Carecoordination.bluecrossmn.com



left0Blue Plus Open Arms Client Referral Form2500 Bloomington Ave, Minneapolis, MN 55404 Phone (612) 767-7333 || Fax (612) 872-0866Open Arms of Minnesota provides home-delivered meals and nutrition education to SecureBlue (MSHO) members diagnosed with one or more qualifying chronic conditions. This program is designed to support MSHO members in making sustained dietary changes to better manage their health. ? Check here for member to receive Medically Tailored Meals and indicate which meal plan the member would like to receive on the next page.Eligible clients will receive a weekly delivery consisting of 14 Medically-Tailored Meals. Deliveries typically include: 5 frozen entrees with vegetable sides, 2 frozen soups, green and deli salads, sandwich, bread, fresh fruit, dessert and snack items. Milk and cereal are available upon request. Open Arms of Minnesota provides nutrition education to all SecureBlue (MSHO) members participating in the Medically-Tailored Meals Program. ? Check here for member to receive nutrition education only for MSHO members discharged to home from an inpatient or short-term nursing home stay. NOTE:To set up post-discharge meal delivery service please complete the Mom’s Meals referral form.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-HispanicCare Coordinators should send this completed form via secure email (referrals@) or fax: 612-872-0866MEDICALINFOSpecial dietary needs or allergies: Height (in): Weight (lbs):Nutrition EducationAdmission Diagnosis:Other Diagnosis:Post Discharge Meal Start Date: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 Meal DeliveryMEAL PLANS OPTIONSMembers may choose one menu at a time. Members have the option to switch menus depending on preferences and dietary needs. Note: OAM kitchen is not an allergen-free facility.? Heart Healthy - On this menu, our chefs use a variety of spices & seasonings for flavor instead of salt. It consists of foods that are rich in vitamins, minerals, antioxidants and fiber that support heart health. Omits high-sodium foods, pork, and red meat.? ?Renal - An option for those with ESRD who are on hemodialysis. Meals are low in potassium, phosphorus, and sodium, as well as high in protein. ?Flavor Neutral/Soft - Designed for those experiencing taste changes and issues with chewing & swallowing as a result of medications and treatment. Low in spice, sodium, and acid with a fork-mashable texture. ?Gluten-Free/Dairy-Free - Designed for people who cannot consume gluten or dairy. ?Vegan - This menu is free of all animal products, designed for vegetarians and vegans. ?Variety - Great for those interested in trying foods from all our menus. ?Latino Style - Meals inspired by the foods of Mexico, South America, Central America, and the Caribbean. ?Meat & Potatoes - Consists of traditional American comfort foods. ??Modified-Texture - Any menu can be blended to textures consistent with a pureed or mechanically altered diet (only applies to frozen entrees; brown bag items can be eliminated entirely if needed) ?Requested Meal Start Date: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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