Care Plan



|[pic] |Public Health Division |[pic] |

| |HIV/STD/TB Program | |

| |HIV Community Services | |

| |Care Plan | |

| |"Confidential ( this form must always be saved on a secure network accessible only by Ryan White | |

| |funded staff." | |

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|Client name: |      | |Care plan date: |   /    /      |

|Problem/primary barriers (check all that apply) |

| Health insurance/ | Transportation | Self sufficiency | Nutrition |

|medical coverage |No personal transportation |Burned bridges |Wasting syndrome |

|No insurance/medical coverage |Unable to pay for |Communication issues |Problems with nutrition |

|Disability determination |personal transportation |Difficulty w/follow-through |Severe problems eating |

|Lack of eligibility documents |Mental health |Unable to fill out own forms |Adherence |

|Housing |Depression |Needs financial assistance |Lacks a regular schedule |

|Housing in jeopardy |Social/emotional support |Medical needs |Medication side effects |

|Homeless |Discrimination |Poor health |Doubts med. effectiveness |

|Basic needs |Willing to get help, |Needs HIV care referral |Complex regimen |

|Lack food |none available |Needs treatment for |Knowledge of HIV disease |

|Difficulty accessing assistance |Unwilling to get help |non-HIV condition |Little understanding |

|Lack of household/ |Addictions |Medical emergency |No understanding |

|personal items |Willing to get help, |Oral health |Other |

|Work related issues |none available |No regular dentist |Care giving responsibilities |

|Home support/activities |Unwilling to get help |Current tooth/gum pain |Child care/child welfare |

|of daily living |Risk reduction |Difficulty eating/talking | |

|Language |High risk behaviors | | |

|Legal |No understanding of risks | | |

| |Undisclosed HIV status | | |

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|Prioritized issues/problem descriptions |

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|Tasks/description |Owner |Target date |Completion date/outcome |

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(Optional) client signature may be obtained based on the discretion of the case manager. Case manager signature is required.

Client’s responsibility/agreement: I have participated in the creation of this plan for my care. I understand that I have to take responsibility for MY plan in order for the plan to succeed. My case manager/health advocate has explained to me what portions of the plan I am solely responsible for and those that my case manager/health advocate will assist me with. I agree to follow all aspects of this plan and advise my case manager/health advocate if there are significant changes in my life that make it necessary to change this plan. I agree to stay in contact with may case manager/health advocate as planned. My case manager/health advocate has discussed with me the consequences if I don’t keep this agreement.

|Client signature | |Date |   /    /      |

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|Case manager signature | |Date |   /    /      |

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