Care Coordination Resources

Minnesota Senior Care Plus (MSC+) and Minnesota Senior Health Options (MSHO)

Care Coordinators foster ongoing primary and preventative care, create a person-centered support plan and assist with communication between all members of the interdisciplinary care team.

To find product-specific tools and forms, select the desired plan from the "Please select" drop-down and click "Select Plan" to explore each category and its contents.

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Requirement Grids

Community Elderly Waiver Care Coordination Requirements Grid (Revised 1/1/2025)
Community Non-Elderly Waiver Care Coordination Requirements Grid (Revised 1/1/2025)
Institutionalized Care Coordination Requirements Grid (Revised 1/1/2025)

Forms

Assessment and Support Plan Forms
2025 Monthly Activity Log (Revised 4/1/2025)
Institutional Health Risk Assessment (Revised 4/7/2025)
Institutional Support Plan (Revised 1/1/2024)
Institutional Support Plan Signature Page (New 1/1/2025)
Refusal Support Plan (Revised 12/6/2024) | Word | PDF
Transfer Member Health Risk Assessment (Revised 1/1/2025) | Word | PDF
UTR Support Plan (Revised 12/6/2024) | Word | PDF

Other Forms
Death Notification Form (Revised 8/1/2024)
Home and Community Based Service Exception Request (New 3/4/2025)
ILOS Request Form (Revised 1/8/2025) | ILOS Instructions (Revised 1/28/2025)
Nursing Facility Coverage Guide (Revised 1/1/2025)
PCC Change Form (Revised 4/9/2025) | Process Flow
Release of Information Form (Revised 7/3/2024)
Support Plan Translation Request (Revised 2/18/2025)

Transitions of Care

Transitions of Care Log (Revised 12/30/22)
TOC Log Instructions (Revised 4/9/2025)
Transition of Care (TOC) Notification to PCP (Revised 6/3/2024)
Transition of Care Talking Points

Elderly Waiver

EW Service Authorization
Waiver Service Approval Form (Revised 2/28/2025)
Waiver Service Approval Form - T2029 (Revised 6/28/2024)
EW T2029 Equipment and Supplies Guide (New 6/28/2024)
EW T2029 Equipment and Supplies Coverage Process (New 6/28/2024)
Home Health Communication Form
EW Budget Tool (Revised 1/1/2025)
CBSM EW Conversion Rates
Elderly Waiver Capitation Dates

CDCS Toolkit
Care Coordinator CDCS Guidelines (Revised 2/1/2025)
CC CDCS Plan Approval Checklist (Revised 2/1/2025)
CDCS DHS 5788A CSP Change Form (Revised 2/1/2025)
CDCS Member Agreement and Checklist (Revised 2/1/2025)
CDCS Post Assessment Communication Form (New 4/3/2025)
Consumer Directed Community Supports (CDCS) Policy Manual
Member Guide to CDCS Allowed Expenditures (Revision coming soon - refer to CDCS policy manual)
Notice of Technical Assistance (New 8/1/2024)

EW DTR Form and Instructions
Elderly Waiver DTR Form | Instructions (Revised 10/4/2024)
EW DTR Reason Code Tool (Revised 1/1/2024)
Home Health Communication Form | HHC Example

PCA/CFSS Authorization

Care Coordination resources
CFSS Care Coordination Guidelines (Revised 3/31/2025)
CFSS FAQ (Revised 3/25/2025)
PCA/CFSS Communication Form (Revised 3/17/2025) | Instructions (Revised 3/25/2025)

Other links
DHS CFSS Policy Manual
UCare PCA/CFSS Provider Forms