Connect HRA Expansion Counties - BlueCrossMN



My Supplemental ICF/DD and HCBS Waiver Health Risk Assessment & Care Plan Date Assessment and Care Plan Reviewed: FORMTEXT ?????(The next annual re-assessment is due within 365 days from this date.)Completion of this form, as described, will meet requirements for a Health Risk Assessment (HRA) and a supplement to the existing care plan for MSHO/SecureBlue & MSC+ Blue Advantage members who have had an LTCC/MnCHOICES or DD assessment within the past 365 days. This form is to be attached to the most recent assessment and care plan. Blue Plus enrollment date: FORMTEXT ????? Product: Choose an item. 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 ?????This Health Risk Assessment was completed: FORMCHECKBOX In person (02) FORMCHECKBOX By phone (01)*Fields with asterisks are required for MMIS entry *Last Name:* First Name:M.I.:Click here to enter text.Click here to enter text. FORMTEXT Click here to enter text.*Birth Date:*PMI NumberBlue Plus ID Number:Click here to enter text.Click here to enter text.Click here to enter text.Address:Phone number:Referral date:Click here to enter text.Click here to enter text.Click here to enter text.*Care Coordinator Name:*Care Coordinator NPI/UMPICare Coordinator Phone:Click here to enter text.Click here to enter text.Click here to enter text.Other CM Name: Other CM Agency:Other CM Phone: Click here to enter text.Click here to enter text.Click here to enter text.Other CM Fax:Other CM Email:Other Assessment Date: Click here to enter text.Click here to enter text.Click here to enter text.Primary Spoken Language:*LTCC CTY:Click here to enter text.BPH*Activity Type Date (Assessment Date)*Activity Type Click here to enter a date.02 Face to Face Assess (P)*COS*COR*CFRChoose an item.Choose an item.Choose an item.*Legal Rep Status – Adult (age 18 or older)Legal Rep Name:Legal Rep Contact Info:Choose an item.Click here to enter text.Click here to enter text.*Primary Diagnosis Name: Click here to enter text.*Dx Code: Click here to enter text. *Secondary Diagnosis Name:Click here to enter text.*Dx Code: Click here to enter text. *Is there a history of a DD Dx? ?Y ?N If so, what is the dx? Click here to enter text.*Is there a history of a MI Dx? ?Y ?N If so, what is the dx? Click here to enter text.*Is there a history of a BI Dx? ?Y ?N If so, what is the dx? Click here to enter text.*Who was present at HRA? (more than one can be selected)? 01 – Client ? 02 – Family ? 03 - LTCC consultant ? 04 - Social worker ? 05 - Public health nurse ? 06 - Hospital discharge planner ? 07 - Qualified mental retardation professional ? 08 - Qualified mental health professional ? 09 - NF staff ? 10 - Primary physician ? 11 - Home care or community based service provider ? 12 – Advocate ? 13 - Conservator/Guardian ? 14 - Consulting physician ? 15 - ICF/MR staff ?16 - Services for children with handicaps ? 17 - Case manager ?18 - Legal counsel ? 19 - Health plan coordinator ? 20 – Ombudsman ? 21 – RRS ? 22 - Interpreter, English ? 23 - Interpreter, ASL ? 98 – Other, please specify: Click here to enter text.Screening & Assessment Information 1. *Reasons for Referral:2. Current Living Situation:3. *Current Housing Type:Choose an item.Choose an item.Choose an item.4. *Assessment Team5. Is member on a waiver? ? Yes ? NoChoose an item.If so, what type? Choose an item.6.*Dressing7. *GroomingChoose an item.Choose an item.8. *Bathing9. *EatingChoose an item.Choose an item.10. *Bed Mobility11. *TransferringChoose an item.Choose an item.12. *Walking13. *BehaviorChoose an item.Choose an item.14. *Toileting 14A *The person needs constant supervision and/or assistance of another to begin and complete toileting. Choose an item.?Yes ?No 15. *Special Treatment 16. * Clinical MonitoringChoose an item. Choose an item.17. *Neuromuscular Diagnosis18. *Case Mix? Yes ? NoClick here to enter text.19. *Orientation20. *Self-PreserveChoose an item.Choose an item.21. *Disability Certification Source22. *Self-EvaluationChoose an item.Choose an item.23. *Hearing24. *CommunicationChoose an item.Choose an item.25. * Vision26. * Mental Status Eval Score (from assmt below)Choose an item.Choose an item.27. *Telephone Answer28. *Telephone Call Choose an item.Choose an item.29. * Shopping (food, other)30. *Meal Preparation/Clean UpChoose an item.Choose an item.31. * Light Housekeeping/Cleaning (dusting/sweeping)32. * Heavy Housekeeping (yard work, empty garbage)Choose an item.Choose an item.33. * Laundry (in/out; run washer/dryer)34. * Medication ManagementChoose an item.Choose an item.35. * Insulin Dependent36. * Money ManagementChoose an item.Choose an item.37. * Transportation38. * Have you experienced any Falls in your home or while out in the community?Choose an item. Choose an item. 39. *Number of Hospitalizations in last year: Click here to enter text.Please describe: Click here to enter text.40. *Number of ER Visits in last year: Click here to enter text.Please describe: Click here to enter text.41. *Number of NF Stays in last 3 years: Click here to enter text.Please describe: Click here to enter text.42. *Vent Dependent: Choose an item.43. *Assessment Results and Exit ReasonsChoose an item.44. *Program Type45. *Effective Date (Assessment Date)Choose an item.Click here to enter a date.** Please detach the remaining pages and send them to the member – pages 1-4 are to be used for Type H LTC Screening Doc entry***Information About Me Name: Click here to enter text.My Health Plan ID Number: Click here to enter text.My Health Plan Name: Choose an item. Today’s Date:Click here to enter text.My Address: Click here to enter text. My Health SummaryPrimary Care Clinic:Click here to enter text. Primary Care Provider:Click here to enter text.Fax Number:Click here to enter text.Phone number:Click here to enter text.DentalDo you have a dentist? ? Yes ? No Do you have any dental concerns? ? Yes ? No If yes, please specify: Click here to enter text.Pain ScreeningAre you experiencing any pain now or in the last two weeks? ? Yes ? NoIf yes, has your pain affected your function or quality of life (e.g.: Activity level, mood, relationships, sleep or work)? ? Yes ? NoHow often do you experience pain? ? Constantly ? Daily ? Once a Week ? Not OftenAt its worst, how severe is your pain (1-10, with 10 being the worst)? Click here to enter text.Have you talked to your doctor or someone else about the cause of your pain? ? Yes ? NoIf yes, please specify who and when Click here to enter text.Pain Management Plan: Click here to enter text.Preventative CareAnnual Preventative Visit: ? Yes ? No ? Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.Dental Exam: ? Yes ? No ? Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.Immunizations/Vaccines Influenza: ? Yes ? No ? Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.Pneumovac: ? Yes ? No ? Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.Tetanus: ? Yes ? No ? Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.Click here to enter text.Advanced DirectivesDo you have any of the following in place? (Check all that apply)? Advanced Directives ? Living Will? Durable Power of Attorney for Health Care? Durable Power of Attorney for Financial~Advance Directive discussion with member completed? ? Yes ? NoIf no, explain why not? Click here to enter text.?????Additional Comments: Click here to enter text.?Review the entire attached assessment for completeness. Record any significant changes since the member’s last assessment here: FORMTEXT ????? My Health Goals (required) Include at least one health related goal. Rank by Priority My GoalsSupport NeededTarget DateMonitoring Progress/Goal Revision dateDate Goal Achieved/ Not Achieved(Month/Year) FORMCHECKBOX Low FORMCHECKBOX Medium FORMCHECKBOX High FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Low FORMCHECKBOX Medium FORMCHECKBOX High FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Signature and title of person completing this form: FORMTEXT ?????Date: FORMTEXT ?????Copy of this form sent to other Case Manager (if different than the Care Coordinator)Date: FORMTEXT ?????Copy of this form or Care Plan Summary mailed/given to PCP (Verbal, phone, fax)Date: FORMTEXT ?????Copy of this form mailed/given to meDate: FORMTEXT ????? ................
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