I have - Care Coordination



Nursing Home/Intermediate Care Facility Member Health Risk Assessment/Care Plan ReviewMember InformationName: FORMTEXT ?????Health Plan ID Number: FORMTEXT ?????Product Name: FORMDROPDOWN Assessment Date: FORMTEXT ?????Facility Name: FORMTEXT ?????DOB: FORMTEXT ?????Facility Admission Date: FORMTEXT ?????Facility Address: FORMTEXT ?????Phone #: FORMTEXT ?????Primary Diagnosis: FORMTEXT ?????Assessment Type: FORMCHECKBOX Initial Health Risk Assessment FORMCHECKBOX Annual Reassessment FORMCHECKBOX Significant Change FORMCHECKBOX Other FORMTEXT ?????*See section V. for semi-annual contact**See section VI. for Product Change*Is there an Advance Directive or Health Care Directive in place? FORMCHECKBOX Yes FORMCHECKBOX NoWas Advance Directive/Health Care Directive discussed: FORMCHECKBOX Yes FORMCHECKBOX NoIf no, reason: FORMTEXT ?????Check all that apply: FORMCHECKBOX Do not resuscitate (DNR) FORMCHECKBOX Do not intubate (DNI) FORMCHECKBOX Do not hospitalize (DNH) FORMCHECKBOX No IVs FORMCHECKBOX No tube feedings FORMCHECKBOX No antibiotics FORMCHECKBOX Comfort Care Only FORMCHECKBOX No hospice FORMCHECKBOX CPR FORMCHECKBOX POLST/Physician Orders for Life Sustaining TreatmentComments: FORMTEXT ????? Member’s Care Team (Interdisciplinary Care Team-ICT)Care Coordinator Name: FORMTEXT ?????Phone #: FORMTEXT ?????Primary Physician: FORMTEXT ?????Phone #: FORMTEXT ?????Fax #: FORMTEXT ?????Clinic: FORMTEXT ?????Legal Guardian/POA: FORMTEXT ?????Legal Guardian/POA Address/Phone: FORMTEXT ????? ?????Authorized Rep (if different): FORMTEXT ?????Authorized Rep Address/Phone: FORMTEXT ?????DD Case Manager (for those residing in ICF): Name: FORMTEXT ????? Phone: FORMTEXT ?????If applicable, contact made with DD CM. Date: FORMTEXT ?????Ask member (if appropriate): Is there anyone else that you’d like to receive a copy of the 8.35 Nursing Home-ICF Visit Summary letter? FORMCHECKBOX Yes FORMCHECKBOX No If yes- name, address and relationship status? FORMTEXT ?????Comments: FORMTEXT ?????Facility Chart ReviewCare Transitions (Hospital/ER Visits in the last 6 months) *Reminder- see Care Coordinator Guidelines for TOC responsibilities*Hospital/ER: FORMTEXT ????? Dates: FORMTEXT ?????Comments: FORMTEXT ????? FORMCHECKBOX Reviewed list of medicationsComments: FORMTEXT ?????Immunization Review *9.03 Immunization Guidelines available on the Care Coordination website*Vaccination/Immunization Is Member up to Date NotesFlu FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMTEXT ?????Pneumococcal FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMTEXT ?????TDAP FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMTEXT ?????Zostavax (Shingles) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMTEXT ????? FORMTEXT <other> FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMTEXT ????? FORMTEXT <other> FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMTEXT ?????Comments: FORMTEXT ?????Nutritional Assessment:Height FORMTEXT ????? Weight FORMTEXT ????? FORMCHECKBOX I have reviewed the current nutritional assessment Comments/Recommendations: FORMTEXT ?????Minimum Data Set (MDS)Date of MDS: FORMTEXT ????? Cognitive Status: FORMTEXT ????? Mood Status: FORMTEXT ?????Comments: FORMTEXT ?????Annual Physician/Provider visit for primary and preventive careDate: FORMTEXT ?????Comments: FORMTEXT ?????Facility’s Plan of Care: FORMCHECKBOX I have reviewed the facility Plan of Care and GoalsComments: FORMTEXT ?????Confirm that the Facilitiy Care Plan addresses each of the following items below. If the Care Plan does not address any of the items below, describe in the Comments below: FORMCHECKBOX Multidisciplinary FORMCHECKBOX Dental visits FORMCHECKBOX Vision Evaluation FORMCHECKBOX Fall risk FORMCHECKBOX Depression screening FORMCHECKBOX Member/Family Participation FORMCHECKBOX Skin Integrity FORMCHECKBOX Hearing Exam FORMCHECKBOX Socialization needs FORMCHECKBOX Nutrition FORMCHECKBOX Tobacco/Alcohol Use FORMCHECKBOX Mental Health status FORMCHECKBOX Holistic FORMCHECKBOX Preventive in focus FORMCHECKBOX Other: FORMTEXT ?????Comments: FORMTEXT ?????I have recommended the following modifications to the facility Plan of Care:DateRecommendationOutcome FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Comments: FORMTEXT ????? FORMCHECKBOX I have asked to be invited to the member’s care conferences. FORMCHECKBOX I have attended OR reviewed the most recent care conference notes. Care Conference Date: FORMTEXT ?????Comments: FORMTEXT ?????Ancillary Care Providers seen in the last year as appropriate: Provider Check if Referral NeededCommentsPodiatry FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX FORMTEXT ?????Psychiatry FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX FORMTEXT ?????Dental FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX FORMTEXT ?????Vision FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX FORMTEXT ?????Hearing FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX FORMTEXT ????? FORMTEXT <other> FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX FORMTEXT ????? FORMTEXT <other> FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX FORMTEXT ?????Member/Responsible Party Interview What are the most important things to you? (For instance, being social, music, family, having choices, etc.) FORMTEXT <member/responsible party response>What activities or things do you enjoy doing? FORMTEXT <member/responsible party response>2a. Is anything needed to support or help you do these activities? FORMTEXT <member/responsible party response>Do you like where you live? FORMCHECKBOX Yes FORMCHECKBOX No **If no, what would you change? FORMTEXT <member/responsible party response>Would you like to live elsewhere? FORMCHECKBOX Yes FORMCHECKBOX NoComments: FORMTEXT ????? FORMCHECKBOX I have assessed this member’s desires and/or ability to relocate back to the community or another facility. Date Assessed: FORMTEXT ????? FORMCHECKBOX If appropriate, Home and Community Based Services (HCBS) options were ments: FORMTEXT ?????Care Coordinator Tasks FORMCHECKBOX Met with member, explanation of Care Coordinator role, addressed member concerns (if any). Comments: FORMTEXT ????? FORMCHECKBOX Contact made with family or responsible party, as applicable. Date: FORMTEXT ?????Comments: FORMTEXT ????? FORMCHECKBOX Discussion of member’s status with facility staffComments: FORMTEXT ????? FORMCHECKBOX Discussed MSHO Supplemental Benefits with MSHO members. *Resources available on the Care Coordination portal*Comments: FORMTEXT ????? FORMCHECKBOX Discussed SecureBlue MSHO enrollment (MSC+ members only)Comments: FORMTEXT ?????Additional Comments: FORMTEXT ?????Care Coordinator Signature (required)Care Coordinator: FORMTEXT ?????Organization: FORMTEXT ?????Date: FORMTEXT ?????Semi Annual Contact: Date FORMTEXT ????? FORMCHECKBOX Contact with member, addressed member concerns (if any). Comments: FORMTEXT ????? FORMCHECKBOX Contact made with family or responsible party, as applicable. Date: FORMTEXT ?????Comments: FORMTEXT ????? FORMCHECKBOX I have discussed any recent acute episodes or hospitalizations Comments: FORMTEXT ????? FORMCHECKBOX I have discussed any significant changes in condition or level of care Comments: FORMTEXT ????? FORMCHECKBOX I have assessed this member’s desires and/or ability to relocate back to the community or another facility. Date Assessed: FORMTEXT ????? FORMCHECKBOX If appropriate, Home and Community Based Services (HCBS) options were ments: FORMTEXT ?????Are there any unmet needs/care concerns to follow up on? FORMCHECKBOX Yes FORMCHECKBOX NoAdditional Comments: FORMTEXT ?????Semi Annual Contact Care Coordinator Signature (required)Care Coordinator: FORMTEXT ?????Organization: FORMTEXT ?????Date: FORMTEXT ?????6.28.01 Nursing Home/Intermediate Care Facility Transitional Health Risk Assessment for Product ChangeThis section of the form is to be used only when a member changes Blue Plus Products (MSC+ to MSHO or MSHO to MSC+). Complete the section below and review the entire 6.15 Nursing Home/Intermediate Care Facility Member Health Risk Assessment/Care Plan Review form for any updates. This must be completed within the required assessment time frames for “new enrollees”. The next annual assessment is due 365 days from the last full assessment date. All member/authorized rep/physician letter requirements must be completed for product changes (see Nursing Home/Intermediate Care Facility Product Change section of the Nursing Home/Intermediate Care Facility Care Coordination Guidelines for complete details). New Product: FORMDROPDOWN New Product Enrollment Date: FORMTEXT ????? FORMCHECKBOX Reviewed current 6.15 Nursing Home/Intermediate Care Facility Member Health Risk Assessment/Care Plan Review including facility chart as needed. Date: FORMTEXT ????? FORMCHECKBOX Reviewed status changes with facility staff as needed. FORMCHECKBOX Met with member or contact made with family or responsible party. Date: FORMTEXT ?????Comments: FORMTEXT ????? FORMCHECKBOX Reviewed MSHO Supplemental Benefits with member or responsible party (as applicable) FORMCHECKBOX Contact made with DD Case Manager (for those residing in ICF), if applicable.Additional Comments: FORMTEXT ?????Product Change Transitional HRA Care Coordinator Signature (required)Care Coordinator: FORMTEXT ?????Organization: FORMTEXT ?????Date: FORMTEXT ????? ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download