GA - Aetna/Kentucky Follow-up Assessment

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

MonthDayYear
Date
GA Client ID *
Member ID
Session type*

Follow upFinal*
*For FINAL SESSIONS: please let the member know that if they would like to continue with the program they need to personally request reauthorization with their health plan. You can direct them to call their care manager or the number on the back of their insurance card.
Name*

First NameLast Name
DOB*

MonthDayYear
Birthdate
Please check all current conditions that apply:*

Diabetes/Pre-DiabetesCongestive heart failureKidney diseaseCOPDMalnutritionHeart Disease (HTN, MI, Stroke, CHF, Hyperlipidemia, etc)Musculoskeletal Injury/DiseaseCancerPregnancy/Lactation/Gestational DiabetesMemory-Related Illness (dementia, brain injury, concussion)Mental Health IllnessSubstance AbuseOther
Are any of these conditions new?*

YesNoUnsure
If Yes, list condition(s) here:
Weight*
Height*
BMI*
Assessment (seeking nutrition education for):*
Nutritional Diagnosis/Nutrition Education Needs*
Intervention:*
Monitoring/Evaluation:*
Tell me how the meals are working for you. Which are your favorites?*
Are you also receiving nutrition drinks? If yes, how have they helped you so far? Can you give an example? *
RD Summary
Member can benefit from an extension of meal authorization as there continues to be a medical necessity for ongoing nutrition support*

YesNo
Member can benefit from an extension of oral nutrition supplements as there continues to be a medical necessity for ongoing nutrition support*

YesNoNot Applicable
RD's justification of meal extension*
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):
Menu Recommendation:

PureedKosherBe Well (Low sodium & low fluid, renal)Be Healthy & Be Healthy Breakfast (Heart healthy, diabetic friendly, weight reduction)General WellnessHigh Calorie & High ProteinShelf Stable MenuN/A (not eligible, doesn't want, etc)
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.
BeWell: Low sodium & low fluid, renal

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

1 BeHealthy Breakfast Box + 2 BeHealthy Lunch Box /week3 BeWell Lunch Box /week1 BeHealthy Breakfast Box + 2 BeWell Lunch Box /week3 High Calorie/High Protein Meal Boxes /week1 BeHealthy Breakfast Box + 2 High Calorie/High Protein /week1 ONS/day + 1 BeHealthy Breakfast Box + 1 BeHealthy Lunch Box /week1 ONS/day + 1 BeHealthy Breakfast Box + 1 BeWell Lunch Box /week1 ONS/day + 1 BeHealthy Breakfast Box + 1 High Cal/High Protein Box /week1 ONS/day + 2 BeHealthy Lunch Box /week1 ONS/day + 2 BeWell Box /week1 ONS/day + 2 High Cal/High Protein Box /week3 Puree Meals Boxes /week1 ONS/day + 2 puree Meal Boxes /week2 ONS/day x 12 weeks3 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
Reason for Declining
Oral Nutrition Supplement Recommendation:*

Ensure Plus, 8 fl ozEnsure High Protein, 8 fl ozGlucerna, 8 fl ozNepro, 8 fl ozEnsure Sugary, 8 fl ozJuven, 8 fl oz preparedPulmocare, 8 fl ozSuplena, 8 fl oz
Flavor

VanillaMilk ChocolateStrawberryButter Pecan
Flavor

VanillaChocolate
Flavor

VanillaChocolateStrawberryButter Pecan
Flavor

VanillaMixed BerryButter Pecan
Flavor

UnflavoredOrangeFruit Punch
Flavor

Vanilla
Service Unit Quantity

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

S5170 U6‐ Medically Tailored MealsNot eligibleNot interested
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
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GA Aetna/Kentucky Follow-up Assessment