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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:
Inspire SNBC
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:
Inspire SNBC
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
Inspire SNBC
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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Inspire SNBC
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:
9
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HealthPartners ID:Member Name:
Inspire SNBC
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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