Care Coordination – Blue Cross and Blue Shield of Minnesota



left000 Blue Plus Open Arms Member Referral Form2500 Bloomington Ave, Minneapolis, MN 55404 Phone (612) 767-7333 || Fax (612) 872-0866SECTION 1: Benefit InformationOpen Arms of Minnesota provides the two benefits listed below for SecureBlue (MSHO) members. Please select the best option for the member you are submitting the referral for. ? OPTION 1 - CHRONIC CONDITION BENEFIT: Open Arms provides home-delivered meals and nutrition education to members diagnosed with one or more qualifying chronic conditions. This program is designed to support members in making sustained dietary changes to better manage their health. Eligible clients will receive a weekly delivery consisting of 14 medically tailored meals, including frozen entrees with vegetable sides, frozen soups, bread, fruit, dessert and a variety of snack items. Milk and cereal are available upon request. For chronic condition members, please provide the information below: Requested Chronic Condition Meal Start Date: Requested Meal Plan (see options on page 2): ? OPTION 2 - POST-DISCHARGE BENEFIT: Open Arms provides nutrition education to all SecureBlue (MSHO) members discharged to home from an inpatient or short-term nursing home stay who are participating in the Medically Tailored Meals Program.NOTE: To set up post-discharge meal delivery service please complete the Mom’s Meals referral form and provide the information below: Post Discharge Member InformationAdmission Diagnosis:Other Diagnosis:Post Discharge Meal Start Date (Mom’s Meals):? OPTION 3 – BOTH: If a member wishes to enroll in both programs, complete the entire form. The requested chronic condition start date should be 4 weeks after the confirmed start date for Mom’s Meals.SECTION 2: Member Information MEMBER INFOMember Name:Member ID #:Address:Apt:City:Zipcode:County:DOB: Member email:Member Phone 1:Member Phone 2:Is an interpreter needed for this member? ? N ? YIf yes, language needed: MEMBER DEMOGRAPHICSThe following information is collected for funding purposes.Gender: ? M ? F ? Transgender M to F ? Transgender F to M ? Gender UnknownRace: ? American Indian/Alaska Native ? Asian (? Asian Indian ? Chinese ? Filipino ? Japanese ? Korean ? Vietnamese ? Other Asian) ? Black ? Native Hawaiian/Pacific Islander (? Native Hawaiian ? Guamanian/Chamorro ? Samoan ? Other Pacific Islander) ? WhiteEthnicity: ? Hispanic (? Mexican ? Puerto Rican ? Cuban ? Other Hispanic) ? Non-HispanicMEDICALINFOSpecial dietary needs or allergies: Height (in): Weight (lbs):MEAL DELIVERY Chronic Condition Diagnosis? Cancer? Chronic Obstructive Pulmonary Disease (COPD) ? Congestive Heart Failure (CHF) ? Coronary Artery Disease (CAD)? Diabetes ? End-stage Renal Disease (ESRD)? HIV/AIDS? Peripheral Vascular Disease ? Rheumatoid Arthritis ? Stroke ? Other: ________________ Partner Relations Approval: ___________MEAL DELIVERYMeal Plan Options for Chronic Condition MembersFOR CHRONIC CONDITION MEMBERS ONLY: Members may choose one meal plan at a time. They have the option to switch meal plans while on service depending on preferences and dietary needs. Note: The Open Arms kitchen is not an allergen-free facility.Standard Heart Healthy – Regular, heart healthy diet. Includes a variety of foods low in salt and saturated fat that support good health for a range of needsRenal - Low in potassium, phosphorus, and sodium for clients on hemodialysisFlavor Neutral/Soft - Fork-mashable foods that are low in spice, acid, and sodiumVegetarian - For those who do not eat meat, poultry, or fish. May contain dairy or eggsPureed - Any menu can be blended to textures consistent with a pureed diet (only applies to frozen entrees; other items can be eliminated entirely if needed).Care Coordinator: Agency: Phone: Email:Care Coordinators should send this completed form via secure email (referrals@) or fax: 612-872-0866Open Arms is an independent non-profit (501c3) providing home-delivered medically-tailored meals and nutrition services ................
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