Inspire SNBC

Inspire (SNBC) Care Plan Information About Me

Name:

My DOB:

HealthPartners ID #: SNBC Enrollment Date: Care Plan Completion Date:

Phone #: Assessment Date:

Initial HRA Annual reassessment Change of Condition Other:

My Address:

Emergency Contact Name/Phone #:

If applicable, Legal guardian/representative Name/Phone#:

Was Advance Directive/Health Care Directive Discussed? Yes No

If No, Reason:

My primary language is: English Other (Type in the “other” language)

I need an interpreter: Yes No Name and Number of Interpreter (If applicable):

My Interdisciplinary Care Team (ICT) Care Coordinator/Case Manager: Name: Phone #:

Primary Physician: Phone #: Fax #:

Clinic:

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Assessment Type:

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If applicable, County Waiver CM Information Name:Phone: Fax:Email:Date care plan was shared with County Waiver worker:

Waiver Type: CAC CADI BI (TBI) DD Other

Disability Type: Physical Developmental Mental Health

I have a Mental Health Targeted Case Manager (MHTCM): Yes No Name of MHTCM: Phone Number of MHTCM:

Other Members of My Team Relationship to Me Phone Number

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Care Plan Shared with Team Member

Yes No

Yes NoYesYesYesYesYesYesYesYesYesYesYes

Yes

NoNoNoNoNoNo

NoNo

NoNoNoNo

Inspire SNBC

I. What’s Important to Me? (e.g. living close to my family, visiting friends)Initial/Annual:

Update:

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

Initial/Annual:

Update:

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

IV. My CaregiverInformal Caregiver listed on HRA: (Caregivers are unpaid person(s) providing services) Yes No

If Yes, is there a need for caregiver resources? Yes No

If Yes, date resources provided to caregiver:

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Update:

Initial/Annual:

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V. 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)

Cervical Cancer Care

Colorectal Screening (Up to age 75)

At Risk for Falls

Flu shot (Annually, ages 50+ and persons at high risk.)

Tetanus Booster (Once every 10 years)

Hearing Exam

Vision Exam

Dental Exam

Blood Pressure: (Blood Pressure Goal is <140/80 to age 75.

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ADL/IADL Dependencies

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Diabetic routine checks as recommended by physician

Family Planning

Rehabilitative Services

Education and/or employment

Child and Teen Check-Up (18-21)

Chemical Health/ Chemical Dependency

Medication Adherence/MTM

Other:

Mental Health Diagnosis: (If applicable)

N/A

Yes No Managed by Other Health Professionals?

(Psychiatrist, Psychologist, Primary Care Physician)

Need Goal?: Yes No *Declined

Disease Management Referral:

Yes Declined N/A Diagnosis:

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*See care plan instructions

Inspire SNBC

VI. My Goals

Discuss with Care Coordinator goals for: everyday life (taking care of myself or my home), my relationships and community connections, my safety, my health, and my future plans.

My Goals My Interventions Target Date Monitoring Progress/Goal Revision Date

Goal Achieved/Not Achieved (Mo/Yr)

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Inspire SNBC

My Goals My Interventions Target Date Progress/Goal Revision Date Goal Achieved/Not Achieved (Mo/Yr)

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VII. Barriers to meeting my goals (if applicable)

Initial/Annual:

Update:

VIII. My follow up plan:

Care Coordinator/Case Manager Follow-up will occur: Once a Month for 3 Months Every 3 Months Every 6 Months Other

Purpose of Care Coordinator Contact:

IX. My Safety Plan

Essential Services Backup Plan: (when providers of essential services are unavailable)

I am receiving essential services Yes No

Essential services I am receiving:

If Yes, briefly describe provider’s backup plan, as agreed to by me:

If I am unable to evacuate independently in an emergency, my evacuation plan will be:

Additional Case Notes:

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Inspire SNBC

X. Choosing Community Long Term Care

Yes No I have been given a choice of different types of services that can meet my needs.

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.

MEMBER/AUTHORIZED REPRESENTATIVE SIGNATURE: DATE:

MEMBER/AUTHORIZED REPRESENTATIVE PRINTED NAME: DATE:

CARE COORDINATOR/CASE MANAGER SIGNATURE: DATE:

CARE PLAN MAILED/GIVEN TO ME ON:

CARE PLAN OR SUMMARY MAILED/GIVEN TO MY DOCTOR (verbal, phone, fax, EMR):

DATE:

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HealthPartners ID:Member Name:

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XI. Home and Community Based Service and Support Plan

Support/Service Provider Payment Type (Medicare, Medicaid, Waiver or Other) Schedule/Frequency Service Start & End

Date (if applicable)

Home and Community Based Services

List of Equipment Member Has

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Inspire SNBC

Support/Service Provider Payment Type (Medicare, Medicaid, Waiver or Other) Schedule/Frequency Service Start & End

Date (if applicable)

List of Supplies

Other: (supports, resources)

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Inspire SNBC

This information is available in other forms to people with disabilities by calling 952-967-7998 (voice) or 1-866-885-8880 (toll free), 952-883-6060 (TTY), 1-800-443-0156 (toll free TTY), 7-1-1, or through the Minnesota Relay direct access numbers at 1-800-627-3529 (TTY, Voice, ASCII, hearing carry over), or 1-877-627-3848 (Speech to Speech relay service). HPCare 2015 LB HPCare_87629 Approved 01/15/2015

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