My Inspire (SNBC) Nursing Facility Care Plan
Information About Me
My Name: My DOB:	HealthPartners ID #:	SNBC Enrollment Date:	Care Plan Completion Date:
Phone #:	Assessment Date: Assessment Type: Initial HRA Annual reassessment Change of Condition Other:
My Address:
My 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)
My Care Coordinator/Case Manager: Name: Phone #:	My Primary Physician: Phone #: Fax #:	Clinic:
Other Members of My Team	Relationship to Me	Phone Number

What’s Important to Me? (e.g. living close to my family, visiting friends)

Initial/Annual
Update

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)

Barriers to meeting my goals (if applicable)

Initial/Annual:
Update:

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:

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:

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