plastic surgery, dentist, audiologist, ENT, speech pathologist, clinical team coordinator 2) Plastic surgery, ENT, dentist, OMS 3) Plastic surgery, ENT, OMS, dentist (if necessary) 4) Pediatrician, dentist/hygienist (to be scheduled by parent) 5) Clinical team coordinator
1) Establish Comprehensive Treatment Plan
1) Medical record review
1) Clinical team coordinator
1) Tracking/monitoring
1) Annual team visit
1) Plastic surgery, dentist, audiologist, ENT, speech pathologist, clinical team coordinator 2) Clinical team coordinator
1) Establish Comprehensive Treatment Plan
1) Pediatrician, dentist/hygienist (to be scheduled by parent) 2) Clinical team coordinator
1) Pediatrician and dentist recommendations
2) Medical record review 11 1/2 YEARS
2) Tracking/team recommendations
3) Primary pediatrician and dentist (to be scheduled by parent)
4) Well child check-up (medical and dental) 5) Medical record review
11 YEARS
OUTCOME
3) Medical and dental check-up
2) Surgical intervention pre-op (if necessary) 3) Post-op appointments
10 1/2 YEARS
RESPONSIBLE PERSON coordinator 2) Clinical team coordinator
1) Medical and dental check-ups 2) Medical record review
Scott and White TDH/CHD Continuation Application/ 09-10
2) Scheduled surgery 3) Schedule therapy and follow-up appointments 4) Pediatrician and dentist recommendations 5) Tracking/monitoring
2) Tracking/monitoring
2) Tracking/monitoring
AGE 12 YEARS
ACTION/INTERVENTION 1) Annual team visit
2) Medical check-up 3) Medical record review 12 1/2 YEARS
1) Dental check-up 2) Medical record review
13 YEARS
1) Annual team visit
2) Medical check-up 3) Medical record review 13 1/2 YEARS
1) Dental check-up 2) Medical record review
14 YEARS
1) Annual team visit
2) Medical check-up 3) Medical record review 14 1/2 YEARS
1) Dental check-up 2) Medical record review
RESPONSIBLE PERSON 1) Plastic surgery, dentist, audiologist, ENT, speech pathologist, clinical team coordinator 2) Pediatrician (to be scheduled by parent) 3) Clinical team coordinator
OUTCOME 1) Establish Comprehensive Treatment Plan Schedule therapy and follow-up visits, consider definitive nasal surgery
1) Dentist/hygienist(to be scheduled by parent) 2) Clinical team coordinator
1) Dentist recommendations
1) Plastic surgery, dentist, audiologist, ENT, speech pathologist, clinical team coordinator 2) Pediatrician (to be scheduled by parent) 3) Clinical team coordinator
1) Establish Comprehensive Treatment Plan/ Schedule therapy and follow-up visits
1) Dentist/hygienist (to be scheduled by parent) 2) Clinical team coordinator
1) Follow-up/cleaning
1) Plastic surgery, dentist, OMS, audiologist, ENT, speech pathologist, clinical team coordinator 2) Pediatrician (to be scheduled by parent) 3) Clinical team coordinator
1) Establish Comprehensive Treatment Plan.
1) Dentist/hygienist (to be scheduled by parent) 2) Clinical team coordinator
1) Cleaning/dentist recommendations
Scott and White TDH/CHD Continuation Application/ 09-10
2) Pediatrician recommendations 3) Tracking/monitoring
2) Tracking/monitoring
2) Pediatrician recommendations 3) Tracking/team recommendations
2) Tracking/monitoring
2) Pediatrician recommendations 3) Tracking/team recommendations
2) Tracking/monitoring
AGE 15 YEARS
ACTION/INTERVENTION 1) Annual team visit
2) Medical check-up 3) Medical record review 15 1/2 YEARS
1) Dental check-up 2) Medical record review
16 YEARS
1) Annual team visit
2) Medical check-up 3) Medical record review 16 1/2 YEARS
1) Dental check-up 2) Medical record review
17 YEARS
1) Annual team visit
2) Medical check-up 3) Medical record review 17 1/2 YEARS
1) Dental check-up 2) Medical record review
RESPONSIBLE PERSON 1) Plastic surgery, dentist, audiologist, ENT, speech pathologist, clinical team coordinator 2) Pediatrician(to be scheduled by parent) 3) Clinical team coordinator
OUTCOME 1) Establish Comprehensive Treatment Plan.
1) Dentist/hygienist (to be scheduled by parent) 2) Clinical team coordinator
1) Follow-up/cleaning
1) Plastic surgery, dentist, audiologist, ENT, speech pathologist, clinical team coordinator 2) Pediatrician/physician (to be scheduled by parent) 3) Clinical team coordinator
1) Establish Comprehensive Treatment Plan
1) Dentist/hygienist (to be scheduled by parent) 2) Clinical team coordinator
1) Cleaning/dentist recommendations
1) Plastic surgery, dentist, audiologist, ENT, speech pathologist, clinical team coordinator 2) Pediatrician/physician (to be scheduled by parent) 3) Clinical team coordinator
1) Establish Comprehensive Treatment Plan
1) Dentist/hygienist (to be scheduled by parent) 2) Clinical team coordinator
1) Follow-up/cleaning
Scott and White TDH/CHD Continuation Application/ 09-10
2) Pediatrician recommendations 3) Tracking/team recommendations
2) Tracking/monitoring
2) Physician recommendations 3) Tracking/monitoring
2) Tracking/ team recommendations
2) Physician recommendations 3) Tracking/monitoring.
2) Tracking/monitoring
AGE 18 YEARS
ACTION/INTERVENTION 1) Annual team visit
RESPONSIBLE PERSON 1) Plastic surgery, dentist, audiologist, ENT, speech pathologist, clinical team coordinator 2) Pediatrician/physician (to be scheduled by parent/patient) 3) Clinical team coordinator
OUTCOME 1) Establish Comprehensive Treatment Plan/ consider definitive orthognatic surgery
1) Dentist/hygienist (to be scheduled by parent/patient) 2) Clinical team coordinator
1) Follow-up/cleaning
1) Plastic surgery, dentist, audiologist, ENT, speech pathologist, clinical team coordinator 2) Pediatrician/ physician (to be scheduled by parent/patient) 3) Clinical team coordinator
1) Establish Comprehensive Treatment Plan
1) Dentist/hygienist (to be scheduled by parent/patient) 2) Clinical team coordinator
1) Follow-up/cleaning
1) Establish Comprehensive Treatment Plan
4) Medical record review
1) Plastic surgery, dentist, audiologist, ENT, speech pathologist, clinical team coordinator 2) Physician (to be scheduled by parent/patient) 3) Dentist/hygienist (to be scheduled by parent/patient) 4) Clinical team coordinator
1) Dental check-up
1) Dentist/hygienist (to be
1) Follow-up/cleaning
2) Medical check-up 3) Medical record review 18 1/2 YEARS
1) Dental check-up 2) Medical record review
19 YEARS
1) Annual team visit
2) Medical check-up 4) Medical record review 19 1/2 YEARS
1) Dental check-up 2) Medical record review
20 YEARS
1) Annual team visit
2) Medical check-up 3) Dental check-up
20 1/2
Scott and White TDH/CHD Continuation Application/ 09-10
2) Physician recommendations 3) Tracking/team recommendations
2) Tracking/monitoring
2) Physician recommendations 3) Tracking/monitoring
2) Tracking/monitoring
2) Physician recommendations 3) Cleaning /dentist recommendations 4) Tracking/ team recommendations
AGE YEARS
ACTION/INTERVENTION 2) Medical record review/ transition begins
21 YEARS
1) Final team visit/transition
RESPONSIBLE PERSON scheduled by parent) 2) Clinical team coordinator 1) Plastic surgery, dentist, audiologist, ENT, speech pathologist, clinical team coordinator
OUTCOME 2) Tracking/transitioning 1) Establish transition services /Dismiss from team and refer to appropriate adult services
* OMS=Osteodistraction techniques to intercept facial growth disturbances at an earlier age Last updated 07/16/2009 by: Clinical team coordinator
Scott and White TDH/CHD Continuation Application/ 09-10
