HEALTH RISK ASSESSMENT FOR MINNESOTA SENIOR CARE PLUS(MSC+)/MINNESOTA SENIOR HEALTH OPTIONS (MSHO) MEMBERS. Used for members on other waiver programs

This assessment is to be used as an annual health risk assessment for MSHO and MSC+ members receiving waiver case management through a county waiver case manager (for example: members on developmental disability (DD), brain injury (BI), or community access for disability inclusion (CADI) waivers managed by other case managers.) Information may be gathered from the members, waiver case manager, group home staff and/or guardians. *Fields with asterisks are required for MMIS entry

Assessment type: ☐Initial ☐Annual ☐6 month ☐Other

*Client Last Name:

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*Client First Name:

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M.I.:

Click here to enter text. / Click here to enter text. / Click here to enter text. /

*Birth Date:

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*PMI Number

/ Medica ID Number:
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Address:

/ Phone number: /

Sex:

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Click here to enter text.

/ ☐Male ☐Female
*Care Coordinator Name: /

*Care Coordinator NPI/UMPI

/ Care Coordinator Phone:
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/ Click here to enter text.
Waiver CM Name: /

Waiver CM Agency:

/ Waiver CM Phone:
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/ Click here to enter text.
Waiver CM Fax: /

Waiver CM Email:

/ Waiver Assessment Date:
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/ Click here to enter text.

Primary Spoken Language:

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Referral Date

/ *LTCC CTY:
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Click here to enter a date.

/ MED /

*Activity Type Date (Assessment Date)

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*Activity Type

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Choose an item.

*COS

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*COR

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*CFR

Choose an item. / Choose an item. / Choose an item. /

*Legal Rep Status – Adult (age 18 or older)

/ Legal Rep Name: / Legal Rep Contact Info:
Choose an item. / Click here to enter text. / Click here to enter text. /

*Primary Diagnosis Name:

/ Click here to enter text. / *Dx Code: Click here to enter text.
*Secondary Diagnosis Name: / Click here to enter text. / *Dx Code: Click here to enter text.
*Is there a history of a DD Dx? ☐Y ☐N If so, what is the dx? Click here to enter text.
*Is there a history of a MI Dx? ☐Y ☐N If so, what is the dx? Click here to enter text.
*Is there a history of a BI Dx? ☐Y ☐N If so, what is the dx? Click here to enter text.
*Who was present at screening? (more than one can be selected)
☐01 – Client ☐02 – Family ☐03 - LTCC consultant
☐04 - Social worker ☐05 - Public health nurse ☐06 - Hospital discharge planner
☐07 - Qualified mental retardation professional ☐08 - Qualified mental health professional / ☐09 - NF staff ☐10 - Primary physician ☐11 - Home care or community based service provider
☐12 – Advocate ☐13 - Conservator/Guardian ☐14 - Consulting physician ☐15 - ICF/MR staff ☐16 - Services for children with handicaps / ☐17 - Case manager ☐18 - Legal counsel ☐19 - Health plan coordinator ☐20 – Ombudsman ☐21 – RRS ☐22 - Interpreter, English ☐23 - Interpreter, ASL
☐98 – Other, please specify: Click here to enter text.

Screening & Assessment Information

1. *Reasons for Referral:

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2. Current Living Situation:

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3. *Current Housing Type:

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4. *Assessment Team

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5. Current Program License

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6.*Dressing

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7. *Grooming

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8. *Bathing

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9. *Eating

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10. *Bed Mobility

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11. *Transferring

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12. *Walking

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13. *Behavior

Choose an item. / Choose an item.

14. *Toileting

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14A *The person needs constant supervision and/or assistance of another to begin and complete toileting.

Choose an item. / ☐Yes ☐No
15. *Special Treatment / 16. * Clinical Monitoring
Choose an item. / Choose an item. /
17. *Neuromuscular Diagnosis / 18. *Case Mix
☐ Yes ☐ No / Click here to enter text.
19. *Orientation / 20. *Self-Preserve
Choose an item. / Choose an item.

21. Self Eval

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22. *Hearing

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23. *Communication / 24. *Vision
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25. *Mental Status Eval

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26. *Telephone Answer

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27. *Telephone Call

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28. *Shopping (food, other)

Choose an item.

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29. *Meal Preparation/Clean Up

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30. *Light Housekeeping/Cleaning (dusting/sweeping)

Choose an item.

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31. *Heavy Housekeeping (yard work, empty garbage)

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32. *Laundry (in/out; run washer/dryer)

Choose an item.

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33. *Medication Management

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34. *Insulin Dependent

Choose an item.

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Choose an item.

35. *Money Management

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36. *Transportation

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37. *Have you experienced any Falls in your home or while out in the community?

Choose an item. /
38. *Number of Hospitalizations in last year: Click here to enter text.
Please describe: Click here to enter text.
39. *Number of ER Visits in last year: Click here to enter text.
Please describe: Click here to enter text.
40. *Number of NF Stays in last 3 years: Click here to enter text.
Please describe: Click here to enter text.

41. *Assessment Results and Exit Reasons

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42. *Effective Date (Assessment Date)

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43. *Program Type

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44. CDCS

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45. Is member on a waiver? ☐ Yes ☐ No

Choose an item. / ☐ Yes ☐ No / If so, what type? Click here to enter text.

Health Summary

Primary Care Clinic: / Click here to enter text.
Primary Care Provider: / Click here to enter text. /
Fax Number: / Click here to enter text. /
Phone number: / Click here to enter text. /
Specialty Provider: / Click here to enter text. /
Specialty Provider: / Click here to enter text. /
Specialty Provider: / Click here to enter text. /

46. Dental

Do you have a dentist? ☐ Yes ☐ No
Do you have any dental concerns?
☐ Yes ☐ No

If yes, please specify:Click here to enter text.

47. Skin Assessment
Are you at risk for breakdown: ☐ Yes ☐ No
  • If yes, please specify interventions:Click here to enter text.

48. DME – Durable Medical Equipment

Are you currently using mobility aides? ☐ Yes ☐ No

If yes, please describe: Click here to enter text.

Are you currently using safety or adaptive equipment? ☐ Yes ☐ No
  • If yes, please describe: Click here to enter text.
Additional Comments: Click here to enter text.
49.Pain Screening

Are you experiencing any pain now or in the last two weeks? ☐ Yes ☐ No

  • If yes, has your pain affected your function or quality of life (e.g.: Activity level, mood, relationships, sleep or work)? ☐ Yes ☐ No

How often do you experience pain? ☐Constantly ☐ Daily ☐Once a Week ☐ Not Often

At its worst, how severe is your pain (1-10, with 10 being the worst)? Click here to enter text.

Have you talked to your doctor or someone else about the cause of your pain? ☐ Yes ☐ No
If yes, please specify who and whenClick here to enter text.
Pain Management Plan: Click here to enter text.

Preventative Care

Annual Preventative Visit: ☐ Yes ☐No ☐Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.
Dental Exam: ☐ Yes ☐No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.
Vision Exam: ☐ Yes ☐No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.
Hearing Exam: ☐ Yes ☐No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.
Mammogram: ☐ Yes ☐No ☐ Unsure Last date completed: Click here to enter a date.
Additional Comments: Click here to enter text.
Colorectal Cancer Screening: ☐ Yes ☐No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.
Diabetic Testing:☐ Yes ☐No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.
Bone Density: ☐ Yes ☐No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.
Aspirin Usage: Has a discussion occurred with provider regarding aspirin usage?
☐ Yes ☐No ☐ N/A At ages 45-79(men) and 55-79 (women), talk with providers about benefits and risks of aspirin use. If risk factors for those under 45 years of age,speak with PCP.
Immunizations/Vaccines
Influenza: ☐ Yes ☐No ☐ Unsure Last date completed: Click here to enter a date.
Additional Comments: Click here to enter text.
Pneumovac: ☐ Yes ☐No ☐ Unsure Last date completed: Click here to enter a date.
Additional Comments: Click here to enter text.
Tetanus: ☐ Yes ☐No ☐ Unsure Last date completed: Click here to enter a date.
Additional Comments: Click here to enter text.
Click here to enter text.

Advance Directives

50. Do you have any of the following in place? (Check all that apply)
☐Advance Directives☐ Living Will☐ Durable Power of Attorney for Health Care
☐ Durable Power of Attorney for Financial
~Advance Directive discussion with member completed? ☐ Yes ☐ No
  • If no, explain why not?Click here to enter text.
Additional Comments: Click here to enter text.

Care Coordinator Information

Notes:

☐Sent to Waiver CM (date)

☐Sent to PCP (date)

51. Care Coordinator received and reviewed a copy of the CSP/CSSP ☐ Yes ☐ No

Care Coordinator Signature: Date: Click here to enter a date.

Care Coordinator Name and Credentials: Click here to enter text.

Last updated 11/17/18

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