Inspire SNBC Care Plan
Information About Me
Name:	HealthPartners ID #:	SNBC Enrollment Date:	Care Plan Completion Date:
My DOB:	Assessment Date: Assessment Type: Initial HRA Annual reassessment Change of Condition Other:
My Phone #:
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:
If applicable, County Waiver CM Information: Name: Phone: Fax: E-mail: 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 MHTCM Name: MHTCM Phone #:
Other Members of My Team	Relationship to Me	Phone Number	Care Plan Shared with Team Member
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
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?)
Initial/Annual:
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:

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 (Every 1-2 years for ages 50-75. Under age 50, talk to your doctor.)
Cervical Cancer Screening (PAP test ages 21-29, every 3 years. For ages 30-65, every 5 years if combined with HPV testing.)
Colorectal Screening (Start screening at age 50. If you are African American, American Indian or Alaska Native, start at age 45. Repeat screening at intervals determined by type of screening type used. End screening at age 75.)
At Risk for Falls
Flu shot (Annually)
COVID-19 Vaccine
Tetanus Booster (Once every 10 years)
ADL/IADL Dependencies
Screening for My Health
Check if educational conversation took place with me	Goal is Needed	Check if N/A, Contraindicated, Declined	Notes
Hearing Exam
Vision Exam (in the last two years)
Dental Exam (in the last year)
Family Planning
Rehabilitative Services
Education and/or Employment
Child and Teen Check-Up (ages 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:

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)

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