GA Foods HealthNet Follow-up Assessment

GA Foods HealthNet Follow-up Assessment
Reminder: Please verify identifiable data such as birthdate or address, and give relevant disclosures.
Date*

MonthDayYear
Date
GA Client ID *
Member ID
Plan*
Name*

First NameLast Name
DOB*

MonthDayYear
Birthdate
Type of Appointment*

Final AppointmentFollow-Up Appointment
Height*
Weight*
BMI*
Do you have any chronic physical health conditions such as obesity, diabetes, high blood pressure, high cholesterol, kidney disease, liver disease, or cancer?*

YesNoUnsure
If Yes, list condition(s) here:
Have you been diagnosed with a mental health condition, such as depression, anxiety, bipolar disorder, substance abuse disorder or addiction?*

YesNoUnsure
If Yes, list condition(s) here:
In the past 12 months, have you been in the hospital, emergency room or a skilled nursing home?*

YesNoUnsure
If Yes/Unsure, please list any additional information provided (or why they were hospitalized):
Have you experienced any changes in your appetite in the past 3 months?*

YesNoUnsure
Have you had any unintentional changes in your weight in the past 6 months?*

YesNoUnsure
If Yes, have you lost or gained weight?

LostGained
Do you have any problems chewing or swallowing?*

YesNoUnsure
If Yes, do you need pureed texture foods?

YesNo
Do you have any physical limitations to shopping, cooking or feeding yourself?*

YesNoUnsure
Rate your overall health on a scale of 1 (extremely poor) to 5 (very good):
What is your confidence level in your ability to make healthy food choices?
Tell me how the meals are working for you. Which are your favorites?*
How have the meals helped you so far? Can you give an example?*
RD Summary
Does member have any contact/demographic info changes (address, phone number, preferred language, etc.)?*

YesNo
Please note changes:
Additional (relevant) information provided by the client (if any):
Member can benefit from an extension of meal authorization as there continues to be a medical necessity for ongoing nutrition support*

YesNo
RD's justification of meal extension*
Choose one of the following:

Member will benefit from MTMs because member has a chronic condition AND has been (or is being) discharged from the hospital or skilled nursing facility.Member will benefit from MTMs because member has a chronic condition AND is at high risk of hospitalization* or nursing facility placement.Member will benefit from MTMs because member has a chronic condition AND has extensive care coordination needs**.Member is not eligible for MTMs at this time.Member declined MTMs at this time.
Please include in note if:

· Member has recently been discharged from the hospital or a nursing facility

· Member is at high risk of hospitalization or nursing facility placement (repeat hospitalizations in the last year, frequent visits to ER or urgent care, uncontrolled chronic conditions, etc)

· Member has extensive care coordination needs (difficulty performing ADLS, difficulty managing their condition(s) or medication(s), etc)
BeWell: Low sodium & low fluid, renal

BeHealthy: Heart healthy, diabetic friendly, weight reduction
Diet Order*

1 BeHealthy breakfast box + 1 BeHealthy lunch box/wk x 12 wks2 BeWell lunch boxes/wk x 12 wks1 BeHealthy breakfast box + 1 BeWell lunch box/wk x 12 wks2 high calorie/high protein meal boxes per week x 12 wks1 BeHealthy breakfast box + 1 high calorie/high protein/wk x 12 wks1 produce box/wk x 12 wks1 BeHealthy breakfast box + 1 BeWell lunch box/wk x 6 wks, then 1 produce box/wk x 6 wks1 BeHealthy breakfast box + 1 BeHealthy lunch box/wk x 6 wks, then 1 produce box/wk x 6 wks1 BeHealthy breakfast box + 1 high cal/high protein box/wk x 6 wks, then 1 produce box/wk x 6 wks2 BeHealthy box/wk x 6 wks, then 1 produce box/wk x 6 wks2 BeWell box/wk x 6 wks then 1 produce box/wk x 6 wks2 High calorie, high protein box/wk x 6 wks, then 1 produce box/wk x 6 wks2 puree meals boxes/week2 Kosher meals boxes/week (Note to dietitians - Please only use this when there is absolutely no other option, it is not controlled for sodium and carbohydrates)NA – Member declined meals
Note: Menus are set by GA Foods and rotate on a regular basis. Members cannot select individual meals. Allergies cannot be accomodated, it is member's responsibilty to read labels.
Service Unit Quantity

1 meal per day for 12 weeks2 meals per day for 12 weeks
Additional Nutrition Appointments Requested*
Visit codes
Food benefit selection*

S5170 U6‐ Medically Tailored MealsDeclined counseling – still wants mealsDeclined meals
Reason for Declining
Name of RD conducting this assessment*
# of mins spent on call*
Do any of the following apply?

Z5941 Food insecurityZ550 Illiteracy and low-level literacyZ597 Insufficient social insurance and welfare supportZ602 Problems related to living aloneZ604 Social exclusion and rejectionZ62819 Personal history of unspecified abuse in childhoodZ630 Problems in relationship with spouse or partnerZ634 Disappearance & death of family memberZ635 Disruption of family by separation and divorceZ636 Dependent relative needing care at homeZ6372 Alcoholism and drug addiction in familyZ651 Imprisonment and other incarcerationZ658 Other specified problems related to psychosocial circumstancesZ5948 Other specified lack of adequate food
GA Customer Care Phone: 1-866-575-2772
GA Customer Care E-mail: carecenter@gafoods.com
Should be Empty: