04/2014 (MA37) v.6

SingleCare or SharedCare(MA37) Health Assessment and Service Plan

1. Last Name: / 2.First Name: / 3.MI:
4.PMI No: / 8.Activity Type:
02 Face to Face Assessment
06 Reassessment
Other:
9. Activity Date:
5.Date of Birth:
6.Address:
7.County of Residence
10.Diagnoses
11.Is there a history of a DD/RC Diagnosis? Yes No
If so, what is diagnosis?
12.Is there a history of a MI Diagnosis? Yes No
If so, what is diagnosis?
13.Is there a history of a BI Diagnosis? Yes No
If so, what is diagnosis?
14.Is there a Mental Health Targeted Case Manager? Yes No
County of Service for the MH-TCM? / 15.Legal Representative Status:
01 Is a competent adult
02 Capacity to give informed consent is in question, referral to Adult Protection if indicated
03 Has a private guardian
04 Has a public guardian
11 Has a Conservator
98 Other
16.Case Manager/Care Coordinator Name: / Phone:
17.Case Manager/Care Coordinator NPI/UMPI:
18.Living Arrangement: Current:
01 – Living Alone
02 – Living with spouse/parent
03 – Living with family, friends, significant other
04 – Living in congregate setting
05 - Homeless / 19.Housing Type: Current: / 20.Reason for Referral:
14 – Health Assessment
Other:
01 – Homeless
02 – Institution ICF/DD
03 – InstitutionHospital
04 – Board and Lodge
05 – Foster Care / 09 – Own Home, Apt.
11 – Institution, NF/Certified boarding care
12 – Non certified boarding care
16 – Correctional Facility
Date Welcome Letter Sent: / Date ICT Communication Letter Sent to PCP:
Advance Directive
Does the member have an Advance Directive? Yes No
If Yes, Location:
If No, Why? / Refused / Inappropriate (cultural, developmental, cognitive, etc…) / Other:
If member does not have an Advance Directive, what is the follow-up plan? Discussion initiated
<Enter the follow-up plan>
Waiver Information (CAC, CADI, BI, DD/RC Waivers)
Is the member receiving waiver services? Yes No
Waiver Type: / County of Service for Waiver Case Mgmt:
Waiver Case Manager’s Name: / Phone:
Interested Persons
Name / Relationship / Primary Phone / Primary Contact / Legal Relationship

HEALTH ASSESSMENT

21. Who is your regular doctor and primary clinic?
22. How often have you seen your doctor or specialist in the last 6 months?
For what reason(s):

24.Preventive Health: When was your last…

Annual Physical / Influenza Vaccination
Pneumonia Vaccination / Varicella (Shingles) Vaccination
Eye Exam / Tetanus Vaccination
Dental Exam / Hearing Exam
Breast Exam (if applicable) / Podiatry Exam
Prostate Exam (if applicable)

25. Nutritional Health

Do you have any problems that make it difficult to eat? For example, dental problems, swallowing problems, nausea, taste problems, food allergies, certain foods. / No Yes Problem(s):

26.Do you have any of the following health problems? Has a doctor ever told you that you have any of the following problems?

Heart Problems / Yes No / Endocrine Problems(diabetes, thyroid, etc…) / Yes No
Lung Problems / Yes No / Visual Problems(glaucoma, macular degeneration) / Yes No
Stomach/Intestinal Problems / Yes No / Gynecological / Yes No
Skin Problems / Yes No / Musculoskeletal / Yes No
Infectious Diseases / Yes No / Cancer / Yes No
Genitourinary(Renal Failure, Prostate, etc…) / Yes No / Allergies / Yes No
Neurological Problems / Yes No / Drug Sensitivities / Yes No
27.Please explain any health problems that are marked YES:
28. Have you had any other health conditions that were not listed or mentioned? Yes No
If yes, please list the other health conditions:

MEDICATIONS (prescription, over the counter, vitamins, herbal supplements)

29. Are you taking any prescription medications, over the counter, vitamins, herbal supplements?Please list them below:

Name / Why are you taking the medication?

EMOTIONAL AND MENTAL HEALTH: Now I have some questions about how you have been feeling during the past month.

30. Over the last four weeks, how often have you been bothered by feeling down, depressed or hopeless? / Yes No
31. Have you suffered a loss or misfortune in the past year that had serious impact on your life? (Job, disability, separation, jail term or death of someone close to you)? / Yes No
32. Are you receiving or would like to receive mental health services or counseling? / Yes No

FUNCTIONAL ASSESSMENT: ACTIVITIES OF DAILY LIVING (ADLs)Enter the value of the score next to the statement that best describes your member.

33.Dressing – How well are you able to manage dressing? Laying out the clothes and putting on the clothes, including shoes, and fastening clothes.
00 – can dress without help of any kind
01 – need and get minimal supervision and reminding
02* – need some help from another person to put on clothes
03* – cannot dress yourself and somebody dresses you
04* – are never dressed / Comments
34. Grooming – How well are you able to manage grooming activities like combing hair, washing face, shaving, and brushing teeth?
00 – can comb hair, wash face, shave, brush teeth without help of any kind
01 – need and get supervision or reminding for grooming activities
02* – need and get daily help from another person
03* – are completely groomed by somebody else / Comments
35. Bathing – How well can you bathe or shower yourself. Running the water, taking a bath or shower without any help, washing all parts of your body including your face and hair.
00 – can bathe or shower without any help
01 – need and get minimal supervision or reminding
02 – need and get supervision only
03 – need and get help getting in and out of the tub
04* – need and get help washing and drying your body
05* -- cannot bathe or shower, need complete help / Comments
36. Eating – How well can you manage eating by yourself? Drinking and eating without any help from anybody else, but you use special utensils and straws, cutting most foods on your own.
00 – can eat without help of any kind
01 – need and get minimal reminding or supervision
02* – need and get help in cutting food, butter bread, or arranging food
03* – need and get some personal help with feeding or someone needs to be sure that you don’t
choke
04* – need to be fed completely or tube feeding or IV feeding / Comments
37. Bed Mobility – How well can you manage sitting up or moving around in bed?
00 – can move in bed without any help
01 – need and get help sometimes to sit up
02* – always need and get help to sit up
03* – always need and get help to be turned or change positions / Comments
38. Transferring – How well can you get in and out of a bed or chair?
00 – can get in and out of a bed or chair without help of any kind
01 – need somebody to guide you but can move in and out of a bed or chair
02* – need one other person to help you
03* – need two other people or a mechanical aid to help you
04* – never get out of a bed or chair / Comments
39. Behavior – Are there any issues? If yes, please describe:
00 – Behavior requires no intervention
01 – Needs and receives occasional staff intervention in the form of cues because the person is
anxious, irritable, lethargic, or demanding. Person responds to cues.
02* – Needs and receives regular staff intervention in the form of redirection because the person has
episodes of disorientation, hallucinates, wanders, is withdrawn or exhibits similar behaviors.
Person may be resistive, but responds to redirection.
03* – Need and receives behavior management and staff intervention because person exhibits
disruptive behavior such as verbally abusing others, wandering into private areas, removing or
destroying property, or acting in a sexually aggressive manner. Person may be resistant to
redirection.
04* – Needs and receives behavior management and staff intervention because person is physically
abusive to self and others. Person may physically resist redirection. / Comments
40. Walking – How well are you able to walk around, either without help or with a cane or walker but NOT a wheelchair? Does not include climbing the stairs.
00 – walk without help of any kind
01 – can walk with help of a cane, walker, crutch or push wheelchair
02* – need and get help from one person to help you walk
03* – need and get help from two people to help you walk
04* – cannot walk at all / Comments
41. Orientation – Defined as the awareness or an individual to his/her present environment in relation to time, place and person.
00 – Oriented 04 – Comatose
01 – Minor forgetfulness 05 – Not determined
02 – Partial or intermittent periods of disorientation
03 – Totally disoriented; does not know time, place, and identity / Comments
42. Self-Preservation
00 – Independent 03 – Physically unable
01 – Minimal supervision 04 – Both mentally and physically unable
02 – Mentally unable / Comments
43. Hearing
00 – No hearing impairment 03 – No useful hearing
01 – Has difficulty at level of convention 04 – Not determined
02 – Hears only very loud sounds / Comments
44. Communication
00 – Communicates needs
01 – Communicates needs with difficulty but can be understood
02 – Communicates needs with sign language, symbol board, written messages, gestures or an
interpreter
03 – Communicates inappropriate content, makes garbled sounds; displays echolalia
04 – Does not communicate needs / Comments
45. Vision
00 – No vision impairment 03 – Has no useful vision
01 – Has difficulty seeing at level of print 04 – Not determined
02 – Has difficulty seeing obstacles in environment / Comments
46. Toileting – How well can you manage using the toilet? Adjusting clothing, getting to and on the toilet, and cleaning one’s self. If reminders are needed to use the toilet this counts as some help.
00 – Can use the toilet without help, including adjustment of clothing
01 – Need some help to get to and on the toilet but don’t have accidents
02* – Have accidents sometimes, but not more than once a week
03* - Only have accidents at night
04* - Have accidents more than once a week
05* - Have bowel movements in your clothes more than once a week
06* - Wet your pants and have bowel movements in your clothes very often / Comments

INDEPENDENT LIVING: INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADLs)

47. Do you need any help with completing the following tasks? NONE
shopping for food and other things you need? heavy housekeeping (yard work, garbage)?
light housekeeping like dusting or sweeping?ability to do your own laundry?
preparing meals (sandwiches, TV dinners) for yourself? / Comments
48. What about your ability to take your own medication?
01 – Need no help or supervision 07 – need verbal or visual reminders only
05 – Don’t take medications. 08 – need medication setups and reminders
06 – need medication setup only 09 – need medication setups and administration / Comments
49.Are you diabetic? If yes, how do you control your diabetes? / Comments
01 – not diabetic
02 – no insulin require; diet controlled only
03 – oral medications / 04 – sliding scale insulin and oral
medications
05 – scheduled daily insulin
06 – scheduled daily insulin plus daily
sliding scale
01- No Help / 02 - Some Help / 03- A lot of Help / 04- Can’t do it
50. How well can you handle your own money, like paying bills or balancing your checkbook?
51.How well are you able to use public transportation, arrange transportation, or drive to places beyond walking distance?

UTILIZATION/FALLS

52. In the past year, have you gone to the hospital emergency department? / Yes No / How many times?
Reason:
53. In the past year, have you stayed overnight or longer in a hospital (other than the birth of a child)? / Yes No / How many times?
Reason:
54. In the past THREE years, have you spent any time in a nursing facility? / Yes No / How many times?
Reason:
55. Have you experience any falls in your home or while out in the community? / 00 No 01 Yes / If no, does concern about your balance or falling affect your daily activities or access to the community? 02 Yes 00 No
56.What is the final action (Assessment Result)?
35 - SNBC health risk assessment 39 – Refusal of health risk assessment / 57.Assessment Effective Date:
58. Program Type 28 – SNBC

ASSESSMENT RESULTS

59.Are there any problems or concerns? Service plan MUST be completed if any over the areas are marked “yes”.

Preventive Health / Yes No / Nutrition Health / Yes No
Medical Health / Yes No / Emotional and Mental Health / Yes No
ADL/IADLs Management / Yes No / Medication Management / Yes No
Alcohol/Tobacco/Substance Abuse / Yes No / Hospital /ED Utilization and Falls / Yes No
Self-Preservation and Safety / Yes No / Environment / Yes No
Abuse and/or Neglect / Yes No / Caregiver and Social Supports / Yes No
Other: / Other:

SERVICE PLAN SECTION

Service Plan
List any formal services the member receives:
Waiver Services:
Home Care Services:
Private Pay services:
List any informal (non-paid) services the member receives:
Concerns or Problems / Goal / Interventions including person(s) responsible / Due Date and Date Completed
Member Identified Outcomes
What the person wants to achieve or accomplish; how they want their life to be:
Remain in the community with health, home management, and safety needs met
Remain in their own home or in the least restrictive level of care with health and safety needs met
Move to a different living arrangement
Maintain level of independence
Continue to be active with family and friends and participate in community activities
Remain at home, acknowledges limitations and risks of residing in their own home
Other
Current supports, what works, skills, talents, interests:
Adequate social supports: friends, religious affiliation, church, etc.
Adequate family support and involvement
Appropriate/safe living arrangement
Recognize physical limitations and follows reasonable plan of care
Understands medication/treatment administration, takes medications as prescribed
Independent with ADL’s and IADL’s
Manage chronic illness well: follows diet, takes medications as directed, seeks medical attention as needed, etc.
Other
Health and Safety / Emergency Preparedness
Identify how health and safety needs will be met. Include identified needs even if the member prefers no intervention.
What services will be used. Identify any backup plans in place for formal and informal services being utilized.
Areas of concern identified in Comprehensive Health Assessment: (check all that apply)
Inadequate housing
Impaired cognition
History of behavior symptoms
At risk for abuse / neglect
Unstable or complicated health condition(s)
ADL’s and/or IADL limitations
Inability to ensure own care, hygiene, nutrition, or safety
Frail, frequently / at risk for falling
Inability to manage and administer medications / treatments
Lack of Motivation
Lack of limited access to reliable transportation
Literacy Issues
Comments:
How will health and safety needs be met? (check all that apply)
Case Management Oversight
Move to a more appropriate living arrangement
Provision of home care and/or waiver services
Individual refuses all or some of offered services
Encourage or referred for legal representation (POA, conservator, or guardian)
Has legal representative (POA, conservator, or guardian)
Comments:
Caregiver Assessment and Support Plan
Was a Caregiver identified in the member’s comprehensive health assessment (SCHA or LTCC)? Yes No
(Caregivers are unpaid person(s) providing services; if there was no Caregiver, the service would have to be purchased.)
If Yes, how was the Caregiver’s Assessment Form completed? / Declined / Face-to-Face / Telephone / Mail / Date Assessment Completed:
What kinds of services have been offered, requested, or started to help the Caregiver?
Help with care (home management/personal care)
List:
Financial
List:
Emotional/Social/Spiritual Support
List
Respite
List:
Home modifications and assistive devices
List:
Other
List:
Caregiver declined additional services. What is your follow-up plan?
Cultural / Linguistic Considerations
Are there specific cultural/linguistic needs for this caregiver? / Yes / No
Comments:
Member Plans
Personal Risk Management Plan
Did member refuse any services? / Yes (if yes, complete Personal Risk Assessment Management Plan) / No
Risk Plan discussed with: / Member / Family / Other
Discussion with member and/or family accept that they are responsible for any risk associated with refusing any recommended formal services and potential consequences.
Risk Plan Includes: Call 911 Family/Friend Support Care Coordinator/Case Manager contacted
Other - Please explain
Emergency Preparedness Plan
As discussed with member and/or family, in the event of an emergency member will: (check all that apply)
Call 911 / Call Emergency Contact - Name: / Use Emergency Response Monitoring System
Call Other Informal Support Person – Name and phone number:
Other (Describe):
Self-Preservation/Evacuation Plan: Member has a safety management plan on file at County.
If member is unable to evacuate independently in an emergency, describe the evacuation plan:
If other self-preservation concerns or plans, please describe:
Essential Services Back-up Plan: Member has an essential services back-up plan on file at County.
Member is receiving essential services: Yes No
If yes, briefly describe the member’s back-up plan if the Provider(s) are unable to provide the essential service:

Other Concerns/Updates

Agreements
  1. I have read the SingleCare or SharedCare Assessment and Service Plan, and agree with it.
/ Yes No
  1. I have received a copy of my complaints, appeals, and grievance rights.
/ Yes No
  1. You can choose the provider you prefer for services. Did the person who helped you with this plan give you a list of providers or tell you about different providers you could choose for services in this plan?
/ Yes No
  1. Did you have the opportunity to develop this service plan, including the kinds of services you want to receive, choice of personal goals, and desired level of involvement in the Service Plan?
/ Yes No
Release of Information/Data Privacy
I understand that in order for the above services to be coordinator effectively, it may be necessary for County Public Health or Social Services to share information regarding my diagnosis, medical needs, treatment plans, and social history with the medical professionals involved in my care. In signing this document I hereby give consent for the above services and sharing of information necessary for the coordination of services with my waiver service provider(s), home care provider(s), primary care provider(s), and/or family member involved in care. This consent expires within one year of signing and I understand that I can revoke this release in writing at any time.
Signatures
Member and/or Authorized Representative Signature:
Date:
Care Coordinator Completing This Plan Signature:
Date:
Date Service Plan given or mailed to member or authorized representative:
NOTES:

Fax the completed Health Assessment to SCHA at 507-431-6329 or via secure email to

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