INSTRUCTIONS FOR INSPIRE (SNBC) CARE PLAN

INSTRUCTIONS FOR INSPIRE (SNBC) CARE PLAN INFORMATION ABOUT ME 1. Name: Enter member s name. 2. My DOB: Enter member s date of birth. 3. Health Plan ID Number: Enter member s HealthPartners Member ID number. 4. SNBC Enrollment Date: Enter the date member enrolled with HealthPartners SNBC. 5. Care Plan Completion Date: Enter the date the care plan is completed. 6. Phone #: Enter member s phone number. 7. My Address: Enter member s address. 8. Assessment Date: Enter the date the assessment was completed. 9. Assessment Type: Choose the type of assessment that was completed. 10. Emergency Contact Name/Phone #: Enter member s emergency contact information. 11. If applicable, Legal guardian/representative Name/Phone#: Enter member s legal guardian/representative information. 12. Was Advance Directive/Health Care Directive Discussed? Document that a discussion occurred by checking yes or no. If no discussion occurred, document reason. 13. My Primary Language is: Check appropriate box. If the member s language is not on the list, check Other and document their language in this section. Include interpreter information. MY INTERDISCIPLINARY CARE TEAM (ICT) 14. Care Coordinator/Case Manager: Enter HealthPartners SNBC Care Coordinator name and phone number. 15. Primary Physician: Enter the name, phone number, and fax number of member s primary care provider. 16. Clinic: Enter the name of the member s primary care clinic. 17. If applicable, County Waiver CM Information: Enter Name, Phone, Fax, and E-mail of the County Waiver Case Manager if member is open to a waiver. 18. Date care plan was shared with County Waiver CM: Enter date that care plan was shared with the Waiver Case Manager. 19. Waiver Type: Indicate type of waiver member is on, if applicable. 20. Disability Type: Indicate member s disability type. 21. Mental Health Targeted Case Manager: Check yes or no. If yes, enter name and phone number 22. Other Interdisciplinary Care Team Members: Enter names of additional ICT members and their relationship to the member. Examples of other team members may include but is not limited to other physicians, specialists, psychiatrist, psychologist, etc. Document yes or no if the care plan is shared with these ICT members. Inspire (SNBC) Care Plan Instructions 1

WHAT S IMPORTANT TO ME? 23. What s Important to Me: Describe what is most important to the member, their wishes, dreams, and goals in life. Complete the first row at the initial/annual assessment. Updates should be dated and entered in the second row. Updates include six month check-ins or any other updates throughout the year. MY STRENGTHS 24. My Strengths: Enter member s supports and describe what works best for the member. Include a list of the member s skills, talents, and/or interests. Complete the first row at the initial/annual assessment. Updates should be dated and entered in the second row. Updates include six month check-ins or any other updates throughout the year. MY SUPPORTS AND SERVICES 25. My Supports and Services: Enter any requests that member has asked for assistance with. Enter any supports or services that member has requested. Complete the first row at the initial/annual assessment. Updates should be dated and entered in the second row. Updates include six month check-ins or any other updates throughout the year. MY CAREGIVER 26. Caregiver Listed on HRA: A caregiver is someone who provides unpaid support or who is paid but works beyond set paid hours. (Example, daughter is paid for 3 hours of PCA support, yet provides 24 hour support. Check yes or no to indicate if there is an informal caregiver. If yes, then check yes or no to indicate if there is a need for caregiver resources. If caregiver resources are needed document the date that resources were provided to caregiver on the Care Plan. Document caregiver resources provided and method resources were provided in chart or case notes. MANAGING AND IMPROVING MY HEALTH 27. Check if an educational conversation took place: CC/CM should have an educational conversation with the member or member s authorized representative about applicable conditions and/or regularly scheduled screenings. Check each box to show that an educational conversation took place for each applicable condition or screening. 28. Goal is Needed: If the member needs assistance with a risk or identified need, check the appropriate box and create a goal in Section VI. 29. Check if N/A, Contraindicated, Declined: Check applicable box if the Condition/Screening or goal is not applicable, contraindicated, or declined. 30. Notes: Free form area for any additional applicable information such as date of the screening, scores, or reason for declining a goal. 31. Diabetic routine checks as recommended by physician: CC/CM should inquire whether a member with diabetes has routine diabetic checks with their doctor. If not, CC/CM should encourage the member to schedule a visit and create a goal to address this in Section VI. CC/CM should review and discuss with member patient education topics such as the importance of an eye exam, diet (i.e. Cholesterol) and knowing their A1C level. 32. Medication Adherence: Check if educational conversation took place. If there are concerns regarding member not taking medications as prescribed mark goal is needed. Create goal in Section VI. Refer to Medication Therapy Management (MTM) if appropriate. 33. Other: Enter any other test or condition not addressed in this section. Inspire (SNBC) Care Plan Instructions 2

34. Mental Health Diagnosis: If member declines to have goal included on his/her care plan, please indicate that you are aware of the mental health need and that you will continue to address it. This can be captured in case notes. 35. Disease Management Referral: Check yes, declined, or N/A. If yes, include the diagnosis. All health plans have different diseases and processes for their Disease Management Programs; please check with the member s health plan for direction. MY GOALS ISSUES, NEEDS, AND ALL AREAS OF CONCERN IDENTIFIED ON THE HRA/LTCC MUST BE ADDRESSED IN THE CARE PLAN Examples available at the end of instructions. 36. My Goals: List appropriate member centered goals to meet the risks identified on the HRA. Goals should be SMART (Specific, Measurable, Attainable, Relevant and Time bound. 37. My Intervention: Document any intervention(s) related to achieving this goal: What will the member need to do to accomplish the goal and how will the CC/CM help the member achieve the goal? 38. Target Date: List the target date (month/year) for completion of the goal. On-going yes or no are not acceptable target dates. Members should have at least one active or open goal on their care plan and the target date should extend to the next annual assessment. 39. Monitoring Progress/Goal Revision Date: This column can be used to document progress during the 6 month contact and/or as needed throughout the year. The CC/CM should have a discussion with the member about each goal and the member s progress toward meeting a goal. This discussion should include determining if the goal was met or not met and an evaluation of whether the goal will be discontinued, modified, or carried forward. The CC/CM should document the date (month/year) of the review and the outcome (e.g., discontinued, modified, or carried forward) in this column. If priorities change, please note. Reminder: The plan of care is a living document that should be updated at minimum twice a year. Best Practice Recommendation: The CC/CM should document their monitoring of the care plan and/or updates directly on the care plan. If CC/CM uses case notes to document progress on goals, the progress regarding each goal should be clearly indicated in the case notes. 40. Date Goal Achieved/Not Achieved: This column is used to document the date (month/year) the goal was achieved or if not achieved, the date (month/year) it was reviewed. This column may also be used to document progress notes and the final outcome (e.g., goal discontinued, modified, or carried forward to next year s care plan). BARRIERS TO MEETING MY GOALS (if applicable) 41. Initial/Annual: Describe any barriers to meeting goals. Update: Complete and date at time of designated follow up. MY FOLLOW-UP PLAN 42. CC/CM Follow-up Plan: Check box to indicate how frequently you will be following up with the member. If other, describe. Must be a minimum of every 6 months. You will be audited according to what you select. Inspire (SNBC) Care Plan Instructions 3

MY SAFETY PLAN 43. Essential Services Backup Plan: Essential services are services that if the member did not receive them, the member s health or ability to remain safety in their home would be compromised. What is their back up plan if essential services providers do not show up? Example, the member is receiving essential services such as Meals-on-Wheels, if that is their only source of nutrition, describe how this need will be met. CHOOSING COMMUNITY LONG TERM CARE Member/Authorized Representative checks the boxes 44. I have been given a choice of different types of services that can meet my needs: The member/authorized representative checks yes or no 45. I have been offered a choice of providers from available providers: The member/authorized representative checks yes or no. 46. I have annually received my appeal rights: Inform member/authorized representative that their annual appeal rights are sent with any DTR and with their annual Evidence of Coverage (EOC). The member/authorized representative should check yes or no. CC/CM can direct member/authorized representative to customer service if they need a copy of the appeal rights documents. 47. I am aware that healthcare information about me will be kept private (Data Privacy rights): Inform member/authorized representative that their privacy rights are sent annually. The member/authorized representative should check yes or no. CC/CM can direct members/authorized representative to customer service if they need a copy of their EOC, which contains data privacy information. 48. I have discussed my plan of care with my care coordinator/case manager and have chosen the services I want. The member/authorized representative checks yes or no. 49. I agree with the plan of care as discussed with my care coordinator/case manager. The member/authorized representative checks yes or no. 50. Member/Authorized Representative Signature and Date. CC/CM must obtain signature from member or authorized representative. 51. Member/Authorized Representative Printed Name: Enter or Print name of member or authorized representative that signed above. 52. Care Coordinator/Case Manager Signature and Date. CC/CM signs care plan. 53. Care Plan Mailed/Given to me on: Enter the Date Care Plan was Mailed/Given to the Member. 54. Care Plan or Summary Mailed/Given to My Doctor: Enter the Date Care Plan or Summary was Mailed/Given to PCP. Enter the method that care plan was shared (Verbal, Phone, Fax, Electronic Medical Record). 55. Member Name and HealthPartners ID: Enter member name and Health Partners ID HOME AND COMMUNITY BASED SERVICE PLAN/BUDGET WORKSHEET DHS s audit protocol requires documentation of type of service; amount, frequency, duration and cost of each service; and type of service provider, including non-paid caregivers and other informal community supports or resources. Services/Supports should be based on a determination of available benefits and resources. Fully completing this (or a similar) budget worksheet provides the required documentation for these audit elements. Inspire (SNBC) Care Plan Instructions 4

Name: My DOB: Phone #: My Address: Emergency Contact Name/Phone #: Inspire (SNBC) Care Plan Information About Me HealthPartners ID #: SNBC Enrollment Date: Care Plan Completion Date: Assessment Date: Assessment Type: Initial HRA Annual reassessment Change of Condition Other: If applicable, Legal guardian/representative Name/Phone#: Was Advance Directive/Health Care Directive Discussed? Yes No If No, Reason: Care Coordinator/Case Manager: Name: Phone #: 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) Primary Physician: Phone #: Fax #: Clinic: 1

If applicable, County Waiver CM Information: Name: Phone: Fax: E-mail: Date care plan was shared with County Waiver CM: 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 Care Plan Shared with Team Member 2

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?) Update: IV. My Caregiver Informal 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: 3

V. Managing and Improving My Health Check if educational conversation took place with me Screening for My Health 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) ADL/IADL Dependencies Hearing Exam Vision Exam Dental Exam Blood Pressure: (Blood Pressure Goal is <140/80 to age 75. 4

Check if educational conversation took place with me Goal is Needed Check if N/A, Contraindicated, Declined Notes 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 Managed by Other Health Professionals? Yes No (Psychiatrist, Psychologist, Primary Care Physician) Need Goal?: Yes No *Declined *See care plan instructions Disease Management, Referral Yes Declined N/A Diagnosis: 5

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 Date Goal Achieved/ Not Achieved (Month/Year) 6

Initial/Annual: Update: VII. Barriers to meeting my goals (if applicable) 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: 7

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 Yes Yes Yes Yes No I have been offered a choice of providers from available providers. No I have annually received my appeal rights. No I am aware that healthcare information about me will be kept private. (Data Privacy Rights) No I have discussed my plan of care with my care coordinator/case manager and have chosen the services I want. 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: Member Name: HealthPartners ID: 8

XI. Home and Community Based Service and Support Plan Support/Service Provider Payment Type (Medicare, Medicaid, Waiver or Other) Schedule/Frequency Service Start Date and End Date (if applicable) Home and Community Based Services List of Equipment Member Has 9

List of Supplies Support/Service Provider Payment Type (Medicare, Medicaid, Waiver or Other) Schedule/Frequency Service Start Date and End Date (if applicable) Other: (supports, resources) 10

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 11

VI. My Goals Inspire SNBC EXAMPLE GOALS for Inspire (SNBC) Care Plan 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 I will receive an annual physical. I will make an informed choice about completing an advanced directive. My Interventions Care Coordinator (CC) will provide list of available providers to member. I will choose a provider from list. I will schedule and attend annual physical appointment. CC will provide educational materials and an advanced directive form. I will review materials and make a decision about completing an advanced directive. Monitoring Progress/Goal Revision Target Date Date 9/30/2017 10/1/2016- CC mailed list of providers to member. 3/16/17- Annual physical was complete on 11/7/16. 9/30/2017 10/1/2016- CC mailed educational materials and advanced directive form. 3/16/17- Goal reviewed. See updates in case notes. Goal Achieved/Not Achieved (Mo/Yr) 3/16/17 - Goal complete. Annual physical was completed on 11/7/16. 3/16/17 - Goal complete. Advanced Directive complete. I will manage fall risk with use of appropriate devices or services. I will establish care with a dental provider. I will maintain services with mental health providers. I will continue to use walker, shower chair, and accept PCA services to prevent falls. I will notify CC if devices and services are no longer meeting needs. CC will provide list of available providers. I will review and choose a provider. I will schedule and attend appointment. CC available to further assist where needed. I will continue to attend appointments with therapist, psychiatrist, and ARMHS worker. I will notify CC if services are no longer meeting member's needs. 9/30/2017 9/30/2017 9/30/2017 3/16/17- Member continues to use walker, shower chair, and PCA services to prevent falls. 10/1/2017 - CC mailed list of providers to member. 3/16/2017 - Member has not scheduled appointment. See additional notes in case notes. 3/16/2017 - Member continues to attend appointments with mental health providers. 9/30/2017- Member continues to use devices and services. Goal will continue to next care plan. 9/30/2017- Goal Complete. Member attended dental appointment in 4/2017. 9/30/2017-Goal is on-going. Goal will continue to next care plan. HealthPartners Confidential and Proprietary Last Reviewed November 2017 Inspire (SNBC) Care Plan Instructions 17