My Supplemental ICF/DD and HCBS Waiver Health Risk Assessment Care Plan

Date Assessment and Care Plan Reviewed:

(The next annual re-assessment is due within 365 days from this date.)

Completion of this form as described will meet requirements for a Health Risk Assessment (HRA) and a supplement to the existing care plan for MSHO/SecureBlue & MSC+ Blue Advantage members who have had an LTCC/MNChoices or ICF/DD assessment within the past 365 days. This form is to be attached to the most recent assessment and care plan. A new LTCC and Collaborative Care Plan must be done if there is not a current one to review and update within the past 365 days. Please refer to MSC+ or MSHO guidelines for details.

I. Information about Me:

Name: / My Health Plan ID Number: / My DOB:
My Address (Street, City, ST, ZIP) / My Phone
()
My Physician / Phone / Clinic
Clinic Address (Street, City, ST, ZIP)
My County of Financial Responsibility / My County of Residence
My Waiver Case Manager / Phone / Email Address

II. Review of my assessment and Care Plan:

Blue Plus enrollment date:
Date of most recent assessment done by the Waiver case manager:
Date of most recent care plan done bythe Waiver case manager:
ThisHealth Risk Assessment was completed with me: In person By phone
Review the entire attached assessment for completeness. Record any significant changes since the member’s last assessmenthere:
My Health Goals (required)
Each member must have at least one health related goal.
Rank by
Priority / My Goals / Support Needed / Target Date / Monitoring Progress/Goal Revision date / Date Goal Achieved/ Not Achieved
(Month/Year)
Low
Medium
High
Low
Medium
High

III.Screening for managing and improving my health:

My preventive care needshave been addressed. (E.g. immunizations, tobacco and alcohol use, fall risk, medication and nutrition)? Yes No

If No, explain how any needs are going to be addressed:
Have you had these immunizations? Flu Pneumonia Tetanus Comments:
Pain Screening: /
  • Have you experienced pain within the past 2 weeks?
Yes No
  • Has 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 (more than once a day, once per day or less than once per day)?
  • At its worst, how severe is your pain (1 to 10 with 10 being the worst)?
  • Have you talked to your doctor about how to handle your pain?
Yes No
Would you likehelp coordinating an Annual Physician/Provider Visit for Primary and Preventive Care?
Yes No NA Comments:
When was your last physician/provider visit? Date: Comments:
Would you like to be contacted by a Blue Plus Health Coach? A Health Coach can assist you and/or your caregiver by providing education and support for your chronic conditions, if any, or complex situations such as catastrophic illness, high medical costs, frequent hospitalizations, etc.
Yes No Comments:
If yes, Care Coordinator should send in form 6.09 Medical Management Referral from the Care Coordination portal.
Do you have an Advance Directive or Health Care Directive in place? Yes No Comments:
Signature and title of person completing this form: / Date:
Copy of this form sent to other Case Manager (if different than the Care Coordinator) / Date:
Copy of this form or Care Plan Summary mailed/given to PCP (Verbal, phone, fax) / Date:
Copy of this form mailed/given to me / Date: