BlueCrossMN



My Care Plan and Community Support PlanInformation about Me Name: FORMTEXT ????My Health Plan ID Number: FORMTEXT ?????My Health Plan Name: FORMTEXT ?????Today’s Date: FORMTEXT ?????Phone #: FORMTEXT ?????My DOB: FORMTEXT ?????Product Enrollment Date: FORMTEXT ?????My Address: FORMTEXT ?????Rate Cell: FORMTEXT ?????Diagnosis: FORMTEXT ?????Date of My Assessment Visit: FORMTEXT ?????Assessment Type: FORMCHECKBOX Initial Health Risk Assessment FORMCHECKBOX Annual Reassessment FORMCHECKBOX Change in My Needs FORMCHECKBOX Other FORMTEXT ?????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 ?????My primary language is: FORMCHECKBOX English FORMCHECKBOX Hmong FORMCHECKBOX Spanish FORMCHECKBOX Somali FORMCHECKBOX Vietnamese FORMCHECKBOX Russian FORMCHECKBOX Other (Type in the “other” language) FORMTEXT ?????I need an interpreter: FORMCHECKBOX Yes FORMCHECKBOX NoName and number of Interpreter (If applicable): FORMTEXT ?????My Care Team (Interdisciplinary Care Team-ICT)Care Coordinator/Case Manager:Name: FORMTEXT ?????Phone #: FORMTEXT ?????Primary Physician: FORMTEXT ?????Phone #: FORMTEXT ?????Fax #: FORMTEXT ?????Clinic: FORMTEXT ?????Emergency Contact Name & Phone: FORMTEXT ?????My Representative is: FORMTEXT ?????They can be contacted for: FORMTEXT ????? ?????I have a Mental Health Targeted Case Manager: FORMCHECKBOX Yes FORMCHECKBOX NoName of MHTCM: FORMTEXT ????? Phone Number of MHTCM: FORMTEXT ?????Other Care Team Members NameRelationship to meGive Copy of Care plan?Date sent FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????What’s Important to Me? (e.g. living close to my family, visiting friends)Initial/Annual: FORMTEXT ????Update: FORMTEXT ?????My Strengths: (e.g. skills, talents, interests, information about me)Initial/Annual: FORMTEXT ?????Update: FORMTEXT ?????My Supports and Services: (What do I want help with? Service and support I requested? From whom? Initial/Annual: FORMTEXT ?????Update: FORMTEXT ?????Caregiver:Informal Caregiver listed on HRA/LTCC: (Caregivers are unpaid person(s) providing services) FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, the Caregiver Assessment Form was completed by: FORMCHECKBOX Face-to-Face FORMCHECKBOX Telephone FORMCHECKBOX Mail FORMCHECKBOX Declined Date Completed: FORMTEXT ?????Managing and Improving My Health Screening for my healthCheck if educational conversation took place with meGoal is neededCheck if N/A, contraindicated, declinedNotesAnnual Preventive Health Exam FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Mammogram (Within past 2 years ages 65-75) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Continence needs (Evaluated by a physician?) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Colorectal Screening(Up to age 75) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????At Risk for Falls (Afraid of falling, has fallen in the past). FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Pneumovax (Immunize at age 65 if not done previously. Re-immunize once if 1st pneumovax was received more than 5 years ago & before age 65) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Flu shot (Annually ages 50+ and persons at high risk.) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Tetanus Booster (Once every 10 years) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Hearing Exam FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Vision Exam FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Dental Exam FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Calcium Vitamin DRx for Ca Vitamin D?(as directed by physician) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????AspirinRx for Aspirin?(as directed by physician) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Blood Pressure:(Blood Pressure Goal is <140/80 to age 75. After 75 based on individual) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Cholesterol check FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Diabetic routine checks as recommended by physician (Discuss with my care team: Hypertension, Neuropathy, Eye exam, Cholesterol, A1C) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Other: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Mental Health Diagnosis (If applicable): FORMTEXT ????? FORMCHECKBOX N/AManaged by a Health Professional? FORMCHECKBOX Yes FORMCHECKBOX No(Psychiatrist, Psychologist, Primary Care Physician)Need Goal? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX DeclinedMy MedicationsI need help with my medications? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A (no medications used)If yes, create a goalList of Medications (If not on LTCC) FORMTEXT ?????Health Improvement Referral FORMCHECKBOX Yes FORMCHECKBOX Declined FORMCHECKBOX N/A Diagnosis: FORMTEXT ?????Hospitalizations (In past year number and reason, date(s) if available) FORMTEXT ?????ER visits (In past year number and reason for visit; dates, if available) FORMTEXT ?????My Goals Discuss with Care Coordinator, goals for: my everyday life (taking care of myself or my home); my relationships and community connections; my future plans, my health, my safety; my choices. Rank by Priority My Goals Support(s) 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 ????? FORMCHECKBOX Low FORMCHECKBOX Medium FORMCHECKBOX High FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Low FORMCHECKBOX Medium FORMCHECKBOX High FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Low FORMCHECKBOX Medium FORMCHECKBOX High FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Low FORMCHECKBOX Medium FORMCHECKBOX High FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Low FORMCHECKBOX Medium FORMCHECKBOX High FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Additional updates/notes about my goals: FORMTEXT ?????Barriers to meeting my goalsInitial/Annual: FORMTEXT ?????Update: FORMTEXT ????? FORMCHECKBOX No barriers identified My follow up plan:Care Coordinator/Case Manager follow-up will occur: FORMCHECKBOX Once a month FORMCHECKBOX Every 3 months FORMCHECKBOX Every 6 months FORMCHECKBOX Other FORMTEXT ?????Purpose of Care Coordinator contact: FORMTEXT ?????I can contact my Care Coordinator to help me with my medical, social or everyday needs. I should contact my Care Coordinator when: Changes happen with my healthI have a scheduled procedure or surgery or I am hospitalized I have experienced falls in my home or communityI can no longer do some things that I had been able to do by myself (such as meal preparation, bathing, bill paying)If I need additional community services such as: equipment for bathroom safety or home safety; assistance with finding a new living situation (senior apartment); information about topics such as staying healthy, preventing falls, and immunizations.I need help finding a specialistI need help learning about my medicationsI would like information to help myself and my family make health care decisionsI would like changes to my care plan or my services and supports I would like to talk about other service options that can meet my needsI am dissatisfied with one or more of my providers My Safety PlanMy safety concerns were discussed with my Care Coordinator: FORMCHECKBOX Yes Notes about safety concerns: FORMTEXT ????? My plan for managing risks that I have discussed with my Care Coordinator is: FORMTEXT ?????Emergency Plan:In the event of an emergency, I will (check all that apply): FORMCHECKBOX Call 911 FORMCHECKBOX Use Emergency Response Monitoring System FORMCHECKBOX Call Emergency Contact FORMCHECKBOX Call Other Person Name: FORMTEXT ????? Phone: FORMTEXT ????? FORMCHECKBOX Other (describe) FORMTEXT ????? Self Preservation/Evacuation Plan:If I am unable to evacuate on my own in an emergency, my plan is to: FORMTEXT ?????If other concerns or plans, describe: FORMTEXT ?????Essential Services Backup Plan: (when providers of essential services are unavailable; essential services are services that if not received, health and safety would be at risk)I am receiving essential services FORMCHECKBOX Yes FORMCHECKBOX NoEssential services I am receiving: FORMTEXT ?????If Yes, describe provider’s backup plan, as agreed to by me: FORMTEXT ?????Community-Wide Disaster Plan:In the event of a community-wide disaster, (e.g., flood, tornado, blizzard), I will (describe plan): FORMTEXT ?????Additional Case Notes: FORMTEXT ?????Choosing Community Long Term Care FORMCHECKBOX Yes FORMCHECKBOX No I have been offered a choice between receiving services in the community or in the Nursing Home. FORMCHECKBOX Yes FORMCHECKBOX No I have been given a choice of different types of services that can meet my needs, as seen on my plan. FORMCHECKBOX Yes FORMCHECKBOX No I have been offered a choice of providers from available providers. FORMCHECKBOX Yes FORMCHECKBOX No I have annually received my appeal rights. FORMCHECKBOX Yes FORMCHECKBOX No I am aware that healthcare information about me will be kept private. (Data Privacy rights) FORMCHECKBOX Yes FORMCHECKBOX No I have discussed my plan of care with my Care Coordinator/Case Manager and have chosen the services I want. FORMCHECKBOX Yes FORMCHECKBOX No I agree with the plan of care as discussed with my Care Coordinator/Case Manager. FORMCHECKBOX I CHOOSE TO SHARE CARE PLAN INFORMATION WITH THE FOLLOWING HOME AND COMMUNITY BASED SERVICES (HCBS) PROVIDERS (EW/HSS) Provider 1 FORMTEXT ????? FORMCHECKBOX Complete Care Plan FORMCHECKBOX Care Plan Summary Letter FORMCHECKBOX None Provider 2 FORMTEXT ????? FORMCHECKBOX Complete Care Plan FORMCHECKBOX Care Plan Summary Letter FORMCHECKBOX None Provider 3 FORMTEXT ????? FORMCHECKBOX Complete Care Plan FORMCHECKBOX Care Plan Summary Letter FORMCHECKBOX None Provider 4 FORMTEXT ????? FORMCHECKBOX Complete Care Plan FORMCHECKBOX Care Plan Summary Letter FORMCHECKBOX None Provider 5 FORMTEXT ????? FORMCHECKBOX Complete Care Plan FORMCHECKBOX Care Plan Summary Letter FORMCHECKBOX None(NOTE: Not an option for HSS) FORMCHECKBOX I CHOOSE NOT TO SHARE MY CARE PLAN WITH ANY EW SERVICE PROVIDERS MY/MY REPRESENTATIVE SIGNATURE: FORMTEXT ?????DATE: FORMTEXT ?????CARE COORDINATOR/CASE MANAGER SIGNATURE: FORMTEXT ?????DATE: FORMTEXT ?????CARE PLAN MAILED/GIVEN TO ME ON:DATE: FORMTEXT ?????CARE PLAN OR SUMMARY MAILED/GIVEN TO MY DOCTOR (verbal, phone, fax, EMR): FORMTEXT ?????DATE: FORMTEXT ?????Name: FORMTEXT ????? Health Plan I.D.Number: FORMTEXT ?????HOME AND COMMUNITY BASED SERVICE AND SUPPORT PLAN/BUDGET WORKSHEETServices offered, if appropriate. Mark “X” if service was offered. If member accepts, fill in applicable sections below for each formal or informal provider. FORMCHECKBOX Adult Day Care Bath FORMCHECKBOX Help w/ MA, Finances, other paperwork FORMCHECKBOX PCA Supervision FORMCHECKBOX Adult Day Services FORMCHECKBOX Homemaking FORMCHECKBOX Personal Emergency Response System (PERS) FORMCHECKBOX Customized Living FORMCHECKBOX Home Modifications FORMCHECKBOX Respite FORMCHECKBOX 24-hour Customized Living FORMCHECKBOX Home Delivered Meals FORMCHECKBOX Therapies at home: PT, OT, ST FORMCHECKBOX Care Coordination/Case Management FORMCHECKBOX Home Health Aide FORMCHECKBOX Transportation FORMCHECKBOX Care Coordination Para Professional FORMCHECKBOX Housing Stabilization Services (HSS) FORMCHECKBOX Yardwork/Chores FORMCHECKBOX Caregiver Support FORMCHECKBOX Individual Community Living Support (ICLS) FORMCHECKBOX CDCS FSM: FORMTEXT ?????Support Planner: FORMTEXT ????? FORMCHECKBOX Companion Services FORMCHECKBOX Nurse Visits FORMCHECKBOX Supplies and Equipment FORMCHECKBOX Foster Care FORMCHECKBOX Personal Care Assistant (PCA)Formal/paid services authorized:Provider NameService ProvidedSchedule/FrequencyStart Date/End DateTotal Cost per Month FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Case Mix Level: FORMTEXT ?????CAP Amount: FORMTEXT ?????Member Waiver Obligation if known: FORMTEXT ?????Total Cost of Authorized Services: FORMTEXT ?????Customized Living Verification Code (if applicable): FORMTEXT ????? Notes: FORMTEXT ?????Informal, non-paid community supports or resources (i.e., caregiver, neighbor, volunteer):Informal ProviderService ProvidedSchedule/Frequency FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Additional comments, if applicable: FORMTEXT ????? ................
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