My Care Plan and Community Support Plan

Information About Me

Name:	My Health Plan ID Number:	My Health Plan Name:	Today’s Date:
Phone #:	My DOB:	Product Enrollment Date:
My Address:	Rate Cell:	Diagnosis:
Date of My Assessment Visit: Assessment Type: Initial Health Risk Assessment Annual Reassessment Change in My Needs Other
Is there an Advance Directive or Health Care Directive in place? Yes No Was Advance Directive/Health Care Directive discussed: Yes No If no, reason:	My primary language is: English Hmong Spanish Somali Vietnamese Russian Other (Type in the “other” language) I need an interpreter: Yes No Name and number of Interpreter (If applicable):

My Care Team (Interdisciplinary Care Team-ICT)

Care Coordinator/Case Manager: Name: Phone #:	Primary Physician: Phone #: Fax #:	Clinic:
Emergency Contact Name & Phone:	My Representative is: They can be contacted for:
I have a Mental Health Targeted Case Manager: Yes No Name of MHTCM: Phone Number of MHTCM:
Other Care Team Members Name	Relationship to me	Give Copy of Care plan?	Date sent

What’s Important to Me? (e.g. living close to my family, visiting friends)

Initial/Annual:
Update:

My Strengths: (e.g. skills, talents, interests, information about me)

Initial/Annual:
Update:

My Supports and Services: (What do I want help with? Service and support I requested? From whom?

Initial/Annual:
Update:

Caregiver:

Informal Caregiver listed on HRA/LTCC: (Caregivers are unpaid person(s) providing services) Yes No If yes, the Caregiver Assessment Form was completed by: Face-to-Face Telephone Mail Declined Date Completed:

Managing and Improving My Health

Screening for my health
Check if educational conversation took place with me	Goal is needed	Check if N/A, contraindicated, declined	Notes
Annual Preventive Health Exam
Mammogram (Within past 2 years ages 65-75)
Continence needs (Evaluated by a physician?)
Colorectal Screening (Up to age 75)
At Risk for Falls (Afraid of falling, has fallen in the past).
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)
Flu shot (Annually ages 50+ and persons at high risk.)
Tetanus Booster (Once every 10 years)
Hearing Exam
Vision Exam
Dental Exam
Calcium Vitamin D Rx for Ca Vitamin D? (as directed by physician)
Aspirin Rx for Aspirin? (as directed by physician)
Blood Pressure: (Blood Pressure Goal is <140/80 to age 75. After 75 based on individual)
Cholesterol check
Diabetic routine checks as recommended by physician (Discuss with my care team: Hypertension, Neuropathy, Eye exam, Cholesterol, A1C)
Other:
Mental Health Diagnosis (If applicable): N/A	Managed by a Health Professional? Yes No (Psychiatrist, Psychologist, Primary Care Physician) Need Goal? Yes No Declined
My Medications	I need help with my medications? Yes No N/A (no medications used) If yes, create a goal
List of Medications (If not on LTCC)
Health Improvement Referral	Yes Declined N/A Diagnosis:
Hospitalizations (In past year number and reason, date(s) if available)
ER visits (In past year number and reason for visit; dates, if available)

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) Needed	Target Date	Monitoring Progress/Goal Revision date	Date Goal Achieved/ Not Achieved (Month/Year)
Low Medium High
Low Medium High
Low Medium High
Low Medium High
Low Medium High
Low Medium High
Low Medium High

Barriers to meeting my goals

Initial/Annual:
Update:
No barriers identified

My follow up plan:

Care Coordinator/Case Manager follow-up will occur:

Once a month

Every 3 months

Every 6 months

Other

Purpose of Care Coordinator contact:

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 health

I have a scheduled procedure or surgery or I am hospitalized

I have experienced falls in my home or community

I 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 specialist

I need help learning about my medications

I would like information to help myself and my family make health care decisions

I 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 needs

I am dissatisfied with one or more of my providers

My Safety Plan

My safety concerns were discussed with my Care Coordinator: Yes My plan for managing risks that I have discussed with my Care Coordinator is:
Emergency Plan: In the event of an emergency, I will (check all that apply): Call 911 Use Emergency Response Monitoring System Call Emergency Contact Call Other Person Name: Phone: Other (describe) Self Preservation/Evacuation Plan: If I am unable to evacuate on my own in an emergency, my plan is to: If other concerns or plans, describe:
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 Yes No Essential services I am receiving: If Yes, describe provider’s backup plan, as agreed to by me:
Community-Wide Disaster Plan: In the event of a community-wide disaster, (e.g., flood, tornado, blizzard), I will (describe plan):
Additional Case Notes:

Choosing Community Long Term Care

Yes No I have been offered a choice between receiving services in the community or in the Nursing Home. Yes No I have been given a choice of different types of services that can meet my needs, as seen on my plan. Yes No I have been offered a choice of providers from available providers. Yes No I have annually received my appeal rights. Yes No I am aware that healthcare information about me will be kept private. (Data Privacy rights) Yes No I have discussed my plan of care with my Care Coordinator/Case Manager and have chosen the services I want. Yes No I agree with the plan of care as discussed with my Care Coordinator/Case Manager.
I CHOOSE TO SHARE CARE PLAN INFORMATION WITH THE FOLLOWING EW PROVIDERS
Provider 1 Complete Care Plan Care Plan Summary Letter None
Provider 2 Complete Care Plan Care Plan Summary Letter None
Provider 3 Complete Care Plan Care Plan Summary Letter None
Provider 4 Complete Care Plan Care Plan Summary Letter None
Provider 5 Complete Care Plan Care Plan Summary Letter None
I CHOOSE NOT TO SHARE MY CARE PLAN WITH ANY ELDERLY WAIVER SERVICE PROVIDERS
MY/MY REPRESENTATIVE SIGNATURE:	DATE:
CARE COORDINATOR/CASE MANAGER SIGNATURE:	DATE:
CARE PLAN MAILED/GIVEN TO ME ON:	DATE:
CARE PLAN OR SUMMARY MAILED/GIVEN TO MY DOCTOR (verbal, phone, fax, EMR):	DATE:

Name: Health Plan I.D.Number:

HOME AND COMMUNITY BASED SERVICE AND SUPPORT PLAN/BUDGET WORKSHEET
Services offered, if appropriate. Mark “X” if service was offered. If member accepts, fill in applicable sections below for each formal or informal provider.
Adult Day Care Bath	Help w/ MA, Finances, other paperwork	PCA Supervision
Adult Day Services	Homemaking	Personal Emergency Response System (PERS)
Customized Living	Home Modifications	Respite
24-hour Customized Living	Home Delivered Meals	Therapies at home: PT, OT, ST
Care Coordination/Case Management	Individual Community Living Support (ICLS)	Transportation
Care Coordination Para Professional	Nurse Visits	Yardwork/Chores
Caregiver Support	Home Health Aide	CDCS FSE: Support Planner:
Companion Services	Personal Care Assistant (PCA)	Supplies and Equipment
Foster Care
Formal/paid services authorized:
Provider Name	Service Provided	Schedule/Frequency	Start Date/End Date	Total Cost per Month
Case Mix Level:	CAP Amount:	Member Waiver Obligation if known:	Total Cost of Authorized Services:	Customized Living Verification Code (if applicable):	Notes:
Informal, non-paid community supports or resources (i.e., caregiver, neighbor, volunteer):
Informal Provider	Service Provided	Schedule/Frequency
Additional comments, if applicable: