Health Action Plan (HAP) - DSHS [PDF]

Katz ADL. Katz ADL. Katz ADL. PHQ-9. PHQ-9. PHQ-9. PSC-17. PSC-17. PSC-17. BMI. BMI. BMI. OPTIONAL SCREENING SCORES. OPT

0 downloads 11 Views 84KB Size

Report

Download PDF

PNG Network

Recommend Stories

ACTION PLAN Action Plan

The beauty of a living thing is not the atoms that go into it, but the way those atoms are put together.

Mental Health Transformation-- A Research Project for Social ... - DSHS [PDF]

Oct 31, 2006 - marketing plan to support Mental Health Transformation in Washington State. A âsocial marketingâ .... more/better advertising and advance communications. ...... Budget priority for mental health is not high in their communities. ..

Action Plan 2016- 2017.pdf

Sorrow prepares you for joy. It violently sweeps everything out of your house, so that new joy can find

Action plan for sexual and reproductive health

There are only two mistakes one can make along the road to truth; not going all the way, and not starting.

Regional Action Plan for Public Health

Don't be satisfied with stories, how things have gone with others. Unfold your own myth. Rumi

Community Health Needs Assessment and Action Plan

The butterfly counts not months but moments, and has time enough. Rabindranath Tagore

OHA 9963 Action Plan for Health

Your big opportunity may be right where you are now. Napoleon Hill

action plan

Ego says, "Once everything falls into place, I'll feel peace." Spirit says "Find your peace, and then

Action Plan

Happiness doesn't result from what we get, but from what we give. Ben Carson

Action Plan

Sorrow prepares you for joy. It violently sweeps everything out of your house, so that new joy can find

Idea Transcript

CLIENT’S FIRST NAME

Health Action Plan (HAP) DATE OF HAP: BEGIN

END

CLIENT’S LAST NAME

MALE FEMALE UNKNOWN OTHER

HEALTH HOME LEAD ORGANIZATION

DATE OPTED IN

DATE OF BIRTH

PROVIDER ONE CLIENT ID

HH LEAD ORGANIZATION PHONE

CARE COORDINATION ORGANIZATION

CARE COORDINATOR’S NAME

REASON FOR CLOSURE OF THE HAP

CARE COORDINATOR’S PHONE

REASON FOR TRANSFER OF THE HAP

Beneficiary Opted Out Death

Move to a county that does not have Health Home services No longer eligible

Client choice to change CCO or Lead Organization Eligibility changed (change to/from FFS or MCO)

CLIENT INTRODUCTION CLIENT’S LONG TERM GOAL

DIAGNOSIS (PERTINENT TO HAP)

Initial / Annual HAP Required Screenings SCREEN

DATE

SCORE / LEVEL

Four Month Update Required Screenings

IF NOT COMPLETE, EXPLAIN

SCREEN

DATE

SCORE / LEVEL

IF NOT COMPLETE, EXPLAIN

Eight Month Update Required Screenings SCREEN

DATE

SCORE / LEVEL

PAM

/

PAM

/

PAM

/

CAM

/

CAM

/

CAM

/

PPAM

/

PPAM

/

PPAM

/

Katz ADL

Katz ADL

Katz ADL

PHQ-9

PHQ-9

PHQ-9

PSC-17

PSC-17

PSC-17

BMI

BMI

BMI

OPTIONAL SCREENING SCORES SCREEN

DATE

OPTIONAL SCREENING SCORES

SCORE

SCREEN

DATE

SCORE

OPTIONAL SCREENING SCORES SCREEN

DAST

DAST

DAST

GAD-7

GAD-7

GAD-7

AUDIT

AUDIT

AUDIT

FALLS RISK

FALLS RISK

FALLS RISK

PAIN ADDITIONAL COMMENTS

HEALTH ACTION PLAN (HAP) DSHS 10-481 (REV. 09/2017)

FLACC

FACES

NUMERIC

PAIN ADDITIONAL COMMENTS

FLACC FACES NUMERIC

IF NOT COMPLETE, EXPLAIN

DATE

PAIN

SCORE

FLACC

FACES

NUMERIC

ADDITIONAL COMMENTS

Page 1

CLIENT’S FIRST NAME

Health Action Plan (HAP) DATE OF HAP: BEGIN

END

DATE OPTED IN

START DATE

Goal End Date: No longer pertinent – life or health change Client request to discontinue

COMPLETION DATE

HEALTH ACTION PLAN (HAP) DSHS 10-481 (REV. 09/2017)

ACTION STEPS

MALE FEMALE UNKNOWN OTHER

HEALTH HOME LEAD ORGANIZATION CARE COORDINATOR’S NAME

START DATE

Goal End Date: No longer pertinent – life or health change Client request to discontinue

COMPLETION DATE

PROVIDER ONE CLIENT ID

CARE COORDINATOR’S PHONE

Four Month Update Short Term Goal: Goal Start Date: Outcome: Completed Revised

DATE OF BIRTH

HH LEAD ORGANIZATION PHONE

CARE COORDINATION ORGANIZATION

Initial / Annual HAP Short Term Goal: Goal Start Date: Outcome: Completed Revised

CLIENT’S LAST NAME

ACTION STEPS

Eight Month Update Short Term Goal: Goal Start Date: Outcome: Completed Revised START DATE

Goal End Date: No longer pertinent – life or health change Client request to discontinue

COMPLETION DATE

ACTION STEPS

Page 2

CLIENT’S FIRST NAME

Health Action Plan (HAP) DATE OF HAP: BEGIN

END

DATE OPTED IN

START DATE

Goal End Date: No longer pertinent – life or health change Client request to discontinue

COMPLETION DATE

HEALTH ACTION PLAN (HAP) DSHS 10-481 (REV. 09/2017)

ACTION STEPS

MALE FEMALE UNKNOWN OTHER

HEALTH HOME LEAD ORGANIZATION CARE COORDINATOR’S NAME

START DATE

Goal End Date: No longer pertinent – life or health change Client request to discontinue

COMPLETION DATE

PROVIDER ONE CLIENT ID

CARE COORDINATOR’S PHONE

Four Month Update Short Term Goal: Goal Start Date: Outcome: Completed Revised

DATE OF BIRTH

HH LEAD ORGANIZATION PHONE

CARE COORDINATION ORGANIZATION

Initial / Annual HAP Short Term Goal: Goal Start Date: Outcome: Completed Revised

CLIENT’S LAST NAME

ACTION STEPS

Eight Month Update Short Term Goal: Goal Start Date: Outcome: Completed Revised START DATE

Goal End Date: No longer pertinent – life or health change Client request to discontinue

COMPLETION DATE

ACTION STEPS

Page 3

CLIENT’S FIRST NAME

Health Action Plan (HAP) DATE OF HAP: BEGIN

END

DATE OPTED IN

START DATE

Goal End Date: No longer pertinent – life or health change Client request to discontinue

COMPLETION DATE

HEALTH ACTION PLAN (HAP) DSHS 10-481 (REV. 09/2017)

ACTION STEPS

MALE FEMALE UNKNOWN OTHER

HEALTH HOME LEAD ORGANIZATION CARE COORDINATOR’S NAME

START DATE

Goal End Date: No longer pertinent – life or health change Client request to discontinue

COMPLETION DATE

PROVIDER ONE CLIENT ID

CARE COORDINATOR’S PHONE

Four Month Update Short Term Goal: Goal Start Date: Outcome: Completed Revised

DATE OF BIRTH

HH LEAD ORGANIZATION PHONE

CARE COORDINATION ORGANIZATION

Initial / Annual HAP Short Term Goal: Goal Start Date: Outcome: Completed Revised

CLIENT’S LAST NAME

ACTION STEPS

Eight Month Update Short Term Goal: Goal Start Date: Outcome: Completed Revised START DATE

Goal End Date: No longer pertinent – life or health change Client request to discontinue

COMPLETION DATE

ACTION STEPS

Page 4

CLIENT’S FIRST NAME

Health Action Plan (HAP) DATE OF HAP: BEGIN

END

DATE OPTED IN

START DATE

Goal End Date: No longer pertinent – life or health change Client request to discontinue

COMPLETION DATE

HEALTH ACTION PLAN (HAP) DSHS 10-481 (REV. 09/2017)

ACTION STEPS

MALE FEMALE UNKNOWN OTHER

HEALTH HOME LEAD ORGANIZATION CARE COORDINATOR’S NAME

START DATE

Goal End Date: No longer pertinent – life or health change Client request to discontinue

COMPLETION DATE

PROVIDER ONE CLIENT ID

CARE COORDINATOR’S PHONE

Four Month Update Short Term Goal: Goal Start Date: Outcome: Completed Revised

DATE OF BIRTH

HH LEAD ORGANIZATION PHONE

CARE COORDINATION ORGANIZATION

Initial / Annual HAP Short Term Goal: Goal Start Date: Outcome: Completed Revised

CLIENT’S LAST NAME

ACTION STEPS

Eight Month Update Short Term Goal: Goal Start Date: Outcome: Completed Revised START DATE

Goal End Date: No longer pertinent – life or health change Client request to discontinue

COMPLETION DATE

ACTION STEPS

Page 5

CLIENT’S FIRST NAME

Health Action Plan (HAP) DATE OF HAP: BEGIN

END

DATE OPTED IN

START DATE

Goal End Date: No longer pertinent – life or health change Client request to discontinue

COMPLETION DATE

HEALTH ACTION PLAN (HAP) DSHS 10-481 (REV. 09/2017)

ACTION STEPS

MALE FEMALE UNKNOWN OTHER

HEALTH HOME LEAD ORGANIZATION CARE COORDINATOR’S NAME

START DATE

Goal End Date: No longer pertinent – life or health change Client request to discontinue

COMPLETION DATE

PROVIDER ONE CLIENT ID

CARE COORDINATOR’S PHONE

Four Month Update Short Term Goal: Goal Start Date: Outcome: Completed Revised

DATE OF BIRTH

HH LEAD ORGANIZATION PHONE

CARE COORDINATION ORGANIZATION

Initial / Annual HAP Short Term Goal: Goal Start Date: Outcome: Completed Revised

CLIENT’S LAST NAME

ACTION STEPS

Eight Month Update Short Term Goal: Goal Start Date: Outcome: Completed Revised START DATE

Goal End Date: No longer pertinent – life or health change Client request to discontinue

COMPLETION DATE

ACTION STEPS

Page 6

CLIENT’S FIRST NAME

Health Action Plan (HAP) DATE OF HAP: BEGIN

END

DATE OPTED IN

START DATE

Goal End Date: No longer pertinent – life or health change Client request to discontinue

COMPLETION DATE

HEALTH ACTION PLAN (HAP) DSHS 10-481 (REV. 09/2017)

ACTION STEPS

MALE FEMALE UNKNOWN OTHER

HEALTH HOME LEAD ORGANIZATION CARE COORDINATOR’S NAME

START DATE

Goal End Date: No longer pertinent – life or health change Client request to discontinue

COMPLETION DATE

PROVIDER ONE CLIENT ID

CARE COORDINATOR’S PHONE

Four Month Update Short Term Goal: Goal Start Date: Outcome: Completed Revised

DATE OF BIRTH

HH LEAD ORGANIZATION PHONE

CARE COORDINATION ORGANIZATION

Initial / Annual HAP Short Term Goal: Goal Start Date: Outcome: Completed Revised

CLIENT’S LAST NAME

ACTION STEPS

Eight Month Update Short Term Goal: Goal Start Date: Outcome: Completed Revised START DATE

Goal End Date: No longer pertinent – life or health change Client request to discontinue

COMPLETION DATE

ACTION STEPS

Page 7

Health Action Plan (HAP) - DSHS [PDF]

Recommend Stories

Idea Transcript

Helpful Links

Smile Life

Get in touch