[DATE]

Dear Dr. [Physician Name]:

[Member Name] [Member DOB] is a member of HealthPartners Minnesota Senior Health Options (MSHO) or Minnesota Senior Care Plus program (MSC+). As your patient’s Care Coordinator, I recently met with your patient or reviewed information to complete a health risk assessment.

Enclosed is a copy of the care plan developed with your patient based on the results of our health risk assessment (HRA) or from a review of information available if your patient did not participate in the HRA. The care plan is intended to support your treatment plan as well as address additional needs of the patient.

[Insert specific visit-related content]

Since you have been treating this patient, you are assumed to be part of this patient’s interdisciplinary care (ICT) team and I want to formally invite you to be on patient’s ICT.

I welcome your ongoing participation in the ICT and involvement with this patient and your input to the development of this care plan. Please notify me of anything you would like to add, change, or remove from this care plan and I will create a new care plan and send you and this patient the updated copy.

I will periodically communicate with you by phone if there are any concerns or needs that I become aware of while case managing your patient.

Please inform me of any specific issues or concerns that I can help address. I can be contacted at [phone number].

My goal is to work with you and your team to keep your patient independent and in the community, while preventing unnecessary hospitalizations or nursing home placements. My role includes:

Partnering with your patient’s interdisciplinary care team and facilitating collaborations as needed.

Working to optimize the patient’s health and well-being and self-management of their chronic conditions in a person-centered fashion.

Alerting you to concerns and issues about how your patient is functioning at home or out in the community, giving particular attention to safety.

Arranging community resources, home-care services, and equipment.

Being a point person during all transitions of care; screening for red flags and encouraging prompt follow up appointments.

Encouragement and monitoring of preventive care including annual dental exam, relevant medical tests, and mental health concerns.

Sincerely,

[Care Coordinator Name]

MSHO/MSC+ Care Coordinator, HealthPartners

Phone: [Phone number]

Toll-Free: [Toll-Free number]

Enclosure: Care Plan