Aetna Better Health - Premier Plan®

1333 Gratiot Ave Suite 400

Detroit, MI 48207

Aetna Better Health Premier Plan (Medicare-Medicaid Plan)

15 June, 2020

Mr. Mustafa Allahma

3881 Caely St
Detroit, MI 48212

Care Plan for: Mustafa Allahma

Member ID #: 1099050296

Dear Mustafa,

Thank you for talking with us today. This Care Plan is a summary of our discussion. Please use this Care Plan to keep
track of what we talked about.

Aetna Better Health Premier Plan is a health plan that contracts with both Medicare and Michigan Medicaid to
provide benefits of both programs to enrollees.

www.aetna.com

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 INTEGRATED CARE PLAN
YOUR INFORMATION
Name: Mustafa Allahma ID: 1099050296
Living Address: 3881 CAELY ST DOB: 10/23/1949 (70)
DETROIT, MI 48212
Mailing Address: 3881 CAELY ST Cell Phone:
DETROIT, MI 48212
Email: Phone 2: 3136037062
Contact Preference: Phone Language: Bengali

Your Care and Support

Team Responsible Party Name Phone Fax or Email

PCP AMITABH PAHARIA 3133691500 3133691205

Care Coordinator April Przybranowski

Member Representative

OUR WORK TOGETHER

Date you joined this health
plan
Date of your last
assessment
Reason why we are talking
about my Care Plan and
goals today
08/01/2019 Date you started working 06/15/2020
with your care coordinator
6/15/2020 Date(s) of Care Plan reviews
New to Care Management My care coordinator and I Date of My Last Care Team
plan to talk about my plan Meeting: 05/03/2020
of care and goals at least
Quarterly

YOUR PLAN OF CARE

Your Story: 6/15/2020 Member file review and Initial Level 1 assessment completed. Mustafa Allahma is a 70
year old male that lives alone in Detroit, Michigan. Mustafa's primary language is Bengali, Aetna interpreter
assisted with the call. Mustafa's diagnoses include: coronary artery disease, diabetes, high blood pressure, and
high cholesterol. Mustafa rates health as "fair." Mustafa's primary care doctor is Dr. Amitabh Paharia, last
seen in April 2020. Mustafa reports severe left knee pain that bothers him daily. Mustafa states, "Sometimes my
left knee pain is so bad that I can't get up." Dr. Paharia recommended he see an orthopedist to further examine
the issue but has not yet followed up. X-rays have been taken that confirm no broken bones. Mustafa requests
Bengali speaking specialist. Writer searched local orthopedists and found there are only podiatrists who speak
Bengali in the area. Mustafa wrote the numbers down and reports he will call to ask about an appointment.
Mustafa also needs hearing aids. He received an audiological report that came in the mail last week. Mustafa
was advised to locate a hearing aid specialist in the area through Aetna. No emergency department visits or
hospitalizations in the past twelve months. Mustafa reports last eye exam was in May of 2020, and has never had
a dental exam. DentaQuest, number given for Mustafa to find a dentist. Mustafa also states his cardiologist
recommends he get injections because "it's better than taking Plavix." Writer referred Mustafa to the benefit
department to further assist. Mustafa reports he is independent with daily living tasks such as bathing, dressing,
cooking, cleaning, and transportation. Mustafa drives but states his car does not always work. Friend, Manzuul
provides support by calling to check on Mustafa and assists with transportation as needed. Mustafa states he
feels his needs are adequately met and currently does not need additional help with daily tasks. Mustafa reports
he follows a low sugar diabetic diet and is compliant with all medications. Mustafa does have an OTC card,
request for card will be made today. No long term planning in place but Mustafa requests more information,
advance directive forms to be mailed. No Flu or pneumonia shots reported. Writer will follow up with Mustafa
Mr.MUSTAFA ALLAHMA Care Plan 2 of 7 June 15, 2020
week of 6/22/2020. -A. Przybranowski, LLBSW
Care Plan Date: 06/15/2020 Next Care Plan Review : 09/13/2020
Your Long Term Goal "I want to continue living independently and find a knee doctor for pain in my left knee."
Your Strengths I have positive social connections such as friends, family, or community support., I have
stable and reliable housing.
Your Barriers I have functional deficits that interfere with my day to day functioning.
Your Conditions I have the following conditions...
Coronary Artery Disease, Diabetes, Heart Failure, Hypertension, Tobacco Use
Your Preferences Talk with me in Bengali
Send written information to me in Bengali
The best time of day to call or visit me is Lunch

Your Prioritized Goals

Goal Priority Goal Target Date Outcome Progress

1 - High I will have a PCP who By 10/15/2020 1

will work with other
providers as needed to
meet my healthcare
needs.
2 - Medium I will understand my By 12/15/2020 0
benefits, prior auth
needs, and network for
hearing aids

The steps we will take together to help you meet your goals.

To help you get the care and services you need

Goal Priority Action Who Will Complete Due Date Action Completed

1 - High Make a plan for Member - MUSTAFA 9/15/2020 In progress

transportation to all
appointments. Contact
Logisticare if you need
help getting to and from
medical appointments
2 - Medium Set up hearing services Member - MUSTAFA 9/15/2020 In progress
to help you
communicate about
your health and service
needs. Call member
services for a list of
Hearing Aid Providers
in your area (855)
676-5772
2 - Medium Work with your Member & CM - 7/15/2020 In progress
providers, your case MUSTAFA/April
manager, and health
plan staff to get your
needs met.
Communicate with April
to check your progress.
First follow up call
scheduled for
6/22/2020 at 11:00 AM

To Help You Take Care of Yourself and Stay as Independent as You Can
Goal Priority Action Who Will Complete Due Date Action Completed

Mr.MUSTAFA ALLAHMA Care Plan 3 of 7 June 15, 2020

 1 - High Talk to your provider Member & CM - 9/15/2020 In progress
about a referral for a MUSTAFA/April
doctor that specializes
in your condition.
Follow up with provider
given by case manager.
Ask Dr. Paharia if there
are any referrals she
can provide for
orthopedic specialists
(knee doctors).

YOUR SERVICES AND TREATMENTS

Service or Treatment . . .
Drugs
Medical Treatment
Equipment
Home or Community Based*
Your Natural Disaster Plan
Your Safety Plan
Your Back Up Plan
To Help With . . .
TAMSULOSIN CAP 0.4MG for urine retention
FEXOFENADINE TAB 60MG for allergies
ACETAMINOPHE TAB 500MG for pain
AMLODIPINE TAB 10MG for high blood pressure
VITAMIN D CAP 50000UNT for supplement
JANUMET TAB 50-1000 for diabetes
OMEPRAZOLE TAB 20MG for heart burn
ASPIRIN ADLT TAB 81MG for helps prevent heart attack
PLAVIX TAB 75MG for heart problems
Blood pressure monitor - owns, fair condition, Glucometer - owns, fair condition,
Walker/cane - cane, good working condition
Transportation (Dial-A-Ride) - Logisticare/Manzuul
I know that there may be a disaster in my area. A disaster may be caused by wind,
rain, fire, floods, extreme heat or extreme cold. I want to be ready.
 I have received help on how to prepare for an emergency: Yes
 Myc arec oordi
natorha soffe redtohe l
pmes ignuponmys t
ate ’
se me rge nc
y
planning web site: N/A
 I ha v
es i
g ne duponmys ta t
e ’
se merg enc ywe bs i
te :N/ A
Emergency Contact
Name: Manzuul Khan
Primary Phone: (313) 327-5357
Secondary Phone:
Address: unknown
Relationship to Member: Friend
Notes:Mustafa has a smoke alarm, flashlight, and several doors and windows in
home. Mustafa can also call friend, Manzuul in an emergency if needed.
I may need help in a crisis or emergency. If this happens, I will Call 911, Go to the
Emergency Department
N/A

Comments:

Plan of Care Acknowledgement: My Plan of Care has been reviewed with me by my care coordinator. My
care coordinator has also explained my rights as a health plan member. I know that:
 I have the choice of my care providers. I may change my provider, choosing from those that work with
my health plan.
 My plan of care can change if my needs change.

Mr.MUSTAFA ALLAHMA Care Plan 4 of 7 June 15, 2020

  My plan of care can change after further review. If it changes, my care coordinator will talk to me
about it.
 If I need more services or other services, I can call my care coordinator at .
 My care coordinator knows about my care team.
o My care team includes my primary care provider (PCP).
o My care team helps to set up and works with me on my care plan
 My care team will get a copy of my care plan.
 My PCP may discuss my care plan with me at my next visit.

Member/Representative Signature Date

April Przybranowski, LLBSW 06/15/2020

Care Coordinator Signature Date

Mr.MUSTAFA ALLAHMA Care Plan 5 of 7 June 15, 2020

Aetna, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color,
national origin, age, disability, or sex. Aetna, Inc. does not exclude people or treat them differently because of race, color,
national origin, age, disability, or sex.
Aetna, Inc.:
•Provide sfreea i
dsa nds ervicestope opl
ewi t
hdi sabiliti
e stoc ommuni catee ffectivelywi thus ,su cha s:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats, other formats)
•Provi
de sf r
e elangua ges ervic e
stope oplewhos epr i
ma ryl angua gei snotEngl ish,
such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact Aetna Medicaid Civil Rights Coordinator
If you believe that Aetna, Inc. has failed to provide these services or discriminated in another way on the basis of race,
color, national origin, age, disability, or sex, you can file a grievance with: Aetna Medicaid Civil Rights Coordinator,
4500 East Cotton Center Boulevard, Phoenix, AZ 85040, 1-888-234-7358, TTY 711, 860-900-7667 (fax),
MedicaidCRCoordinator@aetna.com. You can file a grievance in person or by mail, fax, or email. If you need help filing
a grievance, Aetna Medicaid Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil
Rights, electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call
1-800-385-4104 (TTY: 711).
Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al
1-800-385-4104 (TTY: 711).

Vietnamese: CHÚÝ:Nế ubạ nnóiTi

ếngVi
ệt,c
ócá
cdị
chvụhỗt
rợngônngữmi
ễnphídà
nhc
hobạ
n.Gọis
ố
1-800-385-4104 (TTY: 711).

Albanian: KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi
në 1-800-385-4104 (TTY: 711).

Korean: 주의:한국어를 사용하시는 경우,언어 지원 서비스를 무료로 이용하실 수 있습니다.

1-800-385-4104 (TTY: 711) 번으로 전화해 주십시오.

Polish: UWAGA:J
eże
limówi
szpopol
sku,moż
eszs
kor
zys
taćzbe
zpł
atne
jpomoc
yję
zykowe
j.Za
dzwońpodnume
r

Mr.MUSTAFA ALLAHMA Care Plan 6 of 7 June 15, 2020

1-800-385-4104 (TTY: 711).
German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur
Verfügung. Rufnummer: 1-800-385-4104 (TTY: 711).

Italian: ATTENZI ONE:I nc as

ol ali
nguapa rlat
as i
al’
it
ali
ano,s
onodi
sponi
bil
ise
rvi
zidia
ssi
st
enz
ali
ngui
st
icagr
atui
ti
.
Chiamare il numero 1-800-385-4104 (TTY: 711).

Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-385-4104 (TTY:

711) まで、お電話にてご連絡ください。

Russian: ВНИМАНИЕ:Ес ливыг оворит енар

усс
комя
зык
е,т
ова
мдос
тупныб
еспла
тныеус
луг
ипе
рев
ода
.
Зв
онит е1-800-385-4104 (
теле
тайп:711).

Serbo-Croatian (Serbian): OBAVJ EŠTENJE:Akogovori

tes
rps
ko-hr
vat
ski
,us
lugej
ezi
čkepomoćidos
tupnes
uva
m
besplatno. Nazovite 1-800-385-4104 (
TTY-Tele
fonzaosobes
aošte
ćeni
mgovoromil
isl
uhom:711).

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad. Tumawag sa 1-800-385-4104 (TTY: 711).

Mr.MUSTAFA ALLAHMA Care Plan 7 of 7 June 15, 2020