CHF Medically Tailored Meals Referral · 2018-11-19 · 1.DHCS designated ICD-10 codes for CHF: I50.1 Left ventricular failure, unspecified (must separate beneficiaries with I50.1

Signature of Referrer

Phone Date

CHF Medically Tailored Meals Referral

HIPAA Compliant Fax: 707-387-0898

Questions: 707-861-0602

Healthcare Provider only below this line

Consent to Release Information

PHYSICAL DATA:

Secondary Contact: Name: Phone:

Co-morbidities: Cancer: Renal Disease:

COPD:Diabetes:

Other:

Office Stamp

Clinic/Hospital Name

Printed Name of Referrer

VERSION 11/15/2018

Phone:

Issue Date

Inclusion Criteria

1. DHCS designated ICD-10 codes for CHF:

I50.1 Left ventricular failure, unspecified (must separate beneficiaries with I50.1 to research other diagnosis codes to ensure they indeed have

CHF) I50.2 Systolic (congestive) heart failure

I50.20 Unspecified systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure

I50.3 Diastolic (congestive) heart failure I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestive) heart failure

I50.4 Combined systolic (congestive) and diastolic (congestive) heart failure I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure

2.Must have had an inpatient stay or emergency room visit from congestive heart failureexacerbations in the past 12 months. See acceptable ICD-10 codes above. Comorbidities withcancer, diabetes, or COPD are acceptable.

3.Must currently be and have been enrolled in Medi-Cal for at least a continuous 12 months.

4.Must have had a primary physician or specialist visit within the last 12 months.

5.Must live in Sonoma County.

Exclusion Criteria a. Persons with NYHA Class I and Class IV heart failureb. Persons with severe aortic stenosis.c. Persons with limited physical, cognitive, or behavioral abilities that would interfere with their ability to follow-up witha study as determined by their ability to receive the MTM services and follow up with survey interviews.d. Persons with anticipated life expectancy of less than a year.e. Persons with severe allergies to eggs, soy, wheat, nuts, seeds, seed oils, or pineapple.f. Persons receiving more than seven meals per week from their residency.